Non Union in Personal Injury Claims

Posted 4th June 2010

Joseph Hui has provided this useful article on Non Unions, and how these relate to Personal Injury Claims

ARTICLE - Non-Union


Orthopaedic fractures are one of the most common injuries in personal injury claims and makes up a large majority of all claims.  Whilst the majority of these will recover without any difficulties, there are a percentage of these that are hampered by non union.  According to research, between 2%-7% of all fractures experience non union. 


So what constitutes non union?


According to the Orthopaedic Advisory Panel, non union is defined as a fracture that is a minimum of nine months post accident which has not healed and has not shown radiographic progression for three months.  Various research has been conducted as to the incidents of non union and the most common place for this to occur is at the tibia.  It has been reported that between 35%-62% of all non union cases involved the tibia.  This is followed closely by the femur, humerous, clavicle and the scaphoid.


So what actually causes non union?


Non union can be caused due to various factors which involved systemic problems such as malnutrition or diabetes, could be due to infections or could be related to the actual type of fracture.  Depending on what is the cause of the non union, the treatment will also be different. 


Usual treatments for non union can be operative or non operative.  For non operative measures ultrasound or electronic stimulators are used to help stimulate increased blood flow and bone growth.  Surgical treatment options, there is the standard bone grafting procedures, bone grafting with a bone morphogenic proteins or osteotomy with external fixation.  One of the most commonly used form of external fixation is the Ilizarov frame which is commonly seen on tibial fractures. 



In order to manage non-unions effectively, it is important that a specialist with the required experience is involved for both the treating and medicolegal roles.  Non-union needs to be managed in a proactive manner and any delays with decision making can lead to prolonged healing processes and worse outcomes.  Centres such as the Bristol Royal Infirmary, Northern General Hospital in Sheffield or Royal National Orthopaedic Hospitals in Middlesex are centres of excellence for management of non-unions and a useful resource.


Is limb salvaging going to improve the function or should amputation proceed?


Non union can significantly delay the recovery process and affect mobility.  This in turn will then affect the Claimant's independence with personal care, access in the community and subsequently return to work.  As limb salvaging and surgical techniques improve, surgeons will often more consider limb reconstruction rather than using amputation to manage complicated fractures.  Repeated reconstruction surgery can help with rebuilding a badly injured lower limb, however this may lead to prolonged healing with bad and poor function.


Amputation is a potential alternative option for the chronic non-union fracture as it will immediately bring back the function however, pain often persists.  The non-union specialist will be able to advise on this potentially sensitive area and if the treating surgeon has no experience of non-union, then a second opinion should be sought.


So what is the implication of non unions for personal injury claims?


Non union fractures will continue to feature prominently in the future as limb salvaging and emergency medicine improves and this will potentially increase costs for the insurer and defendant team.  It cannot be stressed enough that appropriate experienced experts should be instructed on these cases to ensure proactive management or else, we may be facing an ever escalating cost of settling these claims. 


Joseph Hui

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