7.3 Delayed Healing

Delayed healing—causes and
treatment principles
AO Trauma Basic Principles Course

Learning objectives
• List factors leading to nonunion
• Understand the difference between delayed union and nonunion
• Discuss how these complications might be avoided in fracture

management
• Outline the principles of treatment of nonunion

Definition of disturbed bone healing
• Delayed union—failure to consolidate

within the normally expected time for
fracture types and location
• Nonunion—the opinion of the treating
surgeon is that healing will not occur
without intervention
• Pseudoarthrosis—Formation of a false
joint where a fibrocartilaginous cavity is
lined with synovial membrane
Fracture healing Contact healing
• Primary bone healing with

osteonal reconstruction is
not really healing
• It is the bone going about its

usual business of
remodelling
Gap healing
Secondary (indirect) bone healing
• True healing process is driven by

inflammatory response to injury
• Described in four stages:
• Inflammation
• Soft callus
• Hard callus
• Remodelling
Requirements for bone healing
• Bone healing organ (BHO) is a hypothetical temporary structure

• Postulating its existence helps us understand the reasons for
failure of bone healing
• BHO is derived from fracture hematoma and migrating
pluripotential stem cells
• Appropriate mechanical environment
Bone healing organ (BHO)
• Formation adversely affected by:

• Open fracture
• High energy (soft-tissue disruption)
• Subcutaneous bone, intraarticular bone
• Surgery?
• Performance adversely affected by:

• Presence of carbon monoxide (smoking)
• Poor blood supply (microvascular disease)
• Infection
• High strain environment (instability)
• Type of tissue formed is dependent

on the mechanical environment
• Interfragmentary Strain Theory of

Fracture Healing—Stephan Perren
(1975)
Interfragmentary Strain Theory
• Strain: ε = ∆L/L (measured in %)
• Tissue cannot be formed by the BHO if the interfragmentary

strain is greater than the yield tolerance of the tissue concerned
Yield tolerances
• Bone = 2%
• Cartilage = 10%
• Granulation tissue = 100%
Thinking in terms of the individual cells of the BHO
Clinical relevance
Clinical relevance
Clinical relevance
Clinical relevance
Clinical relevance
Radiology of nonunion
• X-rays are blocked by the dense nuclei of metallic atoms

• In bony tissue, these are calcium ions
• Callus is not radio-opaque until mineralization occurs
• Mineralization cannot occur in any zone of a fracture gap until the
local strain is 2% or less
• Amount and distribution of callus is a radiological marker of the
strain environment at the fracture
Vascular (hypertrophic)
• Major displacement of fracture
• Distraction of fragment
• Without accurate apposition of

the fragment
Adequate vascularity
/ Lack of mechanical stability
Treatment of nonunion
• Restore alignment
• Stabilize with durable implant
• Prevention
Alignment
• Essential to equalize the strain across the fracture gap

• Osteotomy may be needed to move the plane of the fracture line
closer to perpendicular to the mechanical axis (anti-shear)
Stability
• Essential to achieve low
interfragmentary strain in order
to permit bone formation
• Default options
• Reamed IM nail for lower
limb diaphyseal nonunion
• Compression plates for
upper limb and metaphysis
Exchange nailing
• First option in diaphyseal

femoral and tibial nonunion
• Nonunion occurs because of

instability or malreduction
• Both must be addressed to heal

the fracture
Compression plating
• Implants must be preloaded to

achieve a stabilizing
compressive force
• Prebending the plate and using
load screws in the elliptical hole
of an LCP may have to be
supplemented with a tension or
compression device
• Lag screws are unlikely to
generate sufficient compressive
force to adequately stabilize the
nonunion
Compression plating
Circular fixators
• Advantage of transferring force along the mechanical axis of the bone

• Can store large amounts of energy = large preload = stability at nonunion
site
Avascular
Results from Solution  bone graft

Poor vascularity
(+/- instability)
• Open plating
• Open fracture
• Careless handling of
fracture site
• 2 year after ORIF
• Instability
• Loosening of screws
• Radial shortening
• Little callus formation
• Atrophic after ORIF
• Strategy
• Need stability
• Lengthening of radius
• Biological stability
1. Vital ends
after resecting avascular area
1. Vital ends
after resecting avascular area
2. Lengthening
3. Stability
Osteoporosis  Locking plate
AIBG
Lengthening
+ Compression with LCP
+ Bone graft
After correction Postop 6 months
What about bone grafting?
• Many surgeons no longer use cancellous autograft as an adjunct

to surgery
• Removing existing implants and restoring alignment lead to the
formation of a fresh BHO
• Considerable doubt as to whether the benefits outweigh the extra
morbidity
What about nonsurgical treatments?
• Structure of bone is known and understood right down to an

atomic level
• It must be possible to influence the chemical reactions or
manipulate the microscopic physical/electrical environment
• However, clinically relevant experimental data is extremely
difficult to produce
Prevention of nonunion
• Attend AO course and faithfully follow the principles learned

• Embrace the concept of the BHO
• Understand why some fractures heal faster than others and some
not at all
• Importance of soft-tissue handling
• Advantages of indirect reduction and minimal access techniques
• Use large diameter IM nails where possible
• Do not use an all-locked LCP in simple fracture patterns without
a tension or compression device
Take-home messages
• Understanding how the local strain environment influences bone

formation is crucial
• Restoration of alignment and stable fixation with a durable
implant
• In plate fixation, some energy must be stored (preload) in the
construct to confer sufficient stability to allow healing
• More research is needed on nonsurgical treatment
• Prevention is better than cure

7.3 Delayed Healing

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Delayed healing—causes and

AO Trauma Basic Principles Course

• List factors leading to nonunion

• Understand the difference between delayed union and nonunion

• Discuss how these complications might be avoided in fracture

• Outline the principles of treatment of nonunion

• Delayed union—failure to consolidate

• Primary bone healing with

• It is the bone going about its

• True healing process is driven by

• Bone healing organ (BHO) is a hypothetical temporary structure

• Formation adversely affected by:

• Performance adversely affected by:

• Type of tissue formed is dependent

• Interfragmentary Strain Theory of

• Strain: ε = ∆L/L (measured in %)

• Tissue cannot be formed by the BHO if the interfragmentary

• X-rays are blocked by the dense nuclei of metallic atoms

• Major displacement of fracture

• Without accurate apposition of

• Essential to equalize the strain across the fracture gap

• First option in diaphyseal

• Nonunion occurs because of

• Both must be addressed to heal

• Implants must be preloaded to

• Advantage of transferring force along the mechanical axis of the bone

Results from Solution  bone graft

• Many surgeons no longer use cancellous autograft as an adjunct

• Structure of bone is known and understood right down to an

• Attend AO course and faithfully follow the principles learned

• Understanding how the local strain environment influences bone

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