Malunion

A malunion occurs when a fractured bone heals in an abnormal position. Depending on the
severity, additional malunion symptoms can include:
Reduced functioning in the affected area
Discomfort
Pain
Swelling
Bruising
Cases of malunion do not always require treatment because some will not cause impaired
functioning. But if the altered bone positioning is significant and damaging, it often requires
surgical treatments to allow for future mobility.

Surgical Treatment Options for a Malunion

Surgical procedures can help realign severe cases of malunion. An orthopaedic surgical
procedure called an osteotomy is commonly used to restore the appropriate alignment of
bones that have not healed properly. Surgeons can perform the techniques below in an
osteotomy to correct a malunion:
Shortening
Lengthening
Realignment

Nonunion
A nonunion occurs when a fractured bone fails to heal after an extendedrecovery period. In
some cases a bone may require up to nine months to completely heel. If your doctor or
surgeon does not see any signs of progressive healing over this extended period of time, you
may have a nonunion. In these cases, the body does not produce the necessary bone tissue to
repair the broken bone. Depending on the severity of the nonunion, symptoms also can
include:
Reduced functioning in the affected area
Discomfort
Pain
Swelling
Bruising
Non-surgical treatment options for nonunions may include electric stimulation or bracing.

Surgical Treatments Options for a Nonunion

To repair a nonunion, orthopaedic surgeons may aim to:
Restore damaged bones and tissues around the nonunion.
Fill bone gaps with plates and stabilize the bone.
Stimulate bone healing using bone-grafts.

A malunion is a broken (fractured) bone that has healed in an unacceptable position that causes
significant impairment or loss of function. A nonunion is a fracture that has failed to heal.
Delayed union is when a fracture takes longer than usual to heal (or a nonunion that finally
heals). Failure is arbitrarily set at 6 months or longer without radiographic signs of progression
toward healing for 3 months.
In malunion, the bone may have healed at a bent angle (angulated), may be rotated out of
position, or the fractured ends may be overlapped causing bone shortening.
There are four types of nonunions: hypervascular or hypertrophic nonunion, oligotrophic
nonunion, avascular or atrophic nonunion, and synovial pseudarthrosis. Hypervascular or
hypertrophic nonunions are subdivided into elephant foot (rich in callus), and horse foot
(mildly hypertrophic, with less abundant callus). In oligotrophic nonunions there is no callus,
but bone scan reveals vascularity. Avascular or atrophic nonunions (scar tissue with no
osteogenic potential) are subdivided into torsion wedge (with an intermediate fragment),
comminuted (with one or more necrotic intermediate fragments), and defect (with loss of a
fragment). Finally, in synovial pseudarthrosis there is nonunion with a fluid-filled cavity, with
formation of a synovial-like membrane and pseudocapsule.
The severity of the injury is a strong factor in the healing process.

Incidence and Prevalence: More than 6% of fractures of the collar bone (clavicle) that are
treated nonoperatively result in a nonunion (Robinson).

Nonunions occur in 1.1% of shoulder joint fractures of the proximal humerus, although if there
is slippage of the bone ends while healing, prevalence may reach 33% to 100% (Court-Brown).
Scaphoid fractures are a common wrist fracture resulting in nonunion in 10% to 15% of
individuals (Boles). Fractures of the fingers (phalanges) that undergo surgical correction
proceed to malunion in 9% of individuals and to nonunion in 6% (Van Oosterom).
Following surgery for displaced hip fractures of the femoral neck that require open reduction
with internal fixation (ORIF) to repair, more than 10% of individuals will develop a nonunion
(Stannard).
Nearly 8% of shin bone (tibia) shaft fractures heal with a malunion that results in limb
deformity (Milner), and between 2% and 10% of tibial fractures result in nonunion (Patel).
These numbers are decreasing with improved surgical techniques such as intermedullary
nailing.
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Certain lifestyle and health factors may interfere with bone healing. These include smoking,
excessive alcohol use, poor nutritional status, poor general health, fitness deficits, and
diabetes. Other factors contribute to loss of bone strength and make healing more difficult.
These include use of nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroid drugs,
and other drugs such as anticonvulsants and thyroid hormone (thyroxine) replacement.
Individuals of European or Asian ancestry who have increased risk for osteoporosis and
elderly individuals are at increased risk for poor bone healing. Women who have experienced
early menopause, late menarche, or the loss of their ovaries, also are at increased risk for
bone weakness.

Certain types of fractures are associated with a high risk of nonunion, such as fractures of the
wrist (carpus), including scaphoid bone fractures; certain fractures of the foot, including
navicular fractures and Jones (diaphyseal) fractures of the fifth metatarsal; shoulder long
bone fractures (proximal humerus fractures); and some tibial fractures. Individuals who have
had a severe traumatic fracture, large displacement between fracture fragments, and fractures
where the bone was broken into many pieces (comminuted fracture) are at an increased risk
of nonunion. Open or compound fractures also are at risk of malunion or nonunion.

Nonunion has several causes. The broken ends of bone may be separated too much
(overdistraction), which can occur if excess traction was applied. There could have been
excessive motion at the fracture site, either from inadequate immobilization after the injury or
from having a cast removed prematurely. Muscle or other tissue caught between the fracture
fragments also can prevent healing, as can the presence of infection or inadequate blood
supply to the fracture site. Bone disease (e.g., bone cancer) also can prevent healing.
Malunion may be caused by inadequate immobilization of the fracture, misalignment at the
time of immobilization, premature removal of the cast or other immobilizer, or loss of bone at
the time of injury.

A condition called compartment syndrome can occur when severe trauma leads to such a
degree of swelling that the blood supply is compromised. The result is muscle death around
the fracture site and inadequate bone repair.

History: There is a history of trauma or injury that resulted in a fracture that may or may not
have been treated by a physician. The individual may report pain, swelling (edema),
deformity, instability, or functional loss (decreased range of motion) at the site of a
previously broken bone. If the fracture was in a lower extremity, the individual may report
difficulty bearing weight through the limb.
Physical exam: The exam reveals the deformity of a malunion or the instability of a
nonunion. In a malunion, the bone is solid so bone pain is usually absent, but pain due to
nonanatomic alignment may be present. Pressure over the fracture area may reveal
tenderness for a nonunion.
Tests: Plain x-rays often demonstrate the fracture malunion or nonunion. Computed
tomography (CT) scan, magnetic resonance imaging (MRI), or bone scan may help further
define the condition.

Treatment
Most malunions and nonunions require open surgery to realign the fracture fragments into
their normal anatomical position (open reduction) and stabilize the fracture by use of metal
plates, rods, screws, and/or wires (internal fixation).
Malunion is treated by surgically cutting the bone (osteotomy) to break the malunion,
followed by bone stabilization which is frequently done by open reduction and internal
fixation (ORIF). Infection requires surgical removal of any infected bone or tissue
(dbridement), followed by intensive antibiotic treatment.
Treatment of nonunion, especially in the long bones of the body, may be complemented with
a synthetic bone graft or one that is obtained from the individual (autograft, autogenous
graft), from another individual (allograft, homogeneous graft), or from an animal (xenograft,
heterogeneous graft); bone graft material is placed in the surgical site to stimulate fracture
healing, and is usually successful.
Some cases, whether treated surgically or with noninvasive techniques (closed reduction),
benefit from the use of electrical, electromagnetic, or ultrasonic stimulation to promote
fracture healing and bone growth. Electrical stimulation may be administered by a self-
contained device surgically implanted internally at the fracture site or by multiple electrodes
placed over the skin near the fracture site. The effectiveness of electrical stimulation is
frequently debated. Electrical and electromagnetic bone growth stimulators continue to
evolve and are especially advantageous in management of infected nonunions and in
situations where surgery is not advisable. In some studies of fractures of the radius, lateral
malleolus, and tibia, low-intensity pulsed ultrasound treatments administered through the
skin adjacent to the fracture site have been shown to speed healing (Mundi). Low-frequency
ultrasound therapy may decrease fracture healing time in lower extremity nonunions by as
much as two months (Patel).
Newer approaches are using recombinant bone morphogenic protein and bone marrow
aspirates. Bone marrow injection into the site of nonunion may resolve the nonunion without
need for further surgery (Patel). Bone marrow may be harvested from the individual's hip
bone (iliac crest) and injected directly into the fracture site guided by external imaging
(fluoroscopy). Treatment of pseudarthrosis involves removal (resection) of the false joint
tissue before placement of the bone graft. Treatment of delayed unions and nonunions may
also include functional bracing of the fracture site.
Malunion may be left untreated if it causes little or no functional deficit. For example,
clavicle fractures may be allowed to heal in an imperfect but acceptable alignment
("bayonet" apposition) without resulting functional loss. Similarly, mild angulation of a
humerus fracture does not impair use of the upper extremity. Likewise, in some instances
(e.g., some fractures of scaphoid), nonunion causes only slight problems, and the condition
is left untreated.

Prognosis
Treatment of malunion by ORIF usually has a good outcome. Osteotomy can reduce
deformity and relieve functional impairment, but this places the bone at risk of fracture.
Minor degrees of malunion are common and may not have a significant effect on function or
appearance.
A malunion can result in a functional impairment with limited mobility. Any malunion can
put increased stress on other joints causing pain and/or accelerated wear. Major degrees of
malunion can cause impairment in function and significant deformity and can lead to
degenerative arthritis. Malunion in a finger can interfere with the use of other fingers. Nerve
damage can occur, especially with an elbow fracture. A malunion in a leg can result in an
abnormal gait.
A nonunion may be painless, but the fracture will be unstable and the bone less strong.
Nonunions in a lower extremity may result in reliance upon assistive devices (e.g., crutches,
wheelchairs) for mobility.

Ability to Work (Return to Work Considerations)

The restrictions and accommodations are determined by the specific fracture, the severity of
the malunion or nonunion, and job requirements. See specific fracture topics for more
information. If surgical correction is necessary, work duties may need to be modified
temporarily to avoid use of the affected limb. Company policy on medication usage should
be reviewed to determine if pain medication use is compatible with job safety and function.
Risk: Risk is dependent on the cause of the malunion or nonunion.
Capacity: Capacity is determined by the location and bone involved and the degree of
involvement.
Tolerance: Tolerance is affected by pain which is impacted by the capacity; this is
determined by the location and bone involved and the degree of involvement.

Accommodations: Employers able to accommodate physical demands are more likely to

have employees return to work sooner.

Maximum Medical Improvement

By definition, a nonunion is a fracture that has not healed by 180 days. Treatment for a
malunion or a nonunion is often surgery. Once the malunion is correct and stabilized or the
nonunion is bone grafted and stabilized, the bone must heal. Healing can often take 120 to
180 days after the surgery.