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Common Causes of Malunion and Malalignment
Dr. Miller: You broke a bone and now it's painful? And maybe you're not walking on it correctly? We're going to talk about that next on Scope Radio.
I'm here with Justin Haller. He's an orthopedic surgeon here at the University of Utah. Justin, tell me a little bit about what we call malunion or malalignment. And this occurs in patients who have had fractures and then subsequently develop pain or mechanical dysfunction because maybe the fracture just didn't heal right. Maybe they didn't have it set correctly, something like that. What does that mean?
Dr. Haller: So, a malunion by definition is a bone that breaks and then heals in either a malaligned position or it's malrotated, so the bone itself is twisted and heals in that position.
Dr. Miller: What's the most common cause of that? I mean, obviously, it's a fracture, but then is it because it didn't receive the right treatment, or maybe they didn't follow instructions after they were cast?
Dr. Haller: The most common cause tends to be when patients are treated non-operatively with a cast or something like that, in the United States, in the past.
Dr. Miller: So what do you do? How do you treat these? And then again, what are the most common fracture sites where malalignment occurs?
Dr. Haller: So, most commonly, symptomatic malalignment occurs in the lower extremities. So either the tibia or shin bone or femur, or thigh bone. And what we do for those is first, to determine whether it's healed in a malaligned or malrotated position.
How Doctors Diagnose Malaligned Bones
Dr. Miller: So you can see that on X-ray. So a CT scan or an MRI might show you that?
Dr. Haller: It starts with a full X-ray standing profile to see the mechanical axis of a patient's lower extremities, and using a CT scan to see if there's any rotational component to that.
Dr. Miller: Do you see leg length discrepancy sometimes with these fractures if they've healed incorrectly?
Dr. Haller: Commonly, you do see a leg length discrepancy with these, and that's picked up on the long-standing X-ray.
Dr. Miller: What would somebody experience if one leg were a little bit shorter than the other after a fracture? And I gather they don't have to be that much shorter for them to develop symptoms. Maybe if you're an athlete, it's even more common.
Dr. Haller: Yeah, really, patients can become symptomatic for a couple of centimeters of leg length discrepancy. And most commonly, the symptoms associated with that are back pain, hip pain, and, if it's also, it can get some knee pain if it's in the tibia bone or shin bone.
Surgical Options to Correct Malunion or Malrotation
Dr. Miller: So, how do you treat that? I mean, obviously, you don't put them on a rack and stretch out their leg. So, how do you repair the leg and make the leg the right length?
Dr. Haller: Sure. So we typically will do an osteotomy, or we cut the bone or re-break the bone, as people will typically say, and we'll realign it and fix it there with a plate and screws or a rod down the middle of the bone.
Dr. Miller: How effective is that? Does that work pretty well?
Dr. Haller: It works very well so long as patients can heal the cut in the bone. Normally, patient symptoms are pretty much resolved.
Dr. Miller: Now, do you do the same thing for a malrotation, where the bone is twisted?
Dr. Haller: It's pretty similar. Again, you do an osteotomy or a cut or re-break the bone, and you can rotate the bone and fix it with a plate and screws or with a rod down the middle of the bone.
When to See a Specialist for Persistent Pain or Walking Problems
Dr. Miller: Well, final question. How would a patient find their way to you if they had symptoms? What would they look for and how would they know to come to you?
Dr. Haller: Most commonly, people will present saying that their family members noticed that they have either a limb length discrepancy or they walk funny, or one leg is rotated in or out. Normally, it's family members who notice the most and will point the patient to either an orthopedic surgeon or general practitioner to take an X-ray. And then it can be pretty obvious that the bone is not quite the same as the other side.
Dr. Miller: Do you think going to a specialist is a good idea if you need to have this type of surgery, where you're going in and repairing a prior fracture that's been healed?
Dr. Haller: Absolutely. Orthopedic specialists, particularly orthopedic trauma surgeons, are the ones who are trained to fully evaluate and understand the malalignment that's present and then can fully correct what's going on.
updated: August 21, 2025
originally published: November 11, 2016
What to Do When a Broken Bone Heals the Wrong Way
A bone that heals in the wrong position after a fracture can cause pain, walking problems, or even back and hip issues. Learn how to recognize symptoms and when to seek care from a specialist.
