As a fan, the resurgence of the Sixers this year has been exciting to watch.  So I was disappointed to hear that Ben Simmons would be missing the remainder of the year due to the Jones fracture in his foot.  Reading the online commentary and listening to local sports talk radio has raised questions as to "why" Simmons' recovery from a "simple foot fracture" is taking "so long."

Of course, the concept of fractures not healing properly is a not a new issue.  About 5 to 10 percent of all broken bones go on to a delayed union or non-union, which means that they are not healing at the expected rate or have stopped healing entirely.

The two biggest issues with non-unions of fractures are diagnosing and then treating them.  It is challenging to diagnose a non-union because most fractures want to heal, but there are three ways to do so. Traditional X-rays can be deceiving or inaccurate in determining healing because they are two dimensional projections of three-dimensional objects. CT scans are also used but this introduces a significant amount of radiation to the patient.  Usually, if a patient experiences pain directly at the fracture site even after sufficient time has passed to allow it to heal, that is the sign of a non-union diagnosis.

Once the diagnosis is made, the next step is to figure out the course of treatment, which needs to be specific to the patient and to the fracture.  In general, there are four reasons why a fracture would not heal, but most often non-union results from a combination of these factors:

  • Infection: This can be challenging to figure out because there are no specific blood tests that will tell you if the bone is infected. Not to mention, bone infections don't usually make someone sick the way pneumonia or the flu would.  The best way to tell if there is an infection is to get a specimen of tissue directly from the site where the fracture has not healed. Risk factors for infection include previous surgery to that site and systemic diseases like diabetes.  But, there can be clues like drainage from the fracture site or an open wound that make the diagnosis more obvious.

  • Poor or no blood supply: Bone is a living object that is consistently remodeling, which means the bone requires an appropriate blood supply to stay alive – just like the rest of our organs.  If a fracture has no blood supply or a very poor blood supply, this will have an impact on getting the bone edges to fuse back together. Fractures, like a Jones fracture, in a location where there is already a poor blood supply that gets compromised further as a result of the injury would require a "jump-start" with some kind of stimulation. Stimulation of bone can come in the form of bone grafting by taking bone from one part of the body and moving it, by injecting concentrated bone marrow cells, by using synthetic materials, or electrical signals.

  • Stability of the bone: In some cases when the body is trying to heal a fracture and build new bone, there is no stable foundation for the new bone to grow on.  The fracture will start to heal, but then motion at the fracture site will tear apart any healing that has happened, causing the process to run in circles until it finally stalls. Stability to a fracture can come through keeping weight off it, bracing, casting, or surgically stabilizing the bone ends with plates, screws, rods, or pins.

  • Host factors: Part of getting fractures to heal is making sure all the growth factors — proteins, and vitamins necessary for healing — are present. The "ingredients" we look for in fracture healing include Vitamin D, Calcium, Magnesium, Phosphorus, Albumin, Total Protein, Thyroid Hormone, Parathyroid Hormone, and Testosterone. There are also several other factors that can take away from fracture healing like certain medications, smoking, and diabetes.

A non-union after breaking a bone can be a challenging problem, but an organized treatment approach usually results in a good outcome.

Read more Sports Doc for Sports Medicine and Fitness.