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Vitamin D deficiency
69%
2471/3597
Central hypogonadism
2%
89/3597
Thyroid disorder
63/3597
Parathyroid hormone disorder
7%
262/3597
Calcium deficiency
19%
688/3597
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Figure A is a radiograph showing oligotrophic nonunion of a proximal third humeral shaft fracture. The most likely underlying metabolic or endocrine abnormality with this presentation is vitamin D deficiency. The etiology of fracture nonunion is multifactorial. Predisposing factors include: mechanical instability, poor bone-to-bone contact, infection and biological/biochemical factors. A variety of other contributing factors, such as cigarette smoking and malnutrition, have also been described. Correctable metabolic or endocrine abnormalities are common in elderly patients and are considered contributory in the etiology of fracture non-union. Correction of these abnormalities should be considered prior to surgical fixation. Brinker et al. studied 37 patients with fracture nonunions with identifiable metabolic or endocrine abnormalities. The distribution of nonunion types at the 46 sites were: oligotrophic (23), atrophic (12), infected (7), and hypertrophic (4). They showed that 85% of patients had a previously undiagnosed metabolic or endocrine abnormality. The most common newly diagnosed abnormality was vitamin D deficiency in 25 of the 37 patients (68%). Kuo et al. studied 155 consecutive minimal-trauma fracture subjects for metabolic abnormalities with bone mineral density and laboratory testing. At baseline, only 26% had had proper workup for metabolic abnormalities. After diagnostic work-up, 44% of patients were recommended for anti-resorptive therapy and 56% were recommended calcium/vitamin D medication. Illustrations A and B show open reduction internal fixation of Figure A with a proximal humeral plate. Incorrect Answers: Answer 2: Studies show 15% of fracture nonunions can be attributed to undiagnosed central hypogonadism. Answer 3: Studies show 24% of fracture nonunions can be attributed to previously established or undiagnosed thyroid disorders Answer 4: Studies show 11% of fracture nonunions can be attributed to previously established or undiagnosed parathyroid disorders Answer 5: Studies show 35% of fracture nonunions can be attributed to lack of calcium.
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