Posted: Oct 27 2020 #(C101605) 2021 Orthopaedic Trauma & Fracture Care: Pushing the Envelope

Tibial Nonunion s/p IMN in 43F

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HPI

43-year-old female who sustained a closed left distal 1/3 tibial shaft fracture and concomitant segmental fibula fracture 6 months ago. She was subsequently treated with closed reduction intramedullary nailing through a suprapatellar approach. She presents to the office now 6 months out from surgery with continued pain about the fracture site and difficulty ambulating. She continues to walk with a cane.

PMH

Bipolar disorder Depression Hypothyroidism

Focused exam of the LLE demonstrates healed incisions without evidence of infection. She ambulates with an antalgic gait with the assistance of a cane. Mild TTP about the previous fracture sites. Motor intact to the lower extremity EHL/FHL/GSC. Sensation grossly intact to all distributions of the foot. PT/DP pulses palpable, BCR all toes.

Poll

1 of 9

1. In addition to the plain film radiographs, would you obtain any additional imaging to guide management?

No - current radiographs are sufficient

35%

433/1211

Yes - additional radiographic views (XR)

10/1211

Yes - CT scan of the tibia (CT)

50%

609/1211

Yes - MRI scan of the tibia (MRI)

25/1211

Yes - CT + XR

82/1211

Yes - MRI + XR

4/1211

Yes - MRI + CT

23/1211

Yes - MRI + CT + XR

8/1211

Outside my area of expertise - best if I don't vote

17/1211

2. Would you obtain any additional lab work-up of this patient?

No - it would not change my management

87/1210

Yes - infectious work-up (CBC, ESR, CRP) only

30%

363/1210

Yes - metabolic work-up (calcium, vitamin D)

83/1210

Yes - metabolic + infectious work-up

54%

662/1210

Outside my area of expertise - best if I don't vote

15/1210

3. How would you manage this injury?

Nonoperative

85/1176

Operative

91%

1076/1176

Outside my area of expertise - best if I don't vote

15/1176

4. If you choose Operative management, what procedure would you perform on the tibia?

I would not choose Operative management

11/1185

Retention and dynamization of current nail

41%

489/1185

Hardware removal, Open reduction internal fixation (ORIF) with plate and screws

83/1185

Hardware removal, Reamed exchange nailing

47%

559/1185

Hardware removal, External fixation (includes monoplanar, ringed circular fixation, etc.)

22/1185

Outside my area of expertise - best if I don't vote

21/1185

5. If you choose to perform Reamed exchange nailing, would you address the fibula?

I would not choose Reamed exchange nailing

10%

115/1145

No - it's not necessary

42%

483/1145

Yes - osteotomy

45%

524/1145

Outside my area of expertise - best if I don't vote e

23/1145

6. If you choose to perform a Fibular osteotomy, would you remove any bone?

I would not choose to perform a Fibular osteotomy

22%

251/1125

No - I would perform a simple osteotomy

20%

225/1125

Yes - <1cm

25%

289/1125

Yes - 1-2cm

25%

291/1125

Yes - >2cm

26/1125

Outside my area of expertise - best if I don't vote

43/1125

7. If you choose to perform Reamed exchange nailing, how much larger of a nail would you plan to use?

I would not choose Reamed exchange nailing

110/1112

1 mm

29%

330/1112

2 mm

50%

562/1112

3 mm

38/1112

4+ mm

28/1112

Outside my area of expertise - best if I don't vote

44/1112

8. If you choose to perform Reamed exchange nailing, how would you lock the nail?

I would not choose Reamed exchange nailing

73/1094

Statically - 2 proximal + 2 distal

23%

257/1094

Statically - 2 proximal + 1 distal

30/1094

Statically - 1 proximal + 2 distal

43/1094

Statically - 1 proximal + 1 distal

8/1094

Dynamically - 1 proximal + 1 distal

16%

184/1094

Dynamically - 1 proximal + 2 distal

41%

458/1094

Outside my area of expertise - best if I don't vote

41/1094

9. If you choose Reamed exchange nailing, and obtain the construct shown below, what weight-bearing status would you assign the patient?

I would not choose Reamed exchange nailing

52/1037

Weight bearing as tolerated (WBAT)

72%

749/1037

Touch down weight bearing (TDWB)

18%

187/1037

Non weight bearing (NWB)

36/1037

Outside my area of expertise - best if I don't vote

13/1037

Intra-procedure P1

7 months

Post-procedure P1

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