Malunion or nonunion of a fracture

Disease Description (Causes and Symptoms)

• Definition
  • Malunion: A condition in which the fracture has united, but alignment (length, angulation, or rotation) has healed abnormally.
  • Nonunion: A condition in which fracture healing does not progress, with no radiographic signs of healing even after a certain period (clinically usually around 6 months) and persistent functional problems and pain.
• Summary of pathophysiology
  • Mechanical factors: Persistent micromotion due to insufficient reduction (alignment) or unstable fixation, resulting in failure of bone union.
  • Biological factors: Insufficient blood flow, severe tissue damage, infection, bone defect (insufficient bone fragments needed for union), and patient factors (age, malnutrition, smoking, diabetes, etc.).
  • Types of nonunion: When blood flow is good, hypertrophic nonunion (so-called hypertrophic nonunion, with abundant callus) — improvement of mechanical stability is needed. When blood flow is poor, atrophic nonunion — biological augmentation (such as bone grafting) is needed.
• Main symptoms
  • Pain (especially with weight-bearing or movement), persistent swelling and redness (in cases of infection), instability or abnormal mobility of the affected area (pseudarthrosis), deformity (shortening, angulation, or rotation), and functional impairment.

Treatment Methods

• Basic diagnosis
  • Clinical examination (pain, abnormal movement, deformity), imaging studies (X-ray as the basic examination; CT when necessary to accurately assess alignment and bone defects), and, when infection is suspected, blood tests (CRP, ESR, blood culture) and tissue culture.
• Nonsurgical treatment
  • Conservative immobilization (cast or brace) — for some early nonunions or to relieve symptoms after stabilization.
  • Adjunctive therapies: Electrical stimulation (pulsed electromagnetic field) and low-intensity pulsed ultrasound (LIPUS) — selected according to the case and location (evidence and indications vary).
  • Pain control (analgesics) and antibiotics in cases of infection (based on culture results).
  • Lifestyle measures: Smoking cessation, nutritional improvement (protein, vitamin D, calcium, etc.), and control of diabetes and infection.
• Surgical treatment
  • Malunion: Correction of the deformity with corrective osteotomy, followed by internal fixation (such as a plate or nail) or external fixation.
  • Nonunion (treatment strategy depends on whether the cause is mechanical or biological)
    • When mechanical instability is the cause: More rigid internal fixation (bone plate and screws; open fixation or intramedullary nailing for the tibia or femur), or external fixation (especially in cases of infection or bone defect, such as the Ilizarov method).
    • When biological deficiency is the cause: Debridement followed by autologous bone grafting (iliac cancellous graft), vascularized bone grafting (vascularized fibular graft), etc. Allografts and bone graft substitutes may also be used.
    • Infectious nonunion: Removal of infection (debridement), repeated drainage and antibiotics, followed by reconstruction when necessary after using external fixation.
    • When there is a large bone defect: Bone transport (Ilizarov method), free vascularized bone grafting, etc.
  • Postoperative care: The duration of fixation and weight-bearing restrictions vary depending on the surgical method and location (generally several weeks to several months). Rehabilitation (joint range-of-motion exercises and muscle strengthening) is essential.
• Medications
  • Pain control: Acetaminophen; NSAIDs or opioids when necessary (short-term). (Because NSAIDs may affect bone union, consult the treating physician.)
  • In cases of infection: Antibiotic treatment according to culture results (oral or injectable).
• Precautions, complications, and self-care
  • Smoking cessation is recommended (to promote bone union), along with blood glucose control and nutritional supplementation.
  • Surgical complications: Infection, nerve or blood vessel injury, recurrent nonunion, and complications at the graft site.
  • Long-term complications: Reduced joint function, gait disturbance and arthritis due to bone deformity, and chronic pain.
• Prognosis
  • The prognosis varies depending on the cause (mechanical versus biological), location, and the patient’s health status. Union is possible in many cases with appropriate surgery and rehabilitation, but complete recovery may take several months to more than a year.

Checklist Before an Outpatient Visit (Including Items to Bring and Example Questions)

• Items to bring and preparations
  • A list of all medications currently being taken (including prescription drugs, over-the-counter drugs, and herbal medicines)
  • Films/images or a CD of previously performed imaging studies (including initial fracture images), along with test results (surgical and hospitalization records, if available)
  • A record of when symptoms began and how they have progressed (changes in pain and symptoms during weight-bearing), as well as recent triggers (such as reinjury)
  • Past medical history (diabetes, smoking, alcohol use, immunosuppression, and surgical history) and history of allergies
  • Whether weight-bearing is possible and any limitations in daily activities
• Information to tell the doctor in advance during the outpatient visit
  • Recent fever, wound discharge, or redness of the wound (important when infection is suspected)
  • Smoking status and willingness to quit smoking
  • Joint restriction or neurological symptoms (numbness or paralysis)
• Items useful for patients to observe, record, and bring before the consultation
  • Pain severity (at rest and during activity), and the location and nature of the pain
  • Whether deformity is present (such as outward angulation, inward angulation, or shortening), with photographs attached

Examples of General Questions to Ask the Doctor

• Is this condition a malunion or a nonunion, and what is the basis for the diagnosis (radiographic and clinical findings)?
• Is nonsurgical treatment possible in my case? If surgery is needed, which method do you recommend?
• What complications can be expected with surgery, and approximately how long will recovery take?
• Do my current medications (especially anticoagulants, NSAIDs, etc.) affect treatment?
• What specific measures can I take in daily life to help bone union?

Examples of Condition-Specific Questions

• Is this nonunion hypertrophic (mechanical instability) or atrophic (biological deficiency)? How does this affect the choice of treatment?
• If there are signs of infection, what tests will be performed first (blood tests, cultures, tissue tests, etc.)? If an infection is confirmed, how will the surgical plan change?

(If additional imaging or test results are provided when necessary, more specific and personalized consultation and treatment planning can be provided.)