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Nonunion

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Intramedullary Nailing

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Abstract

The pathogenesis of bone healing disturbances is multifactorial, but especially related to impaired biology, inadequate stability, fracture gapping and infection. The key symptom is pain and discomfort at the site of nonunion while moving and weight-bearing the affected limb. Typical findings on conventional radiographs or CT support the diagnosis: missing progress of bone healing on serial images, loss of bridging trabecular bone crossing the fracture zone or hypertrophic bridging callus with persistent fracture gap. Breakage of implants is an additional, associated sign. Treatment principles consist of improvement of impaired biology and improvement of stability: restoration of axial alignment, stabilization of fracture fragments, reaming, intramedullary nailing with an increased nail diameter, compression of nonunion; and multiple interlocking. The authors prefer antegrade nailing with the patient in lateral position in femur diaphysis nonunion. Overreaming, exact positioning of the nail and interfragmentary compression are most important parts of the procedure. Exchange nailing is done as a closed procedure in hypertrophic nonunion of the tibia. For axis correction and in atrophic nonunion, the nonunion site is opened. Whenever an intact fibula blocks dynamization of the tibia, or compression across the tibial nonunion site, oblique fibula osteotomy and resection of a short segment is performed. Humerus nonunion after conservative treatment is treated with closed nailing, nonunion after nailing is treated with reaming, exchange nailing, compression and multiple interlocking. In metaphyseal nonunion, the use of an auxiliary plate; and in long oblique fractures, the use of cerclage wires is beneficial to secure fracture reduction during nail insertion and enhance stability of the nail-bone construct.

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Author information

Authors and Affiliations

  1. Trauma Center Murnau, Prof.-Kuentscher-Str., Murnau, 882418, Germany

    Christian Hierholzer MD, PhD & Volker Bühren MD, PhD

Authors
  1. Christian Hierholzer MD, PhD
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  2. Volker Bühren MD, PhD
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Correspondence to Christian Hierholzer MD, PhD .

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Editors and Affiliations

  1. Center for Orthopedics &Traumatology, University Medical Center Johannes Gutenberg University, Mainz, Germany

    Pol M. Rommens

  2. Academic Teaching Hospital Fulda, Fulda, Germany

    Martin H. Hessmann

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Hierholzer, C., Bühren, V. (2015). Nonunion. In: Rommens, P., Hessmann, M. (eds) Intramedullary Nailing. Springer, London. https://doi.org/10.1007/978-1-4471-6612-2_25

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  • DOI: https://doi.org/10.1007/978-1-4471-6612-2_25

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  • Publisher Name: Springer, London

  • Print ISBN: 978-1-4471-6611-5

  • Online ISBN: 978-1-4471-6612-2

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