Copyright 2014 American Academy of Orthopaedic Surgeons
Nonunions

With modern treatment methods, most broken bones (fractures) heal without any problems. After a broken bone is treated, new bone tissue begins to form and connect the broken pieces.

Some broken bones do not heal even when they get the best surgical or nonsurgical treatment. In some cases, certain risk factors make it more likely that a bone will fail to heal. When a broken bone fails to heal it is called a "nonunion." A "delayed union" is when a fracture takes longer than usual to heal.

Bone Healing

For bone healing to happen, the bone needs adequate stability and blood supply. Good nutrition also plays a role in bone healing.

  • Stability. All treatment of broken bones follows one basic rule: the broken pieces must be put back into position and prevented from moving out of place until they heal. Some fractures can be held in position with a cast. Some fractures require surgical fixation with devices like screws, plates, rods and frames.
  • A broken tibia stabilized with a metal nail in the center canal and four horizontal screws.
    Blood supply. Blood delivers the components required for healing to the fracture site. These include oxygen, healing cells, and the body's own chemicals necessary for healing (growth factors). The blood supply to the injured bone usually comes back on its own during the healing period.
  • A broken bone stabilized with a plate and screws.
  • Nutrition. A broken bone also needs adequate nutrition to heal. Eating a healthy and well-balanced diet that includes protein, calcium, vitamin C, and vitamin D is the best way to ensure adequate nutrition; dietary supplements that go beyond the daily requirements are not effective. (The rare exception is the severely malnourished patient with many injured organs. In this case, the doctor will discuss dietary guidelines and make recommendations for adding dietary supplements.)
Causes

Nonunions happen when the bone lacks adequate stability, blood flow, or both. They also are more likely if the bone breaks from a high-energy injury, such as from a car wreck, because severe injuries often impair blood supply to the broken bone.

Risk Factors

Several factors increase the risk of nonunion.

  • Use of tobacco or nicotine in any form (smoking, chewing tobacco, and use of nicotine gum or patches) inhibits bone healing and increase the chance of a nonunion
  • Older age
  • Severe anemia
  • Diabetes
  • A low vitamin D level
  • Hypthyroidism
  • Poor nutrition
  • Medications including anti-inflammatory drugs such as aspirin, ibuprofen, and prednisone. The physician and patient should always discuss the risks and benefits of using these medications during fracture healing
  • Infection
  • A complicated break that is open or compound

Blood Supply

Nonunions are more likely to happen if the injured bone has a limited blood supply.

  • Some bones, such as toe bones, have inherent stability and excellent blood supply. They can be expected to heal with minimal treatment.
  • Some bones, such as the upper thighbone (femoral head and neck) and small wrist bone (scaphoid), have a limited blood supply. The blood supply can be destroyed when these bones are broken.
  • Some bones, such as the shinbone (tibia), have a moderate blood supply, however, an injury can disrupt it. For example, a high-energy injury can damage the skin and muscle over the bone and destroy the external blood supply. In addition, the injury can destroy the internal blood supply found in the marrow at the center of the bone.
Symptoms

Patients with nonunions usually feel pain at the site of the break long after the initial pain of the fracture disappears. This pain may last months, or even years. It may be constant, or it may occur only when the broken arm or leg is used.

Doctor Examination

To diagnose a nonunion, the doctor uses imaging studies that provide detailed pictures of the bone and surrounding soft tissues. Depending on which bone is involved, these tests may include x-rays, computed tomography (CT) scans, and magnetic resonance imaging (MRI). Imaging studies let the doctor see the broken bone and follow the progress of its healing.

A nonunion may be diagnosed if the doctor finds one or more of the following:

  • Persistent pain at the fracture site
  • A persistent gap with no bone spanning the fracture site
  • No progress in bone healing when repeated imaging studies are compared over several months
  • Inadequate healing in a time period that is usually enough for normal healing

If the doctor diagnoses a nonunion, he or she may order blood tests to investigate the cause. These tests may show infection or another medical condition that may slow bone healing, such as anemia or diabetes.

Treatment

Nonsurgical and surgical treatments for nonunions have advantages and disadvantages. More than one alternative may be appropriate. Discuss with your doctor the unique benefits and risks of treating your nonunion. Your doctor will recommend the treatment option that is right for you.

Nonsurgical Treatment

An external bone stimulator is applied to the skin overlying the nonunion.
Some nonunions can be treated nonsurgically. The most common nonsurgical treatment is a bone stimulator. This small device delivers ultrasonic or pulsed electromagnetic waves that stimulate healing The patient places the stimulator on the skin over the nonunion from 20 minutes to several hours daily. This treatment must be used every day to be effective.

Surgical Treatment

Bone graft is taken from the back of the pelvis and placed at the nonunion site.
Surgery is needed when nonsurgical methods fail. You may also need a second surgery if the first surgery failed. Surgical options include bone graft or bone graft substitute, internal fixation, and/or external fixation.

  • Bone Graft. During this procedure, bone from another part of the body at the fracture site to "jump start" the healing process. A bone graft provides a scaffold on which new bone may grow. Bone grafts also provide fresh bone cells and the naturally occurring chemicals the body needs for bone healing.
  • During the procedure, a surgeon makes an incision and removes (harvests) pieces of bone from different areas on the patient. These are then transplanted to the nonunion site. The rim of the pelvis or "iliac crest" is most often used for harvesting bone. Although harvesting the bone may be painful, the amount of bone removed usually does not cause functional, structural, or cosmetic problems.

    • Allograft (cadaver bone graft). An allograft (cadaver) bone graft avoids harvesting bone from the patient, and therefore, decreases the pain involved with treating the nonunion. Like a traditional bone graft, it provides scaffolding for the patient's bone to heal across the area of the nonunion. As time goes on, the patient's bone replaces the cadaver bone. Although there is a theoretical risk of infection, the cadaver bone graft is processed and sterilized to minimize this risk.
    • Bone graft substitutes and/or osteobiologics. As with allografts, bone graft substitutes avoid the bone harvesting procedure and related pain. Although bone graft substitutes do not provide the fresh bone cells needed for normal healing, they do provide a scaffold chemicals needed for growth.

Depending on the type of nonunion, any of the above materials, or a combination of materials, may be used to fix the nonunion.

Bone grafts (or bone graft substitutes) alone provide no stability to the fracture site. Unless the nonunion is inherently stable, you may also need more surgical procedures (internal or external fixation) to improve stabililty.

  • Internal Fixation. Internal fixation stabilizes a nonunion. The surgeon attaches metal plates and screws to the outside of the bone or places a nail (rod) in the inside canal of the bone.
  • An external fixator made of pins and wires stabilizes a nonunion of the tibia.
    If a nonunion occurs after internal fixation surgery, another internal fixation surgery may be needed to increase stability. The surgeon may use a more rigid device, such as a larger rod (nail) or a longer plate. Removing a previously inserted nail and inserting a larger one (exchange nailing) increases stability and stimulates healing within the bone. Internal fixation can be combined with bone grafting to help stability and stimulate healing.

  • External fixation. External fixation stabilizes the injured bone, as well. The surgeon attaches a rigid frame to the outside of the injured arm or leg. The frame is attached to the bone with wires or pins. External fixation may be used to increase the stability of the fracture site if instability helped cause the nonunion. External fixation can treat nonunions in a patient who also has bone loss and/or infection.
On the Horizon

To determine why a bone does not heal, scientists are investigating naturally occurring chemicals that the body needs for bone healing. These chemicals are called growth factors. When a bone breaks, they are normally produced in the body in a certain sequence. Other chemicals can decrease the chance of the bone healing. Researchers are concentrating on synthesizing these chemicals and determining the ideal way either to block the negative factors or increase the positive factors to the injured bone. Someday, physicians may be able to inject the chemicals directly into the nonunion to promote healing.

Last reviewed: March 2014

Co-developed by the Orthopaedic Trauma Association

AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS "Find an Orthopaedist" program on this website.
Copyright 2014 American Academy of Orthopaedic Surgeons
Related Articles
Bone Health Basics (http://orthoinfo.aaos.org/topic.cfm?topic=A00578)
Bone Stimulators (Physical Fields) (http://orthoinfo.aaos.org/topic.cfm?topic=A00279)
Fractures (Broken Bones) (http://orthoinfo.aaos.org/topic.cfm?topic=A00139)
Helping Fractures Heal (Orthobiologics) (http://orthoinfo.aaos.org/topic.cfm?topic=A00525)
Infection After Fractures (http://orthoinfo.aaos.org/topic.cfm?topic=A00580)
Internal Fixation for Fractures (http://orthoinfo.aaos.org/topic.cfm?topic=A00196)
Open Fractures (http://orthoinfo.aaos.org/topic.cfm?topic=A00582)
Surgery and Smoking (http://orthoinfo.aaos.org/topic.cfm?topic=A00262)
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