Most broken bones heal without any problems. After initial treatment at our Cambridge clinic, usually new bone tissue forms and connects the broken bone pieces together. However, in some patients some broken bones do not heal despite medical treatment. A non-union fracture, also known as a non-healing fracture, occurs when a broken or fractured bone does not heal in the expected period of time.

The expected healing time for each bone can vary - for example, the forearm bones are expected to fully heal in 3-4 months, whereas the thigh bone can take anywhere from 6-12 months. In general, we consider the possibility of a non-union fracture if there is no sign of healing around 6-9 months after the fracture occurs.

There are a number of different causes as to why a fracture may not heal correctly. It is important for your surgeon to consider these, as correcting this will be vital in determining the proper treatment. Causes for non-healing or non-union fracture include:

• Infection at the site of the fracture
• Inadequate blood supply to the bone
• Separation of the ends of the bone (during surgery or after surgery)
• Inadequate surgical stabilization of the bone

While non-unions can occur in any bone, the most common bones in which non-union fractures can occur are the tibia, humerus, talus, and fifth metatarsal bone.

Most patients will report the following symptoms in a non-union fracture:

• Swelling
• Pain
• Tenderness
• Instability
• Limb or joint Deformity
• Difficulty bearing weight

There are generally 3 types of non-union fractures observed:

1. Hypertrophic: caused by a lack of stability in the fixation used.
2. Atrophic: caused by inadequate immobilization and inadequate blood supply
3. Eutrophic: caused by a combination of factors.
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Hypertrophic non-union fractures:

Non-union fractures classified as hypertrophic are a result of instability of the fixation or metalwork used to fix a fracture. On x-rays we can see a significant lump of new bone formation with a tiny line running where the previous fracture was. What we need to achieve is additional stability of the non-union and the fracture will unite in a relatively short period of time. This can be achieved by adding additional screws to the fixation of exchanging the metalwork to achieve better compression on the non-union site. Success rate for this type of non-union is usually very high.

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‍Eutrophic non-union fractures:

Non-union fractures classified as eutrophic are usually caused by multiple factors like fracture instability, lack of blood supply to the bone ends, inadequate fixation or low grade infection which does not present itself clinically.

If patients with eutrophic non-union classifications require surgery, they will be advised not to take any antibiotics at least two weeks prior to the surgery to improve the chances of identifying any potential infection. During the surgery itself we would remove all the existing metalwork and take microbiology tissue samples which can be investigated in the lab to look for potential infections. In the majority of the cases our non-union fracture specialist would proceed with the refixation after all the metalwork has been removed.  The refixation will include insertion of poller screws (2-4 screws in different planes), reaming the canal and fixation with a rod. Throughout the procedure we use intraoperative X-ray to monitor the progress and position of the metalwork inserted. Depending on the type of fixation achieved you will be advised whether you can weight bear or not post operatively. Unless there will be a high risk of infection you won’t be given any antibiotics post operatively.

If the tissue samples taken during the surgery show any sign of infection (usually takes 7-10 days for the lab to process the samples) you will be advised which antibiotics to take. The duration of antibiotic treatment post surgery is usually around 6 weeks.

Atrophic non-union fractures:

Atrophic non-union classifications occur when the bone ends have a very limited or nonexistent blood supply or parts of the bone  are missing. There is almost certainly infection present. X-ray and CT scans will usually show significant instability of the metalwork with bone defects. In patients with atrophic non-union fractures, we have to be aggressive in treatment otherwise the condition can get worse and it can become more difficult to treat.

As part of your visit to our Cambridge clinic, you will undergo the following in order to diagnose a non-union fracture:

• Physical examination
• Medical history taking
• X-rays
• ± Computed tomography (CT) scan
  

The X-ray in particular is useful in helping us to diagnose a non-union fracture and provide the right support. We will be analysing the x-ray to look for any signs of union, bone instability, broken metalwork and lucency around the metalwork.

Treatment may involve surgery to remove the infection, to better stabilize the fracture, or to stimulate bone growth with bone graft. The main treatment is re-fixation of the non-union fracture. This can be done either by using the method of fixation as before, although most surgeons agree that it is worth considering changing the method of fixation. For the fixation method, any surgical fixation technique can be used (intramedullary nail, plate and screws, fine wire frames (TSF, Ilizarov)).

During your consultation with non-healing fracture specialist Mr Matija Krkovic, you will be explained in detail what the surgery will involve and which method in particular has been chosen to treat your non-union fracture and which type of ongoing support you will need.

Each person we treat at our London and Cambridge clinics have varying recovery periods, based on how well their body can heal. Mr Krkovic will carry out x-rays after the surgery to assess how well the fracture is healing which will determine the length of recovery period and required support.

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