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Non-union

  • John G. Edwards
  • William J. Hunt
Chapter

Abstract

Non-united rib fractures (NURFs) can be a cause of prolonged morbidity. Typically defined as symptomatic rib fractures remaining non-united over three after the original injury, little is known about their incidence or risk factors. Although surgical stabilization of non-united rib fractures (SSNURFs) was first reported in 1941, the literature consisted solely of case reports until 2014. Different techniques have been applied to SSNURFs and are described. Surgical strategies are considered in light of a recently proposed, unifying bone-healing and non-union theory. Aspects of surgical technique which may be employed for SSNURFs include non-union debridement or excision, medullary reaming and bone grafting and plating. Non-surgical management is discussed. There is a need for prospective data collection and clinical trials to define the clinical impact and optimum management of NURFs.

Keywords

Non-union Malunion Rib fractures Flail chest Rib fracture fixation Surgical stabilisation of rib fractures Bone healing Bone-healing and non-union theory 

References

  1. 1.
    Fabricant L, Ham B, Mullins R, Mayberry J. Prolonged pain and disability are common after rib fractures. Am J Surg. 2013;205(5):511–5.CrossRefPubMedGoogle Scholar
  2. 2.
    Marasco S, Lee G, Summerhayes R, Fitzgerald M, Bailey M. Quality of life after major trauma with multiple rib fractures. Injury. 2015;46(1):61–5.CrossRefPubMedGoogle Scholar
  3. 3.
    Fabricant L, Ham B, Mullins R, Mayberry J. Prospective clinical trial of surgical intervention for painful rib fracture nonunion. Am Surg. 2014;80(6):580–6.PubMedGoogle Scholar
  4. 4.
    Leavitt DG. Non-union of three ribs. J Bone Joint Surg. 1942;1942:932–6.Google Scholar
  5. 5.
    Bemelman M, Poeze M, Blokhuis TJ, Leenen LP. Historic overview of treatment techniques for rib fractures and flail chest. Eur J Trauma Emerg Surg. 2010;36(5):407–15.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Elliott DS, Newman KJH, Forward DP, Hahn DM, Ollivere B, Kojima K, et al. A unified theory of bone healing and nonunion: BHN theory. Bone Joint J. 2016;98-B(7):884.CrossRefPubMedGoogle Scholar
  7. 7.
    Weber BG, Czech O. Pseudarthrosen–pathophysiologie biomechanik. Huber: Therapie Ergebnisse; 1973.Google Scholar
  8. 8.
    Gaston MS, Simpson AH. Inhibition of fracture healing. J Bone Joint Surg Br. 2007;89(12):1553–60.CrossRefPubMedGoogle Scholar
  9. 9.
    Gorlitzer M, Wagner F, Pfeiffer S, Folkmann S, Meinhart J, Fischlein T, Reichenspurner H, Grabenwoeger M. Prevention of sternal wound complications after sternotomy: results of a large prospective randomized multicentre trial. Interact Cardiovasc Thorac Surg. 2013;17(3):515–22.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Barcak EA, Beebe MJ. Bone morphogenetic protein: is there still a role in orthopedic trauma in 2017? Orthop Clin North Am. 2017;48(3):301–9.CrossRefPubMedGoogle Scholar
  11. 11.
    Reber P, Ris HB, Inderbitzi R, Stark B, Nachbur B. Osteosynthesis of the injured chest-wall – use of the AO (arbeitsgemeinschaft fur osteosynthese) technique. Scand J Thorac Cardiovasc Surg. 1993;27(3–4):137–42.CrossRefPubMedGoogle Scholar
  12. 12.
    Morgan Jones RL, Mackie IG. Non-union of a fracture of the 8th rib. Injury. 1996;27(2):147–8.CrossRefPubMedGoogle Scholar
  13. 13.
    Cacchione RN, Richardson JD, Seligson D. Painful nonunion of multiple rib fractures managed by operative stabilization. J Trauma Injury Infect Crit Care. 2000;48(2):319–21.CrossRefGoogle Scholar
  14. 14.
    Slater MS, Mayberry JC, Trunkey DD. Operative stabilization of a flail chest six years after injury. Ann Thorac Surg. 2001;72(2):600–1.CrossRefPubMedGoogle Scholar
  15. 15.
    Ng ABY, Giannoudis PV, Bismil Q, Hinsche AF, Smith RM. Operative stabilisation of painful non-united multiple rib fractures. Injury. 2001;32(8):637–9.CrossRefPubMedGoogle Scholar
  16. 16.
    Gardenbroek TJ, Bemelman M, Leenen LPH. Pseudarthrosis of the ribs treated with a locking compression plate a report of three cases. J Bone Joint Surg. 2009;91A(6):1477–9.CrossRefGoogle Scholar
  17. 17.
    Cho YH, Kim HK, Kang D-Y, Choi YH. Reoperative surgical stabilization of a painful nonunited rib fracture using bone grafting and a metal plate. J Orthop Trauma. 2009;23(8):605–6.CrossRefPubMedGoogle Scholar
  18. 18.
    Anavian J, Guthrie ST, Cole PA. Surgical management of multiple painful rib nonunions in patient with a history of severe shoulder girdle trauma: a case report and literature review. J Orthop Trauma. 2009;23(8):600–4.CrossRefPubMedGoogle Scholar
  19. 19.
    Dean NC, Van Boerum DH, Liou TG. Rib plating of acute and sub-acute non-union rib fractures in an adult with cystic fibrosis: a case report. BMC Res Notes. 2014;7:681.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Kaplan DJ, Begly J, Tejwani N. Multiple rib nonunion: open reduction and internal fixation and iliac crest bone graft aspirate. J Orthop Trauma. 2017;31:S34–5.CrossRefPubMedGoogle Scholar
  21. 21.
    DS P, Patton JJ, Jackson DW. Nonunion of a first rib fracture in a gymnast. Am J Sports Med. 1991;19(2):198–201.CrossRefGoogle Scholar
  22. 22.
    Puttmann KT, Satiani B, Vaccaro P. Thoracic outlet syndrome in a volleyball player due to nonunion of the first rib fracture. Vasc Endovasc Surg. 2016;50(8):563–5.CrossRefGoogle Scholar
  23. 23.
    Terabayashi N, Ohno T, Nishimoto Y, Oshima K, Takigami I, Yasufuku Y, Shimizu K. Nonunion of a first rib fracture causing thoracic outlet syndrome in a basketball player: a case report. J Shoulder Elb Surg. 2010;19(6):e20–3.CrossRefGoogle Scholar
  24. 24.
    Gauger EM, Hill BW, Lafferty PM, Cole PA. Outcomes after operative management of symptomatic rib nonunion. Journal of orthopaedic trauma. J Orthop Trauma. 2015;29(6):283–9.CrossRefPubMedGoogle Scholar
  25. 25.
    Young BL, Watson SL, Meyer RD, Ponce BA. Nonunion of first rib fracture in a softball player: case report of a rare cause of thoracic outlet syndrome. J Shoulder Elb Surg. 2016;25(11):e353–7.CrossRefGoogle Scholar
  26. 26.
    Duane TM, O'Connor JV, Scalea TM. Thoracic outlet syndrome resulting from first rib fracture. J Trauma. 2007;62(1):231–3.CrossRefPubMedGoogle Scholar
  27. 27.
    Zura R, Xiong Z, Einhorn T, Watson JT, Ostrum RF, Prayson MJ, Della Rocca GJ, Mehta S, McKinley T, Wang Z, Steen RG. Epidemiology of fracture nonunion in 18 human bones. JAMA Surg. 2016;151(11):e162775.CrossRefPubMedGoogle Scholar
  28. 28.
    Richards CJ, Graf KW Jr, Mashru RP. The effect of opioids, alcohol, and nonsteroidal anti-inflammatory drugs on fracture union. Orthop Clin North Am. 2017;48(4):433–43.CrossRefPubMedGoogle Scholar
  29. 29.
    Haines N, Kempton LB, Seymour RB, Bosse MJ, Churchill C, Hand K, Hsu JR, Keil D, Kellam J, Rozario N, Sims S, Karunakar MA. The effect of a single early high-dose vitamin D supplement on fracture union in patients with hypovitaminosis D: a prospective randomised trial. Bone Joint J. 2017;99-B(11):1520–5.CrossRefPubMedGoogle Scholar
  30. 30.
    Griffin XL, Costa ML, Parsons N, Smith N. Electromagnetic field stimulation for treating delayed union or non-union of long bone fractures in adults. Cochrane Database Syst Rev. 2011;4:CD008471.  https://doi.org/10.1002/14651858.CD008471.pub2.CrossRefGoogle Scholar
  31. 31.
    Iryanov YM. Influence of laser irradiation low intensity on reparative osteogenesis and angiogenesis under transosseous osteosynthesis. J Lasers Med Sci. 2016;7(3):134–8.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Griffin XL, Smith N, Parsons N, Costa ML. Ultrasound and shockwave therapy for acute fractures in adults. Cochrane Database Syst Rev. 2012;2:CD008579.  https://doi.org/10.1002/14651858.CD008579.pub2.CrossRefGoogle Scholar
  33. 33.
    TRUST Investigators Writing Group, Busse JW, Bhandari M, Einhorn TA, Schemitsch E, Heckman JD, Tornetta P III, Leung KS, Heels-Ansdell D, Makosso-Kallyth S, Della Rocca GJ, Jones CB, Guyatt GH. Re-evaluation of low intensity pulsed ultrasound in treatment of tibial fractures (TRUST): randomized clinical trial. BMJ. 2016;355:i5351.  https://doi.org/10.1136/bmj.i5351.CrossRefPubMedCentralGoogle Scholar
  34. 34.
    Lou S, Lv H, Li Z, Zhang L, Tang P. The effects of low-intensity pulsed ultrasound on fresh fracture: a meta-analysis. Medicine (Baltimore). 2017;96(39):e8181.CrossRefGoogle Scholar
  35. 35.
    Ebrahim S, Mollon B, Bance S, Busse JW, Bhandari M. Low-intensity pulsed ultrasonography versus electrical stimulation for fracture healing: a systematic review and network meta-analysis. Can J Surg. 2014;57(3):E105–18.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Martinez-Rondanelli A, Martinez JP, Moncada ME, Manzi E, Pinedo CR, Cadavid H. Electromagnetic stimulation as coadjuvant in the healing of diaphyseal femoral fractures: a randomized controlled trial. Colomb Med (Cali). 2014;45(2):67–71.Google Scholar
  37. 37.
    Adie S, Harris IA, Naylor JM, Rae H, Dao A, Yong S, Ying V. Pulsed electromagnetic field stimulation for acute tibial shaft fractures: a multicenter, double-blind, randomized trial. J Bone Joint Surg Am. 2011;93(17):1569–76.CrossRefPubMedGoogle Scholar
  38. 38.
    Pieracci FM, Majercik S, Ali-Osman F, Ang D, Doben A, Edwards JG, French B, Gasparri M, Marasco S, Minshall C, Sarani B, Tisol W, VanBoerum DH, White TW. Consensus statement: surgical stabilization of rib fractures rib fracture colloquium clinical practice guidelines. Injury. 2017;48(2):307–21.CrossRefPubMedGoogle Scholar
  39. 39.
    Bemelman M, de Kruijf MW, van Baal M, Leenen L. Rib fractures: to fix or not to fix? An evidence-based algorithm. Korean J Thorac Cardiovasc Surg. 2017;50(4):229–34.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Marasco S, Liew S, Edwards E, Varma D, Summerhayes R. Analysis of bone healing in flail chest injury: do we need to fix both fractures per rib? J Trauma Acute Care Surg. 2014;77(3):452–8.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Cardiothoracic Surgery, Northern General HospitalSheffield Teaching Hospitals NHS Foundation TrustSheffieldUK

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