Have you had a fracture which is taking longer to heal then expected.
You have been to the doctor. And your doctor has explained to you in a few medical terms that it could be delayed bone healing, non-union or consolidation.
In this article I will examine what non-union or delayed fracture healing means.
I will rely on my educational knowledge as a diagnostic radiographer and of course on medical scientific studies to answer some of the common questions.
Happy reading!😃
Any questions? remarks? Let’s meet in the comments section at the end of this article.🙏
Last updated: Dec 2024. Written by Juliet Semakula, a diagnostic.
Disclaimer: no affiliate links.
▶️What is a non-union bone fracture?
Summary: A delayed fracture union is the body’s inability to heal a fracture. Any fracture that persists for a minimum of 9 months without showing signs of healing after three months can be classified as a non-union fracture.
when you have been treated for a broken bone after the estimated time of healing usually post 6 months injury.
Your fracture sight is expected to have healed completely for most fractures.
But sometimes, your bone may fall to repair itself as it should, which is called a non-union.
Some people complain of pain and other symptoms post 6 months of treatment which is usually a sign of non-union.
▶️What is non-union
A non-union is an arrest in the stages of the fracture repair process. After a broken bone treatment, begins when new bone tissue (callus) begins to form and connect the broken pieces.
⚫When a broken bone fails to heal it is called a non-union.
⚫A delayed union is when a fracture takes longer than usual to heal.
Images of non-union fractures
X-ray images of a forearm and clavicle fracture showing non-union fracture healing process
▶️Is a non-union fracture very common
Yes, non-union fractures are common and can occur in any bone, they are most common in the tibia, femur humerus, talus and fifth metatarsal bone.
Regardless of the quality of care, you may receive, at the initial fracture treatment. It is estimated in some studies that as many as 20% of fractures may result in a malunion or non-union.
In the United Kingdom, a Study done in Scotland for over 5 years, the statistics showed over 4,895 non-union patients of all ages that were treated for non-union fractures.
It has been estimated that 100,000 fractures go on to non-union each year in the United States (Hak et al 2014)
So, it is relatively common and well known. The causes of these non-union fractures are often difficult to identify and complex to treat sometimes.
▶️What are the 4 types of non-union bone fractures?
1️⃣Hypertrophic non-union.
♦Caused by a lack of stability in the metal used and there is an overgrowth of bone around the fracture.
♦It also shows abundant callus formation with lack of blood supply showing no bridging bone.
2️⃣Septic non-union
♦This reduces blood flow from the organisms consuming the nutrition to healthy bones.
♦ Decreasing the new bone formation.
3️⃣Atrophic non-union
♦Caused by inadequate immobilisation and inadequate blood supply showing an absence of callus.
4️⃣Oligotrophic non-union
♦This is a combination of both atrophic and hypertrophic showing an incomplete callus formation and inadequate reduction.
When you have one of these types, your doctor will be able to determine the degree of fracture to help develop a treatment plan.
▶️What are symptoms of a non-union fracture?
🟢You will feel continued pain at the site of a break even after the initial pain of the fracture has passed.
🟢It will feel difficult to mobilise on the affected side if it’s a leg.
🟢When you have had surgery, and the metal or hardware show any kind of failure or instability this may cause bone non-union.
🟢Swelling around the fracture site sometimes.
🟢Limb or joint deformity.
🟢Tenderness to touch.
▶️How do you know which type of fracture non-union you have?
Symptoms alone are not enough to determine it. You will have additional x-rays, and all information will be in your medical report.
Physical examination will be done by your doctor and focus will be on the tenderness or motion at the fracture site, deformity, status of the soft tissue, any signs of infection, and range of motion at joints adjacent to the fracture site.
Computed tomography (CT) scan may be undertaken to assess fracture union because it has been shown to be highly sensitive in the identification of unhealed fractures
Hak 2014:
For unexpected non-union laboratory evaluation is undertaken to assess for the presence of infection.
▶️Why do some people experience non-union fractures while others do not? causes.
When you have a non-union fracture, it means there could be multifactorial causes in play that explain it. It can sometimes be frustrating for you.
Here are some of the causes:
1️⃣Fracture severity: the more severe a fracture is, the more likely it is to become a non-union.
2️⃣Infection: sometimes your bone may be infected (osteomyelitis) which can make it very difficult to repair because the infection can impair bone development.
3️⃣Nutrition and hormone imbalance: some patients may have vitamin D deficiency or any other hormones not working improperly which are prerequisite in bone healing.
4️⃣Tobacco smoking status: smoking is seen to delay fracture union.
5️⃣You have diseases such as diabetes and kidney failure. Sometimes they hinder bone union.
6️⃣Some patients have immune-modulating agents or take long term medication such as steroids.
▶️Can bone fracture heal without a callus?
Ultimately, the callus becomes bone, which hardens and strengthens over time.
Bone can not heal on its own without the help of callus, during the reparative phase, a sift thick callus composed of fibrous and cartilage replaces the blood clot at the fracture site.
The callus holds the pieces of fractured bone together, as the bone continues to heal, the callus develops into a hard callus which is bone.
So, you really need all the processes of bone healing to fully recover.
▶️How is a non-union fracture treated?
Some non-union fractures can be treated nonsurgical, your doctor may suggest immobilizing the non-union with a splint, cast or brace for a certain period.
In addition to mobilising, you may be given an external bone stimulator to apply to the skin overlying the non-union. This helps to send pulsed electromagnetic waves that can stimulate healing.
If you bone is infected:
Treatment may involve surgery to remove the infection, this will allow the stimulation of bone growth with bone graft.
Or infection may be treated with antibiotics only and waiting a little longer to see the outcome of the treatment.
Surgical option
The main treatment is re-fixation of the non-union fracture. The fracture site will be reopened, and re-adjustments will be done (De Boeck et al 1995)
X-ray images showing a clavicle non-union surgery was done to manage and reduce the risk of long-term morbidity.
You may be given a local bone-marrow injection which contains potentially osteogenic stem cells that can be injected in the site of non-union or delayed consolidation to induce osteogenesis and thus a uniting callus (Tall 2018)
▶️Can you walk on a non-union fracture?
Often, the bone isn’t strong enough to bear full weight on, and you may not be able to use the affected body part fully until the bone heals.
However, having a non-union fracture does not mean that you can not do anything at all with the injured part of your body.
Always discuss with your doctor, surgeon or physiotherapy about the things that may be possible or not.
🔵You can try walking with support of crutches or with partial support.
🔵Ask your doctor on different ways you can use your lower limb.
🔵Ask your doctor when to resume certain activities.
▶️Is physical therapy useful?
There is no physical therapy treatment that directly can stimulate bone healing.
Some studies recommend:
Ultrasound therapy.
Ultrasound may have a therapeutic role in reducing the time to union after fracture by stimulating osteoblasts and other bone-forming proteins (Searle et al 2023)
Due to few studies, it is uncertain of the effectiveness of ultrasound and shock wave therapy for acute fractures in terms of patient feedback on the outcome measures.
🟢 Massage
Is known to help relieve pain, not much evidence how it helps with non-union fractures.
🟢Shockwaves therapy.
Some people use a durable medical equipment device called a Bone Growth Stimulator .It is believed that it sends more energy to the healing bone surface through either pulsed electromagnetic or ultrasound waves, which helps the bone heal more quickly.
All these and more can help the callus to form faster or to better speed up the healing process. But always consult your doctor for better options in your case.
However physical therapy is known to be useful for:
🟨Relieving your pain.
🟨Maintaining your mobility.
🟨Maintaining your general physical fitness.
🟨Healing better copying with any potentially stressful period during.
From a theoretical point of view, without putting too much stress on the affected limb, being active and mobilisation will also improve blood flow to the injured area.
This will promote healing and reduce non-union issues.
▶️Is a non-union fracture a disability?
Non-union fractures cause prolonged pain and disability that can have a significant impact on quality of life.
But bone fractures and broken bones normally heal in a matter of a couple of months. Therefore, it can be difficult to get social security disability benefits for bone fractures.
To qualify for Social Security Disability benefits or any other benefits you must have a medical condition that prevents you from working for at least one year or less in some countries.
Here in the United Kingdom, a non-union fracture does not automatically qualify as a disability or make you eligible for disability-related financial support.
But you may be able to get financial help if your broken bones make it hard for you to do everyday tasks or get around.
We have come to the end of this article; any questions let’s meet in the comments section.
Wishing you a quick recovery!🙋
Below are some of the articles I have relied upon.
📚Sources
Megas P. Classification of non-union. Injury. 2005 Nov;36 Suppl 4:S30-7. doi: 10.1016/j.injury.2005.10.008. Erratum in: Injury. 2006 Sep;37(9):927. Panagiotis, Megas [corrected to Megas, Panagiotis]. PMID: 16291321.
Hak DJ, Fitzpatrick D, Bishop JA, Marsh JL, Tilp S, Schnettler R, Simpson H, Alt V. Delayed union and nonunions: epidemiology, clinical issues, and financial aspects. Injury. 2014 Jun;45 Suppl 2:S3-7. doi: 10.1016/j.injury.2014.04.002. PMID: 24857025.
De Boeck H, Yde P, Opdecam P. Non-union of a sacral fracture treated by bone graft and internal fixation. Injury. 1995 Jan;26(1):65-6. doi: 10.1016/0020-1383(95)90559-g. PMID: 7868218.
Tall M. Treatment of aseptic tibial shaft non-union without bone defect. Orthop Traumatol Surg Res. 2018 Feb;104(1S):S63-S69. doi: 10.1016/j.otsr.2017.05.028. Epub 2017 Nov 26. PMID: 29183822.
Mills LA, Aitken SA, Simpson AHRW. The risk of non-union per fracture: current myths and revised figures from a population of over 4 million adults. Acta Orthop. 2017 Aug;88(4):434-439. doi: 10.1080/17453674.2017.1321351. Epub 2017 May 16. PMID: 28508682; PMCID: PMC5499337.
Thomas JD, Kehoe JL. Bone Nonunion. [Updated 2023 Mar 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan.
Hak DJ, Fitzpatrick D, Bishop JA, Marsh JL, Tilp S, Schnettler R, Simpson H, Alt V. Delayed union and nonunions: epidemiology, clinical issues, and financial aspects. Injury. 2014 Jun;45 Suppl 2:S3-7. doi: 10.1016/j.injury.2014.04.002. PMID: 24857025.
Searle HKC, Lewis SR, Coyle C, Welch M, Griffin XL. Ultrasound and shockwave therapy for acute fractures in adults. Cochrane Database Syst Rev. 2023 Mar 3;3(3):CD008579. doi: 10.1002/14651858.CD008579.pub4. PMID: 36866917; PMCID: PMC9983300.
Lawson J, Crockett S, Griffiths D, Riga C, Sabharwal S, Thomas R, Das R. Ruptured subclavian artery pseudoaneurysm following a shoulder massage on a background of clavicle non-union. BMJ Case Rep. 2023 Jul 4;16(7):e253826. doi: 10.1136/bcr-2022-253826. PMID: 37402587; PMCID: PMC10335590.