Understanding the Problem
Two different ways fracture healing goes wrong
Most fractures heal well with good fracture care. When healing goes off course, it's usually one of these two problems — and they're treated differently, so naming the problem correctly matters.
Malunion — healed, but crooked
The bone healed, but in poor alignment — angled, rotated, or shortened. That can cause pain and stiffness, shift load unevenly onto nearby joints, and over time may accelerate arthritis in the overloaded joint.
Nonunion — a fracture that won’t heal
Months after the injury, the fracture still hasn’t bridged. The usual signs are persistent pain at the fracture site — sometimes with a feeling of motion or giving way — long after the bone should have healed.
Why healing stalls
Bone needs blood supply, stability, and a healthy environment to heal. Poor blood supply, infection, too much motion at the fracture, smoking, nutrition problems, and certain medical conditions or medications can all interfere.
How Repair Works
Diagnose first — then fix stability, biology, and alignment
Understand the problem
Careful history and exam, plus imaging — X-rays and often CT — to see whether the bone has bridged and how the alignment sits. When infection is a possibility, lab work helps rule it in or out, because an infected nonunion is treated differently.
Fix the mechanics and the biology
Nonunions usually fail for a mechanical reason, a biologic reason, or both. When surgery is appropriate, the plan may combine revision fixation for stability, bone grafting to restart healing biology, and correction of alignment.
Protect the healing bone
Bone healing takes time. Follow-up imaging tracks progress while physical therapy rebuilds motion and strength — and we address the factors, like smoking or bone health, that slowed healing the first time.
When malunion has changed the whole limb
If a fracture healed at an angle, the whole limb can end up loading one side of a nearby joint — the same problem addressed in limb deformity correction. And when injury or prior surgery has left a limb short, gradual limb lengthening may be part of the conversation. These are all one family of problems: getting the limb straight, stable, and healed.
An Honest Word on Candidacy
Not every crooked or slow fracture needs an operation
Some malunions are fine
Mild malalignment that doesn't cause pain or threaten a nearby joint often needs observation, not surgery. We operate on problems, not X-rays.
Biology has to cooperate
Infection has to be ruled out or treated first, and factors like smoking, nutrition, and bone health directly affect whether a repair heals. We address them as part of the plan — not as an afterthought.
Expect a marathon, not a sprint
A bone that struggled to heal once needs time to heal again. Recovery is measured in months, with follow-up imaging along the way — and we'll be honest about that timeline up front.
Educational content only; not a promise of results. Bone healing timelines vary widely. Not everyone is a candidate for surgery; candidacy is confirmed with imaging, exam, and — when needed — lab workup.
Why the Workup Matters
The diagnosis drives everything
A stiff nonunion, a mobile nonunion, an infected nonunion, and a painful malunion are four different problems with four different plans. Imaging shows the mechanics; labs, when needed, help rule out quiet infection — because operating on an unrecognized infection sets the repair up to fail.
That's why we don't skip to surgery. We take the time to understand why your bone hasn't healed — then fix that reason.
Fracture Healing by the Numbers
What research shows about fractures that fail to heal — and how often revision surgery works.
Written and Medically Reviewed By
Paul Norio Morton, MD
Board-certified orthopedic surgeon (American Board of Orthopaedic Surgery). Fellowship-trained; Hawai‘i's first fellowship-trained robotic hip & knee replacement surgeon.
Last reviewedJuly 2026 · Read Dr. Morton's full bio →
Explore Related Care
Explore related care
Fracture Care
Treatment of new fractures — casting, splinting, and surgical fixation.
Explore →Limb Deformity Correction
Realignment (osteotomy) when a malunion has changed how the limb loads.
Explore →Limb Lengthening
Gradual lengthening when injury or prior surgery has shortened a limb.
Explore →Bone Health & Osteoporosis
Addressing the bone biology that healing depends on.
Explore →2-Minute Check
Am I a candidate for malunion or nonunion repair?
Answer a few quick questions. This is educational and is not a diagnosis — only an evaluation can tell for sure.
Do you have pain or a problem limiting your daily activities?
Have basic measures not given you lasting relief?
Would you like an expert opinion on your options?
You may be a strong candidate.
Your answers suggest malunion or nonunion repair could be a good fit. The next step is a simple evaluation, where we'll confirm with an exam and imaging and review every option with you — surgical and non-surgical.
This tool is educational and not a diagnosis. Not everyone is a candidate; only a clinical evaluation can determine what's right for you.
You might be a candidate — let's talk.
Some of your answers point toward malunion or nonunion repair, but the right path depends on the details. A short evaluation will give you a clear, honest answer and a plan.
This tool is educational and not a diagnosis. Not everyone is a candidate; only a clinical evaluation can determine what's right for you.
Let's take a closer look.
Your answers don't point clearly to malunion or nonunion repair yet — but that doesn't mean we can't help. We'll evaluate what's going on and point you to the care that fits, often starting with non-surgical options.
This tool is educational and not a diagnosis. Not everyone is a candidate; only a clinical evaluation can determine what's right for you.
Answer all 3 questions to see your result.
Patient Reviews
What patients say
“My forearm bone repair was done well and provided full healing. I’m a pilot and amateur athlete, and I do not take my body’s health for granted. Dr. Morton is professional, knowledgeable, and enthusiastic.”
— Paul C.· Google review
Review excerpts reflect individual patient experiences and may be lightly condensed. Results vary.
Questions, Answered
Malunion & nonunion FAQ
How do I know if my fracture is a nonunion?+
There is no single test — it’s a judgment made from your timeline, symptoms, and imaging. Persistent pain at the fracture site months after injury, a sense of motion at the old break, or X-rays that show the fracture line isn’t bridging are the common clues. Some fractures are simply slow healers, so the first step is a careful evaluation rather than assuming the worst.
Why didn’t my fracture heal?+
Usually it comes down to mechanics, biology, or both. The fracture may have had too much motion to bridge, the bone ends may have limited blood supply, or something in the healing environment — infection, smoking, poor nutrition, or certain medical conditions and medications — interfered. Identifying which factors apply to you is what shapes the treatment plan.
What does malunion repair involve?+
When a malunion causes symptoms, correction generally means an osteotomy — a planned cut through the healed bone — to restore alignment, length, or rotation, followed by fixation while it heals in the corrected position. Whether that’s worthwhile depends on how much the deformity affects your function and nearby joints; not every malunion needs surgery.
Do all nonunions need surgery?+
No. Some slow-healing fractures go on to heal with more time, protected weight-bearing, or treatment of contributing factors like nutrition or bone health. When a nonunion is established, though, surgery — revision fixation, bone grafting, or both — is often the more reliable path. We’ll walk through the options honestly, and not everyone is a candidate for every approach.
What is bone grafting?+
Bone graft adds healing biology to a fracture that has stalled. Depending on the situation it may be your own bone (often from the pelvis), donor bone, or bone-graft substitutes. The choice depends on the size of the defect, the biology of the nonunion, and your overall health.
Where is surgery performed, and does smoking really matter?+
The right venue depends on the complexity of your case — on Oahu, Dr. Morton operates at The Queen’s Medical Center and Adventist Health Castle, and we’ll discuss the appropriate setting for your repair at your evaluation. And yes — smoking and nicotine impair bone healing, so quitting is one of the most meaningful things you can do to help a repair succeed. Individual results vary.
Still hurting from a fracture that should have healed?
Start with an evaluation. Imaging — and labs when infection is a concern — will show us what's really going on, and we'll walk through every option honestly.
For medical emergencies, call 911. This page is educational and is not a substitute for medical advice. Not everyone is a candidate; individual results and recovery vary.