Review Question - QID 3930

A 26-year-old female sustained a closed femoral shaft fracture which was treated as shown in Figure A. She subsequently developed a painful oligotrophic nonunion and an exchange nailing was performed 6 months later. However, she has had persistent pain in the thigh since time of revision surgery seven months ago, but denies any fevers, chills, or night sweats. Current examination reveals a mildly tender right thigh with no obvious deformity. Laboratory studies for infectious markers are normal, but her radiograph in Figure B continues to show an oligotrophic nonunion. Which of the following factors has most likely contributed to her current presentation?