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Update on Treatment for Femoral Fractures That Don't Heal

Posted on: 02/28/2008
In this article, surgeons from the University of Washington (Seattle, WA) review femoral nonunion fractures. They define nonunion and explain the various types or classifications of femoral nonunion fractures. Diagnosis, risk factors, and treatment are also presented.

A femoral nonunion fracture affects the shaft of the femur (thigh bone). Nonunion refers to the obvious fact that the bone hasn't healed. But more specifically, healing hasn't occurred in the first nine months after the injury. At the same time, there has not been any sign of healing on X-rays taken over the last three months. There is no evidence of bone crossing the fracture site. The fracture line is still clearly present.

Patients at risk for this type of nonunion include those who smoke or use tobacco products, who have poor nutrition, or who use nonsteroidal anti-inflammatory drugs (NSAIDs). Poor health or the presence of other health conditions can also increase the risk of fracture nonunion. The type of injury and condition of the soft tissues around the bone may also affect healing.

Sometimes fractures that have been surgically repaired don't heal. Besides the risk factors already mentioned, the surgical technique itself may delay healing. For example, damage to the blood supply can occur with procedures such as reaming or stripping. These steps are necessary when making a space large enough for a pin or nail to be put down the middle of the bone to stabilize the fracture.

The authors provide a detailed discussion of exchange nailing, plate osteosynthesis, and external fixation. These are surgical treatment methods for femoral nonunions. Exchange nailing is the removal of a nail already present. The canal inside the bone where the nail is located is made larger. Then a larger and stiffer nail is put back into the canal. Exchange nailing stabilizes the bone and gives a larger surface area for bone graft to occur.

Plate osteosynthesis refers to the use of a metal plate to stabilize the fracture. The plate applies direct pressure across the nonunion site. This may be an advantage over nailing for some fractures. And in some cases, plating is used when nailing has failed. Bone grafting can be used to help improve the filling in of bone around the plate. Infection, blood loss, and further damage to the nearby soft tissues are potential problems with plate osteosynthesis.

External fixation is used less often than nailing or plating. Pins through the skin with attached hardware have several disadvantages compared to other treatment methods. Pain and infection at the pin site are common problems. External fixation is used when the fracture site is already infected. The pins can be placed without a large incision, which could further compromise the infection site.

Whenever selecting a surgical approach to femoral nonunion fractures, the surgeon considers the need to avoid infection, blood loss, and malalignment of the fracture site. Surgical treatment is followed by rehabilitation. Electrical stimulation of the fracture site may be used as an additional treatment tool to foster bone healing. The surgeon and the physical therapist work together to optimize patient healing and recovery during the postoperative period.

Joseph R. Lynch, MD, et al. Femoral Nonunion: Risk Factors and Treatment Options. In Journal of the Academy of Orthopaedic Surgeons. February 2008. Vol. 16. No. 2. Pp. 88-97.

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