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Review Question - QID 219552

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QID 219552 (Type "219552" in App Search)
A 22-year-old male is involved in a motorcycle accident where he sustained an injury to his right leg. On presentation to the trauma bay, radiographs show a midshaft tibia fracture with a small degree of comminution. The injury is closed and he is neurovascularly intact. He is splinted and taken to surgery the following day for a tibial intramedullary nail. Nine months later, he comes to the clinic with the radiograph seen in Figure A. He still has tenderness about the fracture site but no erythema or swelling. Labs are ordered and are as follows - CRP:5 mg/L (nl <10 mg/L), ESR:10 mm/h (nl <20 mm/h), Vitamin D:51 ng/mL (nl >40 ng/mL). Which of the following is the most likely cause for this patient's problem?
  • A

Infection

1%

7/813

Vitamin deficiency

1%

6/813

Lack of biology

58%

468/813

Lack of stability

28%

227/813

Failure of reduction

12%

98/813

  • A

Select Answer to see Preferred Response

This patient has an atrophic nonunion, as evidence by the lack of bone formation at the fracture site at 9 months post-operatively.

Tibial shaft fractures are common long bone fractures and most often require surgery. The type of surgery performed depends on the nature of the fracture but typically involves intramedullary nailing in the setting of a diaphyseal tibia fracture. Union rates are quite high in the setting of a closed fracture treated with reamed intramedullary nail. However, nonunion can occur and most agree that nonunion can be diagnosed by 9 months post-operatively, although this time frame is somewhat controversial. Different types of nonunion can occur, with hypertrophic and atrophic nonunions being the most common. Lab work should always be performed and should include inflammatory labs and vitamin D. Atrophic nonunions typically occur when there is a lack of biology and should be treated with intramedullary nail exchange and supplementation of bone graft, which can be obtained in multiple ways. Hypertrophic nonunions occur when there is a lack of fracture stability and the excess motion at the fracture site causes overgrowth without the ability to create a stable callus.

Andrzejowski et al. discuss the "diamond concept," for long bone nonunion management, noting that long bone nonunion is still a large problem considering the number of these fractures that ultimately present. The diamond concept is a framework for successful bone healing that focuses on mechanical stability, biologic environment, bone vascularity, and physiologic host state. A deficit in any of these components is thought to equally influence the odds of fracture nonunion occurring.

Moghaddam et al. looked at treatment of atrophic tibia nonunions based on either one- or two-step treatment plans. They treated 49 patients with one-stage procedures, while 50 patients got a two-step Masquelet type procedure. They noted similar results, with 84% fracture consolidation in the one-stage group and 80% in the two-stage group, with healing time being longer in the two-stage group. They concluded that both methods are reasonable for treatment, especially depending on the cause of nonunion.

Figure A is the AP tib-fib radiograph of the right leg showing an atrophic nonunion after tibial intramedullary nailing of the midshaft tibia fracture.

Incorrect Answers:
Answer 1: Based on the patient's labs and physical examination, there is no evidence of infection.
Answer 2: The patient's vitamin D is within normal limits (>50 ng/mL).
Answer 4: Lack of stability causes a hypertrophic nonunion which is seen on radiographs as an overgrowth of bone surrounding the fracture site.
Answer 5: Failure of fracture reduction typically leads to an oligotrophic nonunion.

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