A malunion occurs when a fractured bone heals in a position that is misaligned, shortened, twisted, or bent. This incorrect healing can happen if the bone fragments were not adequately stabilized after the initial injury or if the fracture was complex. For many minor or specific malunions, non-surgical management is a valid and often preferred approach.
Understanding Malunion Severity
The severity of a malunion is generally classified by two interconnected factors: the degree of anatomical deformity and the resulting functional impairment. Anatomical misalignment refers to the measurable error in the healed bone, such as angulation (bending), rotation (twisting), or shortening compared to the uninjured limb. These deformities are precisely measured using imaging techniques like X-rays and CT scans to determine the extent of the error.
Functional impairment describes how the physical deformity affects the patient’s ability to use the limb, including pain, limping, limited range of motion, or muscle weakness. A minor malunion may show some anatomical error but cause minimal or no lasting functional deficit or pain. Conversely, a severe malunion often leads to significant functional limitations and may cause premature arthritis in adjacent joints due to uneven load distribution, making intervention more likely.
Criteria for Non-Surgical Management
A physician will typically opt for non-surgical management only when the malunion is considered functional and the risks of surgery outweigh the benefits of correction. The patient’s age and skeletal maturity are key factors. Children possess a remarkable capacity for bony remodeling, meaning their growing bones can gradually correct angulation over time, especially near the growth plates. This potential for natural correction decreases significantly as a child approaches skeletal maturity and is almost non-existent in adults.
The location and type of bone play a role, as small or non-weight-bearing bones may tolerate more misalignment than major weight-bearing bones like the femur or tibia. If the malunion is anatomically noticeable but the patient reports minimal or no pain and maintains good functional use of the limb, a conservative approach is often chosen. A patient’s overall health and co-morbidities, such as advanced age or severe heart disease, may make them too frail to safely undergo definitive corrective surgery. In these situations, the non-surgical approach focuses on managing the consequences rather than attempting to physically correct the established bony alignment.
Conservative Treatment Modalities
When a conservative management plan is selected, the goal is to alleviate symptoms and compensate for the deformity, as non-surgical methods cannot physically realign a fully healed bone. For minor, non-progressive cases that are not causing immediate functional issues, a period of observation, or “watchful waiting,” may be recommended. This strategy allows the physician to monitor for potential long-term complications, such as progressive joint wear, before deciding on further action.
Physical therapy and occupational therapy focus on improving the mobility of adjacent joints and strengthening the muscles surrounding the malunited bone. Targeted exercises help maximize the limb’s functional capacity and can sometimes offset the biomechanical disadvantages caused by the misalignment. Pain management often involves over-the-counter or prescription non-steroidal anti-inflammatory drugs (NSAIDs) to control localized discomfort and swelling.
For cases involving limb length discrepancies or angular deformities that affect walking, orthotics and bracing can provide support and compensation. A shoe insert or shoe lift, for example, can be used to equalize leg length, reducing strain on the back and hips caused by a shortened limb. Braces can help stabilize a limb or improve gait mechanics by supporting the limb and compensating for an angular deformity. If the functional deficits or pain become severe and cannot be controlled by these methods, a surgical procedure called an osteotomy remains the definitive treatment for correction.