Nonunion, referring to a broken bone which shows no evidence of healing within a specific time frame, is a massive deterrent to rehab and recovery after a complex orthopaedic trauma.  There are several contributing factors to nonunion, such as infection, poor blood supply, the type of fracture (e.g. open fractures) and the energy force from the trauma itself.1, 2  However, many clients and case managers may not realise that nutrition and other lifestyle factors, also play a significant role in bone healing.  Clients who provide their body with adequate nutritional “building blocks” for bone repair (and avoid substances which impede bone healing), are actively doing what they can to aid in their recovery.

Here are our top 7 tips for clients experiencing nonunion of a bone:

1. Request blood tests to see if clients are deficient in vitamin D and/or iron.

Vitamin D deficiency has been found in 60-68% of people with nonunion. 3, 4  This deficiency results in less calcium being absorbed by the intestine, increased bone resorption and delayed recovery.  Given the high prevalence of vitamin D deficiency in the UK, this is one blood test that we recommend (and request) for all of our clients, unless someone is already taking a vitamin D supplement.

While there are no stats on the incidence of iron deficiency anaemia in this population, we do know that anaemia can reduce the oxygen-carrying capacity of red blood cells which will also interfere with bone healing.  Dietitians therefore recommend that all clients with nonunion have their haemoglobin and ferritin levels checked as well, to see if low iron is a contributing factor.

2.  Screen clients for malnutrition.

Malnutrition refers to an inadequate intake of protein, vitamins and/or minerals. Inadequate levels of even one nutrient (e.g. vitamin D) can impede recovery.  Changes in weight can be a good way to predict who might be malnourished.  Clients who unintentionally lose over 10% of their body weight within 3-6 months are at high risk of malnutrition, regardless of what they weigh.5   Case managers can screen clients for malnutrition using the Malnutrition Universal Screening Tool (MUST).

It’s worth knowing that even if a client was well nourished prior to their injury,  a complex orthopaedic trauma can actually INDUCE a state of malnutrition, due to increased metabolic demands and a reduced food intake – both of which can occur immediately following an injury and any subsequent surgery.4   Early dietetic intervention is therefore needed to help clients replete nutrient stores and speed recovery time.

3.  Discuss options to help clients stop smoking.

Smoking increases the risk of nonunion significantly.6  This is because smoking reduces blood flow to the bone, reduces the oxygen-carrying capacity of haemoglobin and reduces collagen deposits – all of which impede bone healing. 2, 6  Clients may be more motivated to quit smoking after a major trauma, particularly if they know that it will aid in their recovery.

4.  Ask about alcohol intake and refer on if support is needed.

Excessive alcohol use in the early healing period can inhibit new bone formation and cause new bone to lack mineralisation and strength.1  Clients often won’t volunteer information about their alcohol intake, so it is something you will need to specifically ask about.

5.  Refer clients to a dietitian if they are dealing with obesity.

Having a BMI over 30kg/m2 is another significant risk factor for nonunion. 6, 7  Obesity actually results in low grade systemic inflammation which causes complications with bone healing.8  Immobilisation of the affected bone is also very difficult to achieve in obese clients.8

6.   Ask the GP or pharmacist to review medication.

The medication that clients take to manage pain (and/or other co-morbidities) can actually have a negative impact on bone healing.  NSAIDS, opiods, anticonvulsants, anticoagulants and corticosteroids are all known to have a negative effect on bone metabolism and/or bone density.7

7.  Ask the GP to refer to endocrinology.

In addition to the vitamin D deficiency mentioned above, other underlying medical conditions such as diabetes, osteoporosis, thyroid disorder, parathyroid disorder and hypogonadism, can all impede the healing process.4. Eighty four percent of people with nonunion have been found to have a metabolic or endocrine abnormality and should therefore be referred to an endocrinologist for further evaluation.4

If you are looking for a dietitian with expertise in nonunion and orthopaedic injuries to assess and support a client, please contact Specialist Nutrition Rehab at info@specialistnutritionrehab.co.uk or 0121 384 7087.

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