Long Bone Non-Unions and Malunions: Risk Factors and Treatment Outcomes in Calabar, Southern Nigeria

doi:10.4236/ojo.2013.36047

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Open Journal of Orthopedics, 2013, 3, 253-257

http://dx.doi.org/10.4236/ojo.2013.36047 Published Online October 2013 (http://www.scirp.org/journal/ojo)

253

Long Bone Non-Unions and Malunions: Risk Factors and

Treatment Outcomes in Calabar, Southern Nigeria

Ikpeme A. Ikpeme1*, Nkese E. Mkpanam2, Innocent E. Abang1, Ngim E. Ngim1, Anthony M. Udosen1

1Department of Orthopaedics & Traumatology, University of Calabar, Calabar, Nigeria; 2Department of Community Medicine, Uni-

versity of Calabar, Calabar, Nigeria.

Email: *[email protected]

Received August 28th, 2013; revised September 25th, 2013; accepted October 1st, 2013

cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Diaphyseal non-unions and malunions constitute significant morbidities in fracture care. Fracture treat-

ment modalities seek to restore anatomic orientation and functional rehabilitation as soon as possible after a fracture

incident. Malunions and non unions present a treatment challenge with the need for prolonged hospitalization, multiple

surgical interventions and economic burden. In the developing world, traditional bonesetting practices are popular and

these often result in a host of preventable complications. The added socioeconomic costs of treating these complications

present a considerable strain on the resources of these already fragile economies and households. Aim: To document

the risk factors, treatment options and outcomes for diaphyseal non-unions and malunions in our environment. Patients

and Methods: Fifty-two consecutive patients comprising 37 non-unions and 15 malunions who presented in the ortho-

paedic unit of a tertiary hospital in Southern Nigeria were evaluated. Information sought included biodata, location of

pathology, type of incident fracture, local risk factors including traditional bonesetting; treatment options and final out-

comes. Information obtained was analyzed using SPSS version 20 (IBM, New York). Results are presented in simple

frequency tables. Results: There were 34 males and 18 females (M:F = 1.9:1) with a mean age of 38.76 ± 14.55 years.

There were 37 non-unions and 15 malunions. The femur was the commonest site of pathology in 21 (40.4%) cases, and

among the non-unions, the atrophic variety was the commonest type (n = 26; 70.3%). The mean fracture-to-surgery

interval was 11.35 ± 7.95 months and traditional bonesetting was the commonest risk factor (n = 36; 69.2%). Plate and

screw Osteosynthesis with bonegraft augmentation was the commonest treatment modality and the overall union rate

was 94%. Conclusion: Traditional bonesetting plays a major role in the health seeking behaviour of many African so-

cieties. The complications are varied and add to the overall socioeconomic burden of fracture care in these developing

economies. Identification of traditional bonesetting practices as an important risk factor should translate into a focus on

these practices in preventive public health decisions in fracture care. Continuing public health education backed by po-

litical will and can potentially drive a paradigm shift in health seeking attitudes in the developing world.

Keywords: Non-Union; Malunions; Traditional Bonesetting; Resource-Poor Economy

1. Introduction

Long bones serve to support the trunk providing a stable

framework for propulsion and facilitate pre-hension,

reach and grasp, functions which are important in the

homo erectus. Non-unions are estimated to occur in 1% -

10% of humeral shaft fractures treated non-operatively,

10% - 15% of humeral fractures treated operatively, 0.9%

of femoral shaft fractures treated with modern intrame-

dullary nailing techniques and 2% to 10% of all tibial

fractures in the United States [1-3], and result in a large

number of therapeutic interventions with significant so-

cio-economic costs [1-4]. The factors that cause non un-

ions may be considered as those inherent in the fracture,

patient (host) factors and surgical (treatment) factors. They

include the involved bone and bony region injured, the

degree of soft tissue injury, patient’s age, the presence of

co-morbidities, smoking and non-steroidal anti-inflam-

matory drug (NSAID) abuse. Unstable fixation, excessive

iatrogenic stripping of the periosteum, infection, malnu-

trition, chronic alcoholism and injudicious interventions

by traditional bonesetters are other risk factors for non-

unions [1,5,6-8].

The definition of non-union has undergone an evolution.

Prior to 1998, the definition of the condition was time-

*Corresponding author.

Long Bone Non-Unions and Malunions: Risk Factors and Treatment Outcomes in Calabar, Southern Nigeria

254

bound as failure of union in a fracture ≥9 months post

injury with no observable progressive signs of healing

for at least 3 months [9]. The prevention of prolonged

morbidity and recognition of the need for early interven-

tion necessitated a review of the definition to be the ab-

sence of progressive signs of bone healing on radio-

graphs over 3 consecutive months [4,9,10]. Some regions

still however define non-union as a failure to heal within

the time boundaries of injury and treatment [6,7]. The ti-

bia is the most commonly affected bone [1,4,10], owing

to its subcutaneous location and relative lack of muscle

cover except in the postero-lateral aspect.

Non-unions are classified in different ways, each with

a therapeutic and prognostic significance. Atrophic non-

unions have traditionally been ascribed to failure of hea-

ling biology, while hypertrophic non-unions are said to

occur in the presence of excessive movement or infection

in a setting of appropriate healing biological factors. The-

rapeutically therefore, while bonegrafts are always nec-

essary in atrophic non-unions, stabilization with compres-

sion and reduction of excessive movements may be all

that is required in hypertrophic non-unions. In terms of

their anatomic location, Non-unions may be diaphyseal or

metaphyseal. Diaphyseal non-unions have a reduced bio-

logic potential compared to metaphyseal non-unions, but

are amenable to a wider range of treatment/stabilization

options [1]. Non-unions may also be classified as aseptic

or infected. While the goal of management of aseptic

non-union is the promotion of stability and union, the

goal of treatment of an infected non-union is to first con-

vert it into a non-infected non-union and then treat the

fracture.

Acceptable reduction in the tibia is characterized as

greater than 50% cortical contact, less than 100 angula-

tion in any plane, less than 50 valgus or varus tilt, less

than 100 of anterior or posterior angulation, less than 100

of rotation and less than 10 mm leg length discrepancy.

Fracture site distraction is not tolerated because a 5 mm

distraction may increase healing time to 8 - 12 months

[11]. The treatment of diaphyseal non-unions involves crea-

ting fresh bone ends and restoration of marrow continuity,

stable fixation with compression of the non-union and

augmentation of bone healing using biologic and non-

biologic agents like low-intensity pulsed ultrasound sti-

mulation, electrical bone growth stimulation, bone grafts

and bonegraft substitutes with osteobiological agents.

A malunion occurs when a fracture has healed in a

non-anatomic or unacceptable attitude with respect to

alignment, length and angulation, often with significant

functional impairment especially in the lower limbs. Ge-

nerally, greater than 15 mm shortening, 10

[12]. In the upper limb, malunions often present more of

a cosmetic than functional nuisance. Generally, malun-

ions frequently result from conservative treatment of frac-

tures, failure to adhere to physicians’ instructions, ill-ad-

vised weight bearing and injudicious interventions by tra-

ditional bonesetters. The treatment of long bone malun-

ion aims to correct translational, rotational and angular

deformities and achieve a cosmetically and functionally

accepted limb. This often involves osteoclasis, open re-

duction and internal fixation using intramedullary rods or

plate and screw assemblies and various types of osteoto-

mies. Understanding the biology of fracture healing is es-

sential and bonegraft augmentation may be required. The

aim of this study is to document the risk factors, treat-

ment options and outcomes for long bone diaphyseal non-

union and malunions in our environment.

2. Materials and Methods

A study of 52 consecutive patients with 15 malunions

and 37 non-unions is over a 2-year period. Patients were

evaluated for age, sex, location of pathology, type of in-

cident fracture, risk factors for malunions and non-union,

type of non-union, treatment options and final outcomes.

Information obtained was analysed using SPSS statistics,

Version 20 (IBM Corp, New York).

3. Results

There were 52 cases of long bone diaphyseal malunions

and non-unions in this series. There were 34 males and

18 females (M:F = 1.9:1) with a mean age of 38.76 ±

14.55 years. There were a total of 15 malunions and 37

non-unions. Of the non-unions, there were 26(70.3%)

atrophic, 6(16.2) hypertrophic and 5 septic (13.5%) va-

rieties. The incident fracture was closed in 41 cases and

open in 11 patients. Forty-two (80.7%) patients had at

least secondary level education while 10(19.3%) had pri-

mary level or no education. Thirty-eight (73.1%) patients

were employed in the public or private sector, 13(25%)

were students and 1 patient (1.9%) was unemployed. The

mean fracture-surgery interval was 11.35 ± 7.95 months

and the femur was the commonest site of pathology in

21(40.4%) patients followed by the tibia in 16(30.8%)

patients. Union was achieved in 47(90.4%) patients after

the first surgical intervention. Five patients (9.6%) requir-

ed more than one surgical intervention, and out of these,

union was subsequently achieved in two. Non-union per-

sisted in three patients. Two out of these 3 cases were in-

fected non-unions and 1 was atrophic. The overall union

rate was therefore 94% (Table 1).

In terms of risk factors, traditional bonesetting was the

commonest being present in 36(69.2%) patients followed

by open fractures in 6(11.5%) patients (Table 2). Plate

0 varus or val-

gus angulations, 100 recurvatum, 100 internal rotation and

150 external rotation are unacceptable for tibial fractures

Long Bone Non-Unions and Malunions: Risk Factors and Treatment Outcomes in Calabar, Southern Nigeria 255

and screw osteosynthesis with bonegraft augmentation

was the commonest treatment option and was used in

28(53.8%) cases (Table 3).

Table 1. Clinical parameters.

Variable Malunion

n(%) Non-union

n(%)

Gender Male 12(80) 22(57.5)

Female 3(20) 15(40.5)

Total 15(100) 37(100)

Incident fracture Open fracture 3(20) 9(24.3)

Close fracture 12(80) 28(75.7)

Total 15(100) 37(100)

Education level Tertiary 19(36.5)

Secondary 23(44.2)

Primary 9(17.3)

No education 1(1.9)

Total 52(100)

Type of non-union Atrophic 26(70.3)

Hypertrophic 6(16.2)

Infected 5(13.5)

Total 37(100)

Anatomic location Clavicle 1(1.9)

Humerus 9(17.3)

Radius 3(5.7)

Ulna 2(3.8)

Femur 21(40.4)

Tibia 16(30.8)

Total 52(100)

Mean ± SD Minimum Maximum

Age(years) 38.76 ± 14.55 12 74

Duration of

symptoms (months) 11.35 + 7.95 1 27

Outcomes Union achieved after

first surgery 47(90.4)

Union not achieved

after first surgery 5(9.6)

Total 52(100)

Table 2. Risk factors.

Variable Malunion

n(%) Non-union

n(%)

Traditional bonesetting 12(80) 24(64.9)

Plate and screw osteosynthesis - 5(13.5)

Intramedullary nail osteosynthesis - 1(2.7)

Local infection 1(6.7) 1(2.7)

Open fracture 2(13.3) 3(8.1)

Severely comminuted fracture - 1(2.7)

Wide displacement - 1(2.7)

Total 15(100) 37(100)

Table 3. Treatment options.

Variable Malunion

n(%) Non-union

n(%)

Plate and screw osteosynthesis

with bonegraft 8(53.3) 20(54.1)

Plate and screw osteosynthesis

without bonegraft 2(13.3) 3(8.1)

IM nail osteosynthesis with

bonegraft 2(13.3) 5(13.5)

IM nail osteosynthesis without

bonegraft - 1(2.7)

Linear rail with bonegraft 2(13.3) 3(8.1)

Linear rail without bonegraft 4 3(8.1)

Cast bracing 1(6.7) 2(5.4)

Total 15(100) 37(100)

4. Discussion

Fracture repair techniques continue to evolve in orthopa-

edics, the aim being to restore the injured bone to its pre-

injury functional status as soon as possible. Non-unions

and malunions are severe complications of fracture repair

resulting in shortening, angular deformities and rotational

deformities [6]. Minimal displacement, adequate stability,

sufficient nutrition and absence of infection are some of

the factors that support fracture repair. Western literature

identify the risk factors for non-union to include displa-

cement, smoking/nicotine use, infection, magnitude of

injury, biomechanical instability, malnutrition and vita-

min deficiency, iatrogenic factors, diabetes mellitus and

nonsteroidal anti-inflammatory drugs use [6,7,13-15]. The

role of osteoporosis is inconclusive [13]. Diaphyseal non-

unions and malunions are common problems in orthopa-

edics and often necessitate multiple surgical interven-

tions and prolonged hospitalization to treat, as well as the

use of non-surgical treatment adjuncts to stimulate frac-

ture union [9]. Years of disability, the risk of amputation

and the significant socioeconomic burden of these condi-

tions make their treatment often frustrating to the surge-

on and the patients. Their prevention is therefore the pre-

ferred option and is hinged on an understanding of the

risk factors with respect to the patient, the fracture and

the sociocultural environment [9,13,16].

There were more males than females in this series, and

more non-unions compared to malunions. The male pre-

ponderance and mean age of the patients (38.76 ± 14.55

years) within the first four decades of life agree with data

from Asian and Western studies [7,17]. Fractures are com-

moner in males and within the first four decades of life in

our environment. Seventy-three percent of the patients

were gainfully employed in the public or private sectors

at the time of the antecedent injury. The socioeconomic

costs of prolonged disability, prolonged hospitalization

and multiple surgical interventions inherent in these con-

Long Bone Non-Unions and Malunions: Risk Factors and Treatment Outcomes in Calabar, Southern Nigeria

256

ditions is well documented in different regions of the

world and arise from a variety of factors [7,9]. In our set-

ting with a fragile economy the involved age bracket is

the dominant productive group and the economic costs of

their injuries and consequent treatment puts direct pres-

sure on the economic viability of their households. This

is so because there is no social support and universal in-

surance system to help alleviate the financial burden of

their treatment.

The femur was the commonest site of pathology in this

series. This differs from other literature from Asia and

the Western world which report the tibia and forearm

with the highest rates [7,17-19]. The role of traditional

bonesetting in African society is documented in other

studies [20-22]. As this study shows, the incident fracture

was close in 41(79%) cases. Orthodox fracture repair te-

chniques like interlocking nails and plate & screw osteo-

synthesis would have been offered to these patients with

the documented advantages of stable anatomical recon-

struction and early mobilization, and early return to eco-

nomically productive activities. However, 36(69.2%) pa-

tients chose to be treated by traditional bonesetters and

only returned to seek orthopedic surgical care when the

complications had developed at a mean fracture-surgery

interval of 11.35 ± 7.95 months. Considering that 42(80.7%)

of the patients had at least secondary level education and

38(73.1%) of them were gainfully employed, it appears

that neither educational level nor socio-economic status

have any inhibitory influence on the choice of traditional

bonesetting as the option of first choice in patients with

fractures in our environment. Lower limb complications

with attendant deformity and limb-length inequality ul-

timately force the choice and need for orthopaedic surgi-

cal intervention.

Plate and screw osteosynthesis with bonegraft aug-

mentation was the treatment option in the majority of our

patients (n = 28; 53.8%). This may be explained by the

majority cases being atrophic non-unions. Also, in a so-

ciety where orthopaedic surgical care is not the option of

first choice among the majority, augmenting the chances

of healing at first contact must be seen as an integral part

of the first treatment plan. This philosophy seems to be

consistent in the developing world [20,23]. Consistency

in improved outcomes compared to the outcomes of tra-

ditional bonesetting will ultimately sway confidence from

age-old suboptimal traditional bonesetting practices that

have been sustained by erroneous cultural beliefs in the

supernatural powers of the traditional bonesetters. Union

was achieved in 47(90.4%) of the patients after the first

surgical intervention. Five patients (9.6%) required more

than one operative intervention, with union subsequently

achieved in two of them. Persistent non-union occurred

in 3 patients after the second operative intervention. These

may have benefited from such augmentations as low in-

tensity pulsed ultrasound stimulation or non-invasive

electrical bone growth stimulation. These options are not

accessible within our healthcare system currently. Our

overall union rate of 94% however compares favourably

with the results of other studies from the developing

world [7,20,23]. This study focused on risk factors within

the local fracture environment. The role of systemic risk

factors like smoking/nicotine use, diabetes, NSAIDS use

and malnutrition is well documented and addressing these

issues is an integral part of fracture treatment protocol in

our institution. The role of traditional bonesetting as a

risk factor for non-unions and malunions is important be-

cause it is a potential focus of public health enlighten-

ment intervention in our locality. By the application of

herbal formentations, scarifications, ill-informed splint-

ing and excessive massage protocols, traditional boneset-

ting presents the risk of the creation of local ischaemia,

subclinical infections and biomechanical instability in the

pathogenesis of malunions and non-unions.

5. Conclusion

Diaphyseal non-unions and malunions are associated with

significant morbidity especially in the lower limb where

limb-length inequality, malrotation and malalignment can

cause severe functional deficiencies. The treatment of

these conditions also results in a severe economic burden

for these patients with such issues as prolonged hospita-

lization, multiple surgical interventions and application

of expensive adjunctive treatment modalities. Traditional

bonesetting plays a significant role in the health care seek-

ing behaviour of people in African societies. While cul-

tural beliefs and financial consideration continue to fuel

its popularity, the long-term complications and overall

socioeconomic cost of treating these complications should

drive a paradigm shift in health-seeking behaviours in the

developing world. However, identifying and addressing

this risk factor in the public health enlightenment inter-

vention processes is a necessity if these complications

are to be prevented in these resource-challenged econo-

mies. This study suggests that neither educational level

nor gainful employment has addressed healthcare issues

fueled by age-long erroneous cultural bias and beliefs.

Aggressive health education campaigns, supported by po-

litical will, should help drive a paradigm shift in health

seeking behaviors and interventions.

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