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Joey Wahler (Host): We've all heard the term fracture, but did you know that a broken bone can fail to heal properly due to a non-union or malunion fracture? So we're discussing the difference between those two and how they're treated. This is McLaren's In Good Health, a podcast from McLaren Health. Thanks for listening. I'm Joey Wahler. Our guest, Dr. Trevor Crean, Orthopedic and Trauma Surgeon at McLaren Health. Dr. Crean, thanks for joining us.

Trevor Crean, DO (Guest): Thanks. I appreciate you guys having me on.

Host: Same here. So first, what are the most frequently broken bones. And how common is it for a fracture to not properly heal?

Dr. Crean: Not very common. Most fractures, especially when they're treated acutely, and taken care of by the orthopedic surgeon, most fractures heal routinely. However, in a small subset of patients, there is something called a non-union, or a malunion. Non-union, means that the fracture, for a various number of reasons, didn't heal. And malunion, means that the fracture may have healed, but healed, in a poor position or a nonfunctional position. This can happen with any bone, any fracture. Some of the more common non-union fractures are seen in the distal femur region, as well as the ankle region. But any bone, could potentially develop a non-union where, it doesn't heal.

Host: And so since these terms are new to many, what's basically the difference between non-union and malunion fracture?

Dr. Crean: Sure. That's a great question. Non-union means that the fracture hasn't healed fully. And malunion, just means that the fracture has successfully healed, but in less than optimal position or poor position. This might mean that the overall alignment of the bone after the fracture has changed and this can be to varying degrees all the way from not totally noticeable for the patient in their daily life, all the way to having significant impacts on their ability to ambulate, their ability to move, and do the things that they enjoy doing on a daily basis.

Host: And so that's what I was going to ask you next symptom wise, how would someone know if they have a nonunion or malunion fracture?

Dr. Crean: I would say that the major thing would be pain. Typically as fractures heal, they get more solid. I often in my clinic, attribute it to trying to glue two pieces of wood together. And as that glue sets up and gets hard, the ability for there to be any motion at the fracture site itself, goes down. As that motion goes away at the fracture site, that's what reduces the pain. And, in terms of having a successful fracture healed your pain goes away and you're able to move around once that motion at the fracture site goes away. In the setting of a non-union, that motion never fully goes away because the fracture doesn't get solid enough to be able to move. And so the patient would experience increased pain, which would therefore limit their ability to walk or to move effectively without having significant pain.

Host: And so when there's a lack of proper healing in either of those cases, is it usually because of the way the injury occurred or maybe genetics? Are some people just more prone to this type thing? Or maybe a combination? What's the, what's the root of it usually?

Dr. Crean: Definitely a combination. There's three, really main causes of non-unions in particular. And I can kind of touch on some of major differences. I would say, one common reason that we see nonunions happen with fractures is due to infection. Either if the injury was an open injury where the bone was exposed to the open environment, or if the patient has other chronic infection already, perhaps in the setting of a fracture. But an infection that gets to the fracture site itself, would inhibit the fracture from healing. And usually that's our first check to see if there is any type of infection either obvious infection or maybe even a subtle infection when we're dealing with non-union cases. If that's the case, then treating the infection usually means that you can get the fracture to heal successfully. But usually that's kind of the first check.

The second check, is usually a biologic issue of some sort. In patients, for example, that have osteoporosis or patients that have diabetes that is maybe poorly controlled, those types of things inhibit bone healing. Another example would be patients that are heavy smokers. All of those types of things can inhibit bone healing and cause either delayed union of fractures or non-union of fractures. So that would be the second check is rule out infection and then try to modify those risk factors. You know, in the setting of a smoker, talking about smoking cessation. In the setting of an uncontrolled diabetic, if we can somehow get their blood sugars more under control while their healing process is going on, a lot of times that can help heal a fracture when dealing with a non-union scenario.

And then I would say the third is more kind of on my end of things, on the surgeon's end of things. If you're, for example, if you're trying to treat a fracture non-operatively and there are certainly quite a few fractures that we can treat non-operatively, but if you're watching a fracture that you're treating non-operatively and it's not healing, perhaps that's an indication to go in to perform a surgery to try to increase the stability at that fracture site. A lot of times what happens is if the fracture isn't stable enough, the body isn't allowed a chance to heal it itself. Kind of going back to that kind of analogy that I use about gluing two pieces of wood together.

If you're not holding those two pieces of wood still, while that glue is setting up, it doesn't ever have a chance get hard and glue those two pieces of wood together. So it's very similarly fracture care if there's too much motion or not enough stability at the fracture site itself, sometimes that can lead to a non-union as well.

So in the setting of non-operative fracture care, the treatment might be going in and using a plate and screws or some sort of device to hold the fracture stable. And also in the case of a fracture that has been treated surgically, being really critical of the construct that you used to hold the fracture together and possibly going back in and revising that to increase the stability at the fracture site is something that you have to look at as well.

So, I know that's a long-winded answer and a little bit complicated, but there are really multiple factors that play into the possibility of developing a non-union and looking at kind of those three factors are a starting point for any orthopedic surgeon trying to treat it.

Host: Well, you actually answered both my question and the one I was going to ask next about how nonunion and malunion fractures are treated. Having said that, when a fracture needs corrective surgery, what's usually the expected recovery time and resume an active lifestyle?

Dr. Crean: It definitely can depend on a multitude of things. You have to take into account the patient's overall health. If they're are otherwise a young, active, healthy patient, you can expect them to recover a little bit quicker than somebody that may due to other medical comorbidities, such as COPD or hypertension, peripheral vascular disease; those are things that might make the recovery process a little bit more lengthy. I would say, my goal for any patient is to get them back to their pre-injury level of function. So if that means that they were playing sports and running and very active, then my goal is to get them back to as close to that active lifestyle as possible.

Now you have to be realistic. And if a patient maybe uses a walker, and only really ambulates around their home at baseline, then it's not realistic to get them back to maybe walking without a walker and jogging and doing things like that. But my goal is to get them back to at least that pre-injury level of function.

I would say that treating the non-union as if it's a fresh fracture and starting over is typically my way to view it. Typically a fracture heals in about six to eight weeks. But again, kind of touching back, if a patient is a smoker or a diabetic, that six to eight weeks typically turns into more like eight to 10 or eight to 12 weeks, just because that fracture healing process is a little bit slower.

Host: Understood. So if untreated though, Doctor, what other complications can fractures cause?

Dr. Crean: I think the biggest thing is just the inability to ambulate effectively. A fracture in and of itself, isn't a life-threatening issue in most cases. Of course, with anything, there are exceptions to that rule. But the reason that we treat fractures and want in some cases, to do surgery to fix fractures, are to allow patients to get back to moving, get back to ambulating, and get back to being as relatively pain-free as possible.

The risks of not treating fractures would most likely be all of the secondary and downstream effects that immobility and inactivity can lead to. Often, we're trying to fix fractures in order to allow patients to get up and ambulate and mobilize to prevent things like pneumonia or blood clots or things that are associated with being bedridden and bedbound that could potentially cause more life threatening injuries or life altering injuries to patient.

Host: And so to sum things up here, is there anything patients can do themselves to prevent these types of fractures from recurring?

Dr. Crean: It's preventative measures, I think are really the things that we try to focus on. Leading a healthy, active lifestyle, not smoking, if you're a diabetic, controlling your blood sugars, all of these things that you can try to optimize throughout your life before you sustain a fracture, I think has been before.

Obviously, nobody really chooses when they sustain fractures, unfortunately, but I think if you can optimize yourself beforehand, you have much better results afterwards. And the same is true once you sustain a fracture. I think, trying to have a healthy diet. Trying to limit your smoking or quit smoking if you're a smoker, making sure you're controlling your blood sugars, are all things that help fractures heal. Now, I, I do think that there are conversations that need to be had with the patient's primary care physician, in order to help optimize these things as well.

Host: Sure. Well folks, we trust you now have a better understanding of the difference between nonunion and malunion fractures and how they're addressed. Dr. Trevor Crean, thanks so much again.

Dr. Crean: Thank you so much having me. I appreciate it.

Host: Same here. And for more information, please visit mclaren.org/crean. That's M-C-L-A-R-E-N.org forward slash C-R-E-A-N. And folks, if you found this podcast helpful, please share it on your social media. And thanks again for listening to McLaren's In Good Health, a podcast from McLaren Health. Hoping your health is good health. I'm Joey Wahler,