Living With a Nonunion Fracture: A guide to reassure you

What is a nonunion fracture concretely? Definition

When you break a bone, your body usually manages to repair the cracked or fractured bone. This is achieved primarily through the formation of a callus: new bone that is fragile at first but becomes increasingly solid over the weeks and months.

Sometimes, this automatic repair mechanism doesn’t work well. Despite the passing months, your body fails to repair the fractured bone.

➡️ The callus either does not form or does not become stronger.

It’s a nonunion.

In French, “nonunion fracture” is called false joint.

Because when the fracture does not heal properly, it gives the impression of a joint where there should not be one.

A nonunion fracture can also occur after cervical, thoracic, or lumbar arthrodesis: a surgical procedure on the back or neck.

Does it happen often?

2 out of 100 people experience a nonunion fracture after a fracture, especially among those aged 25-40 (Schmal 2021).

So, it’s relatively common and relatively well-known.

The 4 types of nonunion fractures

There are 4 different types of nonunion fractures (Thomas 2023).

Septic nonunion: In this case, the non-healing of the fracture is associated with an infection.

This can occur when bacteria enter the fracture site, causing inflammation and hindering normal bone healing.

Atrophic nonunion: This occurs when there is a decrease in vascularization (blood supply) in the fracture area, which impairs the healing process.

No callus forms.

Hypertrophic nonunion: There is an overgrowth of bone around the fracture, but despite this, proper healing does not occur.

There is a callus formation, but it is not sufficient to stabilize the bone.

Oligotrophic nonunion: There is incomplete callus formation. This is not sufficient to stabilize the bone.

How do you know which type of nonunion fracture you have? Symptoms alone are not enough to determine it.

Generally, additional imaging examinations specify the type of nonunion fracture. This information may be written in your medical reports.

If you don’t have this information, know that it doesn’t change much in terms of what you can do at your level to address this problem.

The location of nonunion fractures

Any fractured bone in the body can lead to a nonunion fracture.

Here are the ones that internet users have the most questions about:

• Scaphoid
• Clavicle
• Bones of the foot
• Tibia, fibula (leg)
• Ankle
• Greater trochanter, etc.

Why do some people experience nonunion fractures while others don’t? Causes

When there is a nonunion fracture, we talk about multifactorial causes. This means that there are likely several factors at play that explain it.

Even people who have all their medical records may not necessarily be able to pinpoint THE cause that led to it (though it’s frustrating, I understand!).

The main factor related to the individual with the fracture in non-consolidation is blood supply. When the bone has decreased blood supply, it cannot heal.

Blood supply is decreased if:

• You are malnourished
• You smoke or drink a lot of alcohol
• You have diseases such as diabetes, lower limb arteriopathy, kidney failure
• You take certain medications for a long time: steroids, NSAIDs, opioids.

If you have had a complex, open, or highly displaced fracture, the risk of delayed or absent consolidation is also higher.

Source: Thomas 2023

Can bones heal without a callus?

No, typically the callus is what allows bone fragments to reconnect and heal.

The callus is a crucial part of this process, as it provides a temporary bridge between bone fragments, thus enabling consolidation and bone regeneration.

If the callus is not formed correctly and it causes discomfort (pain, difficulty using the affected body part), surgical interventions are sometimes proposed.

How is a nonunion fracture treated?

If the cause of the nonunion fracture is an infection, the infection must be treated. Sometimes, only medical treatment (antibiotics) is sufficient, while in other cases surgery may be required to perform a “washing.”

In any case, the first treatment for a nonunion fracture often involves waiting a little longer.

For example, if you have a follow-up X-ray 6 weeks after your fracture, it may be decided to simply wait for another X-ray 6 weeks later.

If this delay is not sufficient and you have significant pain or discomfort:

• A more significant immobilization of the affected segment may be proposed.
• In the case of a fracture in the lower limb: partial or total restriction of weight-bearing may be advised.
• Surgery is sometimes scheduled.

Can surgery be performed to promote bone healing?

In some cases, surgery may be offered to attempt to compensate for the absence of a “natural” callus.

Surgical options may include:

• Bone grafting
• Internal fixation: plate, nail, screws
• External fixation using an external fixator

Is physical therapy useful?

There is no physical therapy treatment that directly stimulates bone healing.

Ultrasound therapy, massage, shockwaves therapy, etc. do not help the callus to form faster or to be of better quality.

However, physical therapy can be useful for:

• Maintaining your mobility
• Maintaining your general physical fitness
• Relieving your pain
• Helping you better cope with this potentially stressful period.

From a purely theoretical point of view, being active and mobilizing the affected limb (without putting stress on the injured bone) can also improve blood flow to the injured area.

And therefore, promote its healing. This is provided that a balance is found between too much stress and not enough: hence the importance of seeking the advice of a physiotherapist, who is accustomed to treating fractures (which is the case for most physiotherapists in France).

How long does a nonunion fracture last?

There is no maximum duration for a nonunion fracture.

The Food and Drug Administration (FDA) of the United States defines a nonunion fracture as a fracture (Calori 2017):

• That has been present for at least 9 months
• And has shown no signs of healing for 3 consecutive months.

After this period, the nonunion fracture can sometimes remain “for life.” Just as it is possible for consolidation to eventually occur, either naturally over time or as a result of surgery.

Can you resume your life despite having a nonunion fracture?

Having a nonunion fracture does not mean that you cannot do anything at all with the injured part of your body.

Do not hesitate to discuss with your surgeon, general practitioner, or physiotherapist about the things that may be possible for you:

• How to use your upper limb? How?
• Walking with support or with partial support?
• Resuming certain physical activities?

Without knowing your situation at all, it is difficult to say what is possible in your case. Your healthcare professionals are therefore your best interlocutors.

If you are among the minority of people who have a long-term nonunion fracture, know that your body can compensate by creating fibrous tissue, using your muscles differently to stabilize the fractured area, etc.

That’s why a “lifetime” nonunion fracture doesn’t necessarily mean a “lifetime” disability.