Challenges and Solutions for Nonunion Fractures in Hand Surgery

Nonunion of fractures (Hand Surgery)

Hello Doctor: Last October, my finger was crushed by a metal plate.
Except for my thumb, the other fingers suffered from bone fractures, as well as vascular and nerve damage.
After the first surgery, my middle finger still had poor blood flow, so I underwent another operation where a segment of a blood vessel was taken from near my wrist to my finger.
This August, due to non-union fractures in my ring and middle fingers, I had another surgery for a periosteal graft.
However, the bone growth has not improved significantly, and the range of motion in my fingers is still similar to what it was after the first surgery; I can only perform slight extensions and cannot use them flexibly, let alone lift anything heavy.
Additionally, I experience pain with changes in weather, and my leg is also affected (due to the periosteal graft).
Although my index finger appears to have healed well externally, the bone is still misaligned, but my attending physician assured me that it was not a concern, which raises some doubts for me.
It has been a year since the incident, and I am worried not only about the bone not healing completely but also about muscle and nerve atrophy due to the limited range of motion in my hand.
I am also wondering if the index finger should be corrected.
I would like to ask if there are any other methods to improve the condition of my fingers, and whether hyperbaric oxygen therapy could help with the non-union fractures.
Otherwise, my hand will only serve a decorative purpose...

Fang, 30~39 year old female. Ask Date: 2018/10/07

Dr. Zhou Hongzhang reply Plastic Surgery

1.
This condition may require a complete medical history or a consultation with the original treating physician for a better prognosis.

2.
Poor fracture healing can have many causes, such as severe injury, compromised circulation, wound infection, and so on.

3.
Hyperbaric oxygen therapy is particularly helpful for chronic osteomyelitis or radiation-induced bone necrosis.

4.
If there are still concerns, you can seek further consultation at an orthopedic outpatient clinic in a domestic medical center.

Reply Date: 2018/10/07

More Info

Nonunion fractures, particularly in the hand, present significant challenges for both patients and surgeons. Nonunion refers to the failure of a fractured bone to heal properly, which can lead to persistent pain, dysfunction, and a decreased quality of life. Your case, involving multiple finger fractures with complications such as vascular and nerve damage, highlights the complexities involved in treating such injuries.

Challenges of Nonunion Fractures
1. Complex Anatomy: The hand consists of intricate structures, including bones, tendons, nerves, and blood vessels. Injuries that involve these components can complicate healing. In your case, the involvement of blood vessels and nerves adds layers of difficulty, as any surgical intervention must consider the preservation and restoration of these critical structures.

2. Inadequate Blood Supply: Bone healing relies heavily on an adequate blood supply. If the blood flow to the fractured area is compromised, as seen in your case with the middle finger, it can lead to nonunion. Surgical interventions, such as the vascular graft you underwent, aim to restore this blood flow, but they may not always be successful.

3. Bone Quality and Health: Factors such as age, nutritional status, and underlying health conditions can affect bone healing. If the bone quality is poor, it may not heal properly, necessitating additional interventions like bone grafting or membrane transplantation, as you experienced.

4. Infection: Surgical sites, especially in the hand, are at risk for infection, which can further complicate healing. Infections can lead to inflammation and additional tissue damage, hindering the healing process.

5. Patient Compliance: Post-operative care and rehabilitation are crucial for recovery. Patients must adhere to prescribed physical therapy and avoid activities that could stress the healing bone. Noncompliance can lead to poor outcomes.

Solutions for Nonunion Fractures
1. Surgical Intervention: In cases of nonunion, surgical options may include internal fixation (using plates or screws), bone grafting, or the use of bone stimulators. Bone grafting can provide the necessary biological material to promote healing, while bone stimulators can enhance the healing process through electrical or ultrasound stimulation.

2. Physical Therapy: Engaging in a structured rehabilitation program is essential. Physical therapy can help improve range of motion, strengthen surrounding muscles, and prevent stiffness. It is crucial to work with a therapist experienced in hand injuries to tailor a program that suits your specific needs.

3. High-Pressure Oxygen Therapy: Hyperbaric oxygen therapy (HBOT) has shown promise in promoting healing in nonunion fractures. The increased oxygen levels can enhance blood flow and stimulate the healing process. However, the effectiveness can vary, and it should be considered as part of a comprehensive treatment plan.

4. Regular Monitoring: Frequent follow-ups with your orthopedic surgeon are vital to assess the healing process. X-rays and clinical evaluations can help determine if additional interventions are necessary.

5. Addressing Pain and Functionality: Managing pain through medications and possibly nerve blocks can improve your ability to engage in therapy. Additionally, addressing any functional limitations through adaptive devices or splints can help you maintain some level of activity while healing.

6. Consideration of Corrective Surgery: If there is significant malalignment or deformity, corrective surgery may be warranted. This could involve realigning the bones or addressing any residual issues from previous surgeries.

Conclusion
Your situation is understandably frustrating, especially after multiple surgeries and ongoing pain. It is essential to maintain open communication with your healthcare team about your concerns and the limitations you are experiencing. Exploring all available treatment options, including advanced therapies like HBOT, and adhering to a rigorous rehabilitation program can significantly enhance your chances of recovery. Remember, healing can be a slow process, and patience, combined with proactive management, is key to regaining function in your hand.

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