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Introduction: Isolated distal ulnar fracture is an uncommon injury. Only a few case series that look into the management of ulnar fracture nonunion have been reported in the literature. Case presentation: A middle-aged manual worker presented to us for isolated fracture of his left distal ulna. He received open reduction and fixation of the distal ulnar fracture using distal ulna locking plate. It was complicated with nonunion and he complained of persistent wrist pain. This distal ulnar fracture nonunion was finally treated by Sauve-Kapandji procedure with good functional outcome. Discussion: Displaced distal ulnar fracture should be reduced anatomically with rigid fixation to prevent disruption of the distal radioulnar joint. Fracture nonunion was traditionally managed with revision osteosynthesis and bone grafting. It is, however, technically difficult at the distal ulnar region because of the poor bone stock and lack of soft tissue coverage. Conclusion: We have demonstrated that the Sauvé-Kapandji procedure is a good treatment alternative for distal ulnar fracture nonunion.

Aims Clavicle fracture nonunions are extremely rare in children. The aim of this systematic review was to assess what factors may predispose children to form clavicle fracture nonunions and evaluate the treatment methods and outcomes. Methods We performed a systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, aiming to find papers reporting clavicle fracture nonunion in children under the age of 18 years. Data was collected on patient demographics, fracture type, mechanism of injury (MOI), surgical intervention and reported outcome. Two independent reviewers evaluated all the data. Results A total of 13 articles reporting 21 cases of clavicle fracture nonunion were identified. The mean age at time of injury was 11.4 years (4 to 17). Falls were the most common MOI. The majority of nonunions occurred after displaced fractures on the right side. Six were refractures. Mean time of presentation following injury was 13.5 months (4 to 60). In all, 16 were treated surgically. Radiographic union was eventually achieved in 12 cases, with functional outcome satisfactory in all cases. Conclusion Clavicle nonunion is an extremely rare but possible complication in children. The majority occur after displaced right-sided fractures or refractures and present around one year after injury. Surgical fixation provides good radiographic healing and functional outcomes. Level of evidence IV

The aim of the present study was to investigate the incidence of scaphoid fracture surgery by obtaining data from the national discharge register in Finland, a country of 5 million inhabitants, for the period from 1997 to 2014. A total of 1380 patients with scaphoid fracture were treated surgically. Half of the patients were aged under 28 years and 84% were men. The surgical treatment of scaphoid fractures was classified into two groups. There were 640 (46%) primary fracture fixations and 740 (54%) treatments of fracture nonunion. The overall incidence of all scaphoid fixations increased twofold (from 14.8 to 30.1 per 1,000,000 person-years) and threefold in the primary fixation group (from 5.5 to 17.8 per 1,000,000 person-years) during the study period. Level of evidence: III

Introduction: Elderly patients are at risk of fracture nonunion, given the potential setting of osteopenia, poorer fracture biology, and comorbid medical conditions. Risk factors predicting fracture nonunion may compromise the success of fracture nonunion surgery. The purpose of this study was to investigate the effect of patient age on clinical and functional outcome following long bone fracture nonunion surgery. Materials and Methods: A retrospective analysis of prospectively collected data identified 288 patients (aged 18-91) who were indicated for long bone nonunion surgery. Two-hundred and seventy-two patients satisfied study inclusion criteria and analyses were performed comparing elderly patients aged ≥65 years (n = 48) with patients Results: Despite demographic differences in the aged population, including a predominance of medical comorbidities ( P < .01) and osteopenia ( P = .02), there was no statistical differences in the healing rate of elderly patients (95.8% vs 95.1%, P = .6) or time to union (6.2 ± 4.1 months vs. 7.2 ± 6.6, P = .3). Rates of postoperative wound complications and surgical revision did not statistically differ. Elderly patients reported similar levels of function up to 12 months after surgery. Regression analyses failed to show any significant association between age and final union or time to union. There was a strong positive association between smoking and history of previous nonunion surgery with time to union. Age was associated (positively) with 12-month SMFA activity score. Conclusions: Smoking and failure of previous surgical intervention were associated with nonunion surgery outcomes. Patient’s age at the time of surgery was not associated with achieving union. Advanced age was generally not associated with poorer nonunion surgery outcomes.

Treatment of nonunion has radically changed in recent years. We define nonunion as a fracture of bone induced either by trauma or surgery which does not show clinical or radiographic signs of progression to healing within a reasonable time span. The reparative processes are present but inadequate. Fracture healing may be considered to be a balance between repair and breakdown processes at the fracture site. When breakdown exceeds repair, nonunion is the result. Altering the conditions at the fracture site even marginally in favour of repair will eventually lead to bony continuity being restored. Nonunion treatment should follow three principles: a) realignment; b) stabilization; and c) stimulation. Any surgical proce dure should address one or all of these areas. In this article the principles of nonunion management are explained, together with different bone healing stimulation techniques and our clinical results.

In this article, a case of talar neck fracture nonunion is presented. Union was accomplished with an indirect placement of a corticocancellous fibular graft through a posterolateral approach. The advantages and indications for this method of the treatment of talar neck nonunion are discussed, together with a review of the literature.

Introduction To the best of our knowledge, there is not an optimal classification for vertebral fracture nonunion (VFNU), this study is to investigate the value of establishment of the novel therapy-oriented classification of VFNU based on the manifestation of extended CT reconstruction images. Patients and Methods All of the senior patients suffered from thoracolumbar spine fracture (December 2009 to March 2013) were retrospectively reviewed, 36 cases of VFNU were included in this study according to inclusion criteria. The reducibility and stability of index vertebrae were evaluated with extended CT reconstruction images, and all patients with VFNU were divided into three subgroups, type A owns the reducibility and stability, which is recommended to treat by percutaneous vertebroplasty in extension posture, type B owns the reducibility, but lacks stability, which should be treated by in situ fixation and fusion in extension posture, type C loses the reducibility, which is eligible for the spine deformity correction by osteotomy or canal decompression. Whether the patients were treated according to this classification and the perioperative complication were recorded. The clinical outcome was investigated by the comparison of VAS and ODI in preoperation, 3 months after surgery and last follow-up, the transformation of profile of index vertebrae was evaluated radiographically with the local kyphotic Cobb angle and anterior height of VFNU vertebrae in the above time points. Results Overall, 39 level of VFNU vertebrae in 36 patients were located in the region of T9 to L4, in which the thoracolumbar segments were compromised frequently, and 16 level of VFNU existed in L1. According to extended CT reconstruction images, 25 level of type A, 7 level of type B, 7 level of type C VFNU were identified. Overall, 24 cases of type A VFNU accepted percutaneous vertebroplasty in extension posture, 4 cases of type B VFNU were treated by in situ fixation and fusion in extension posture, but 2 of them also accepted percutaneous vertebroplasty in extension posture like type A patients, 6 cases of type C VFNU were treated by spinal deformity correction by osteotomy or decompression, no severe complication occurred in both of type A and type B patients, except that 2 patients of type B VFNU, who accepted PVP, had notable but asymptomatic bone cement leakage, however, 1 case of type C VFNU had a deep wound infection, and 1 case got heart function failure during perioperative period. The different treatment oriented by this novel classification could be effective in the corresponding types of VFNU, by which the VAS, ODI could be improved, local kyphotic angle, and anterior height of VFNU could be corrected significantly ( p Conclusion The validity of this novel therapy–oriented classification has been investigated by clinical and finite element study, which is beneficial to make more accurate evaluation and select the eligible surgery procedure before operation, and decrease the rate of usage of aggressive operations, like spinal osteotomy and decompression, in the older patients.

Introduction Our previous study suggested that vertebral fracture nonunion(VFNU) could be classified into stable and unstable types based on whether there are fracture fragment in the middle column of fractured vertebrae, and we hypothesize that vertebral augmentation could restore the stability of fractured vertebrae in unstable type of VFNU, this study is to determine the effect of percutaneous vertebral augmentation on stable and unstable vertebral fracture nonunion by three-dimensional finite element analysis. Material and Methods An elderly senior, who suffers from osteoporosis, but owns the normal alignment and profile of thoracolumbar spine was included into this finite element study and accepted CT examination. The finite element three-dimension model of physiological thoracolumbar spine (T11-L3) was established and investigated with Mimics, Rapidform, and Abaqus softwares, then wedge-shaped osteotomy was performed in L1 vertebral body to stimulate intravertebral bone defect, which is the main feature of VFNU, to make the pathological finite element model of type A VFNU, which is named pathological model A. Furthermore, the posterior–inferior region of vertebral body was cut to build a piece of separated fracture, with the purpose of simulation of the pathological feature of type B VFNU and establishment of corresponding Finite element model which is called as Pathological model B. After that, imitated bone cement augment was performed in pathological model A and B, distributing cement in the whole intervertebral cleft or 5 mm ahead posterior edge of vertebral body, to establish four therapy finite element model, which were called as therapy model A1, B1, A2, and B2. All of the models were calculated under the same axial loads of 400 N, to investigate the validity of physiological model and compare the mechanical status of different models. Results The physiological finite element model owns good mechanic conformity with the reported models. Compared with physiological model, there was notable stress, strain concentration in the L1 vertebral body of pathological model A, mainly distributing beside the posterior cortex and in the posterior inferior part of the vertebral body, which indicated that there was a risk of further fracture in this model. Although there was also stress and strain concentration in pathological model B, the extent and level of stress and strain were lower than the corresponding value in the pathological model A, furthermore, concentration mainly located in the posterior–inferior fracture piece, which implied that the separated posterior–inferior fracture piece of vertebral body intended to dislocate, and the stress, strain concentration were dispersed after pathological Model A became Model B. According to calculation of therapy model A1, A2, the stress and strain concentration could be dispersed with bone cement augmentation, and the mechanic conduction function of L1 vertebral body could be restored after imitated PVP, which indicated that vertebroplasty could be used effectively in VFNU patients with reliable mechanic stability. However, on the basis of the calculation of therapy model B1 and B2, the tendency of stress, strain concentration, and displacement of posterior–inferior fracture piece could be found, even though the whole concentration could be dispersed by cement augmentation, which implied that there was risk of dislocation of posterior–inferior fracture piece after bone cement augmentation in pathological model B. Conclusion A favorable mechanical performance was revealed in stable VFNU after PVA, but the risk of redislocation of posterior–inferior bony fragments might be increased result from PVA.

Introduction This study is to summarize the main radiographical feature of osteoporotic vertebral fracture nonunion (VFNU) in extended CT reconstruction images, and to evaluate reducibility and stability of the vertebrae. Patients and Methods All of the senior patients suffered from thoracolumbar spine fracture (December 2009 to March 2013) were retrospectively reviewed, 36 cases of VFNU with 39 level of vertebrae were included in this study according to inclusion criteria. The main radiographical features of 39 level of VFNU vertebrae were analyzed, including the specific segment, the type of substance in the intravertebral cleft, the starting points and terminals of intervertebral cleft, to explore the different radiographic feature of various type of VFNU. Results According to the over extension CT, new classification criteria are reported in the literature, all of VFNU patients were divided into the following three subgroups: reducible type (type A), unstable but can be reset type (type B), and loss of reducibility type (type C). Overall, 39 level of VFNU vertebrae in 36 patients were located in the region of T9 to L4, in which the thoracolumbar segments were compromised frequently, and 16 level of VFNU existed in L1. According to extended CT reconstruction images, 25 level of type A, 7 level of type B, and 7 level of type C VFNU were identified with the radiographic analysis, the starting points of intervertebral cleft located in the anterior edge of vertebral body (18 levels) or disc plate (21 levels), the terminals of cleft located in the intersecting point of pedicle and posterior–inferior edge of vertebral body (18 level) or superior disc plate (14 levels), the fracture line could be displayed clearly in the all coronal CT reconstruction images, however, terminals of intravertebral cleft in type C VFNU located in the trabecular bone region in the middle one-third part of vertebral body(4 level), and the middle one-third part of superior disc plate, even though there were significant collapse or intracranial retropulsion of posterior one-third part of vertebral body, fracture line could rarely be shown except for one patient, the fracture lines lateral cortex united in three patients, or just be shown in anterior–middle part of vertebral body in three patients according to the coronal CT reconstruction images. Conclusion Thoracolumbar segments are the most common region compromised by VFNU. There is a difference between the terminals of intravertebral cleft of types A, B, and C VFNU, and existence of fracture lines from the anterior edge to the posterior cortex might explain the mechanism of reducibility of types A and B.