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Olympians to Weekend Warriors – Warning Signs for Non-healing Fractures

Broken Arm - to cropIf you’re like me and become an all-sport super fan during the Olympics, you will probably remember some of the iconic Olympic-related injuries that have occurred over the years. Kerry Strug summoning the strength  to stick her vault landing during the 1996 Atlanta Games despite a terrible ankle injury, and being carried to the medal stand by her coach. Great Britain’s top marathoner Paula Radcliffe’s foot injury forcing her to drop out of the 2004 Athens marathon with just 4 miles to go.  Manteo Mitchell’s cracked fibula during his leg of the USA men’s 4x400m relay at the 2012 London Games. The stakes are high, and so, too, is the risk of injuries, both during and leading up to the Olympic Games.

Following the 2008 Olympics in Beijing, a report published in the American Journal of Sports Medicine detailed 1,055 total injuries reported during these summer games. Ranging from ankle sprains and contusions to ruptured Achilles tendons and fractured feet, nearly 10 percent of the athletes followed in the study sustained some form of injury. While some of these traumatic events garnered media attention throughout the Games, others were recorded and treated without so much as a tweet.

What’s interesting is that for some athletes, there may never be another word uttered about their injury – unless, of course, it affects their ability or performance in another competition. These athletes are often treated, heal, and go on their way – much like any of us would after an injury. But what about those whose injuries do not heal correctly?

Professional athletes aside, according to the American Academy of Orthopaedic Surgeons (AAOS) an average of 6 million people in the United States will break a bone each year.

“Of those who fracture a bone, statistics show up to 20 percent will not heal properly,” said Samir Mehta, MD, chief of the division of Orthopaedic Trauma. “And more often than not, some of these nonunion or malunion fractures will go uncorrected.”

A malunion occurs when a fractured bone heals in an abnormal position, which can lead to impaired function of the bone or limb. Similarly, a nonunion is the result of a fractured bone failing to heal after an extended period of time – in some cases this could be 9 or even 12 months later.

But, Mehta explains that there are some things that folks can monitor and look out for to prevent nonunion or malunion fractures from going untreated for months and years on end.

“Patients who suspect their fracture has not healed after treatment or is not healing properly should look out for three things: pain at the site, deformity – the bone was straight and now it’s bent – and impaired use or function – leg or ankle still cannot support weight. These are some clear warning signs that something is not right,” he said.  

In the event that a nonunion or malunion injury is apparent as determined by a physician or surgeon, there are four main things the surgeon would need to check before completely treating a non/malunion fracture: infection, adequacy of blood supply, stability – which involves the way the fracture was stabilized (cast, brace, plates and screws, a rod) – and the patient’s own biology.

“These categories will determine the course of treatment for the specific injury. Before we can determine how to treat a non/malunion fracture, we must uncover why is hasn’t healed properly,” Mehta added.

While some of this may seem relatively clear, identifying whether there is an infection present or if the patient has the right levels of Vitamin D, calcium and other essentials nutrients to support healthy bones, checking whether the injury has a steady supply of blood and determining whether the hardware used in the initial repair is adequate, is bit more complicated—and invasive.

“Evaluating blood supply – a surgical step – means we open up the patient at the fracture site and drill into their bone to see if the area will start bleeding. If it does, then there is adequate flow, however if we come up dry, the next step will be to cut the bone little by little until we reach a point that is getting blood. From there, we would adjust treatment to make up for the bone loss and re-set the fracture,” Mehta said. “To check the hardware, we would use x-rays, potentially a CT scan, and some advanced imaging we have here at Penn called “digital tomography” to assess whether everything is installed properly. We look at whether plates and screws are in place and to see if there are too many or too little pieces of hardware used.” 

Interestingly, fractures that are repaired with too much hardware can also not heal properly, which may sound s little odd. One too many screws could throw it all off.

“Think about it: if you are trying to glue two piece of wood together and you load both sides up with a ton of glue, the pieces are going to slide away from each other and not lock in the right place. Conversely, if you don’t have enough glue, the pieces won’t stick long term.”

While this is a basic example, the concept can be applied to repairing fractures – too much hardware can result in the bone or limb not returning to full function because the hardware will overcompensate and bear the brunt of the pressure, and too little hardware can lead to misaligned bones and gaps at the fracture site.

And of course, Mehta cautioned “with any injury, it is always better to identify a problem sooner rather than later to avoid additional treatment and recovery time. Being in tune with your body and monitoring physical and visual cues in the treatment process are critical to proper treatment and healing.”


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