Nonunion 733.82

Tibial shaft fracture nonunion A/P xray

Tibial shaft fracture nonunion lateral xray

Tibial shaft fracture nonunion IM nail xray


Bone Stimulators

EBI Bone Stimulators

Exogen bone healing system

DONJOY bone stimulators

Orthofix bone stimulator

  • synonyms:
  • ICD-9=733.82(nonunion of fracture)
  • Nonunion = fractured bone that has not completely healed within 9 months and/or shows no progression toward healing on serial xray over 3 consecutive months.
  • Types of nonunion: hypertrophic, oligotrophic, and atrophic.
  • Hypertrophic nonunions:  have a biologic capacity for healing, lack mechanical stability = abundant callus formation without bony bridging. 
  • Oligotrophic nonunions:  have biologic capacity for healing, lack ability to initiate healing =  little to no callus formation. 
  • Atrophic nonunions: lack capacity for healing =  sclerotic bone ends with no callus formation and pseudarthrosis.
  • The risk factors for impaired bone healing in frac- tures can be classified as modifiable or nonmodifiable. Intervention in modifiable risk factors offers an oppor- tunity to enhance bone healing in compromised pa- tients.

Nonunion Risk Factors

  • Open fractrue
  • tobacco use (smoking)
  • Diabetes
  • Nutritional deficiencies: dietary calcium and vitamin D, 
  • Hyperparathyroidism and low growth hormone levels
  • Malnutrition
  • Increased age

Nonunion Treatment

  • Consider evaluation for underlying metabolic disturbances.  Any patient with 1) an unexplained nonunion that occurred despite adequate reduction and stabilization (and debridement in initially infected cases) without obvious technical error and without any other obvious etiology; 2) a history of multiple low-energy fractures with at least one progressing to a nonunion; or 3) a nonunion of a nondisplaced pubic rami or sacral ala fracture should be referred to an endocrinologist for evaluation of undiagnosed metabolic or endocrine abnormalities (Brinker MR, JOT 2007;21:557).  Most common abnormality is vitamin D deficiency.
  • Bone growth stimulators: Non-invasive electrical bone growth stimulation is considered medically appropriate when all of the following criteria are met:
    -At least three (3) months have passed since the date of fracture; and
    -Serial radiographs have confirmed that no progressive signs of healing have occurred; and
    -The fracture gap is one (1) cm or less; and
    -The individual can be adequately immobilized and is likely to comply with non-weight bearing.

Specific Nonunions

Fusion / Nonunion Clinical Utility

  • Amplify rhBMP-2 Matrix; Medronic: slown to decrease operative time, and blood loss and increase fusion rates compared to iliac crest graft for lumbar fusion (Dimar J, JBJS 2009;91A:1377).

Nonunion References

  • Palmer M, Costerton W, Sewecke J, Altman D. Molecular techniques to detect biofilm bacteria in long bone nonunion: a case report. Clin Orthop Relat Res. 2011 Nov;469(11):3037-42.
  • Palmer MP, Altman DT, Altman GT, Sewecke JJ, Ehrlich GD, Hu FZ, Nistico L, Melton-Kreft R, Gause TM 3rd, Costerton JW. Can we trust intraoperative culture results in nonunions? J Orthop Trauma. 2014 Jul;28(7):384-90.