Nonunion: not united Fractures

What a nonunion is

Healing a broken bone is a biological process, not simply a mechanical one. New bone forms across the fracture as blood supply, cells and mineral reach the gap, and this depends on the bone ends being reasonably close together, stable and well supplied with blood. When one of those conditions is missing, healing can slow or stop. A fracture taking longer than expected is called a delayed union, and one showing no further progress a nonunion.

Nonunions are often grouped by what the bone ends look like on imaging. A hypertrophic pattern shows abundant new bone that cannot bridge the gap because the fragments move too much, pointing to a problem of stability. An atrophic pattern shows little biological activity at the bone ends, pointing instead to blood supply. Infection is a third possibility, and is looked for in cases that do not behave as expected. Factors making nonunion more likely include smoking, diabetes, poor nutrition, open injury and bone loss.

Symptoms that often bring people in

• Pain at an old fracture site persisting well beyond the expected time
• A sense of movement, clicking or giving way at the level of the previous break
• Difficulty putting weight through the limb or using it normally
• Swelling, warmth or tenderness that has not resolved
• Follow-up X-rays described as showing little or no progress
• Drainage from a wound near the fracture

How a nonunion is evaluated

Evaluation looks at mechanics, biology and the possibility of infection together. Serial X-rays are compared over time, since the question is whether anything has changed rather than what one image shows, and CT can clarify how much bone has bridged the gap. Blood tests may be used to look for infection, and tissue sent for culture at surgery. A general medical review is often included, since nutrition, metabolic factors and tobacco use influence healing.

Treatment options in general terms

Not every stalled fracture requires an operation, and treatment begins by addressing what can be corrected without one.

• Adjusting the mechanical environment. Changes in bracing, support or loading may give healing a better chance.
• Addressing contributing factors. Stopping tobacco use, correcting nutritional deficiencies and managing conditions that affect bone are often part of the plan.

When a fracture has clearly stopped progressing, surgical options may be discussed, depending on whether the underlying problem is stability, biology, infection or bone loss.

• Revision fixation. Previous hardware may be exchanged or supplemented so the fracture is held more securely.
• Bone grafting. Bone from elsewhere in the body, or graft material, may be placed at the site to supply cells and structure for new bone.
• Debridement. Where infection or dead bone is present, that tissue is removed first and reconstruction follows later.
• External fixation and bone transport. A circular frame can stabilize the limb and, using the Ilizarov method of gradual distraction, move a segment of healthy bone across a gap so new bone forms behind it.

What to expect when you consult Dr. Wolfson

Dr. Wolfson trained in the Ilizarov method of limb lengthening and reconstruction, developed in part for these problems: fractures that have not united, and bone lost to injury or infection. A consultation generally involves reviewing your entire imaging history rather than the most recent study alone, and identifying which contributing factors are at work. Related pages cover malunion and bone infection.

This page provides general information about nonunion of fractures and is not medical advice. It is not a substitute for examination, imaging and diagnosis by a qualified physician. Every case is different and requires individual evaluation. If you have severe pain, an obvious deformity, loss of function, fever, or an injury from a significant accident, seek medical care promptly.

Contact Dr. Wolfson if you would like to setup an appointment. If you are a new patient, please book all in-person appointments with Dr. Wolfson via telephone.

If you live outside of the San Francisco Bay Area, you can request a complimentary phone consultation with Dr. Wolfson to assess your case. Please call or e-mail us to set up your complimentary consultation.

Call: (415) 221-4400

E-mail: [email protected]