Trauma.

A non-union is a fracture that has not healed within the expected timeframe. The diagnosis is typically made between six and nine months from injury, when serial X-rays show no significant progress and the fracture line remains visible.

Causes & risk factors

• Initial fracture displacement or instability.
• Poor blood supply to the fracture site.
• Infection.
• Smoking — a major modifiable risk factor.
• Diabetes and other metabolic conditions.
• Certain medications, including some anti-inflammatories.

Symptoms

Persistent pain at the fracture site months after the injury, movement at the fracture, and an inability to bear full load.

Treatment

Non-union typically requires surgery — debridement of the non-healing tissue, stable fixation with plates, screws, or an intramedullary nail, and a bone graft (autograft or substitute) to stimulate healing. Underlying contributing factors — particularly smoking, infection, and metabolic conditions — must be addressed in parallel.

A mal-union is a fracture that has united, but in an incorrect position. The bone is healed; however the alignment, rotation, or length is altered.

Consequences

• Visible deformity.
• Limb length difference.
• Restricted joint motion (where the mal-union is close to a joint).
• Altered load distribution — accelerating wear of adjacent joints.

Treatment

Surgery is indicated when there is functional loss, deformity, or accelerating arthritis in an adjacent joint. A corrective osteotomy is performed — a precise bone cut that allows the alignment to be restored, then stabilised with plates and screws while healing proceeds. Mal-unions close to a joint may instead be managed with joint replacement when arthritis is the dominant problem.

Metalware — the plates, screws, intramedullary nails, and wires used to stabilise fractures — usually stays in place for life without causing problems. In some patients, however, the implant irritates surrounding soft tissue, becomes prominent, or generates persistent pain. Once the underlying fracture has fully healed, the metalware can usually be removed.

Indications for removal

• Prominence — palpable or visible metalware that catches clothing or rubs against the skin.
• Persistent localised pain over the implant.
• Infection of the implant.
• Patient preference, once the fracture is healed.

Considerations

Implant removal is typically a day-case procedure but the technical challenge varies — well-healed-in screws and nails can be unexpectedly difficult to retrieve, and a small refracture risk exists particularly with long-bone plates. Mr Gormack will discuss the specific risks for your situation.