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A non-union fracture is defined by the FDA as a fracture that is at least 9 months old and has not shown progressive signs of healing for 3 consecutive months.
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clinical union refers to the absence of tenderness, abnormal motion, and pain on loading, while radiological union refers to the presence of bridging bone in three out of four cortices on AP and lateral views.
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The local factors that can affect fracture healing include the extent of soft tissue trauma, bone loss, infection, inadequate blood supply, comminution, and inadequate mechanical stability at the fracture site.
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The systemic factors that can affect fracture healing include diabetes mellitus, poor nutrition, associated head injury, and smoking. Smoking inhibits angiogenesis as bone is remodelled, increases platelet aggregation, and displaces O2 from Hb, resulting in lower oxygen tension in tissues. Bisphosphonates, quinolones, steroids, and NSAIDs can also affect fracture healing.
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The different types of non-union are hypertrophic and atrophic non-union. Hypertrophic non-union is due to a lack of stability with a high strain environment, while atrophic non-union is a problem with the biology and has sclerotic bone edges.
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The treatment for hypertrophic non-union involves addressing any fracture instability, such as dynamisation, exchanging nailing for a larger and stiffer nail, or freshening up the bone ends to increase stability. Bone graft is not needed for hypertrophic non-union.
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The treatment for atrophic non-union involves identifying modifiable risk factors and using bone graft. Exogen, a low-intensity pulsed ultrasound, can also be used to speed up fracture healing.
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The treatment for infected non-union involves radical surgical debridement of infected and non-viable bone ends, achieving bone stability, and dead space management using the Masquelet technique. The Masquelet technique involves using a cement spacer to fill the void, which leaves behind a space encapsulated by a fibrous membrane. This space can be filled with bone graft at a later date.