eMedicine Specialties > Orthopedic Surgery > Knee

Tibial Nonunions: Workup

Author: Minoo Patel, MBBS, MD, MS, FRACS, Senior Lecturer, Monash University; Consulting Adult/Pediatric Orthopedic Surgeon, Department of Orthopedic Surgery, Monash Medical Center, Australia
Coauthor(s): James J McCarthy, MD, FAAOS, FAAP, Associate Professor, Consulting Orthopedic Surgeon, Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health;; John Herzenberg, MD, FRCSC, Head of Pediatric Orthopedics, Co-director of International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore
Contributor Information and Disclosures

Updated: Apr 9, 2009

Workup

Laboratory Studies

  • The most critical step in the workup is to review the patient's prior history carefully, through evaluation of previous records, imaging studies, and discussion with the patient and previous treating physicians. Most often, the nonunion has occurred despite appropriate care, and rushing into treatment without a good understanding of why the nonunion occurred and how treatment will overcome these obstacles is a mistake.
  • The role of the diagnostic workup is 3-fold. The first goal is to assess the patient to determine if he or she is able to undergo successful surgery. This obviously implies a routine preoperative assessment, but more specific laboratory tests may be indicated in an effort to determine if any systemic factors contribute to the failure of union. Laboratory assessment to determine the patient's nutritional status may be indicated. The total lymphocyte count and Rainey-MacDonald nutritional index may be helpful in identifying patients who may (or may not) develop infections after long-bone fractures.12,13
  • The second goal is to assess for any signs of infection. Evaluation with a routine complete blood cell count (CBC), sedimentation rate, and C-reactive protein (CRP) may be helpful. The CRP is the most accurate indicator of infection, but it is not necessarily specific for infection.14 Cultures may be helpful, but findings are often negative, especially if the patient has been treated with antibiotics.

Imaging Studies

  • The third goal of the diagnostic workup is to assess fracture deformity. Plain radiography is typically the most helpful tool. The deformity must be assessed in both anteroposterior (AP) and lateral planes, with resolution of the plane and degree of maximum deformity. Any rotational component must be assessed either clinically or with CT scanning. Leg-length equality should be determined clinically or more accurately with scanography. Finally, fracture stability must be determined. Often, the fracture nonunion is difficult to assess on plain radiography; fluoroscopy, CT scanning, or tomography may be helpful. Assessment of the fibula is important to determine whether it is preventing tibial union.
  • MRI is probably the most sensitive and specific study for osteomyelitis, with an accuracy of over 90%.15 It also provides additional information regarding the anatomy and location of infected bone, sinus tracks, and sequestrums. Unfortunately, MRI is less effective if residual hardware is present, and other studies may be more appropriate. Technetium-99m diphosphonate bone scanning has been used in an attempt to identify infections, but it is not specific for infection. However, combining this scan with indium-111–labeled leukocyte imaging increases the accuracy to 82%.16

Other Tests

  • Vascular studies may be indicated if prior injury is a concern or if a free soft-tissue transfer is indicated. Consultation with a plastic surgeon may be warranted. Careful assessment and documentation of skin integrity and motor and sensory function are critical for surgical planning.

Histologic Findings

A histologic assessment may be helpful and has been shown to have a high sensitivity (87%) and specificity (100%) when assessing nonunion for the possibility of infection, especially when microbiologic findings are inconclusive.17

More on Tibial Nonunions

Overview: Tibial Nonunions
Workup: Tibial Nonunions
Treatment: Tibial Nonunions
Follow-up: Tibial Nonunions
Multimedia: Tibial Nonunions
References
Further Reading
[ CLOSE WINDOW ]

References

  1. Reed LK, Mormino MA. Distal tibia nonunions. Foot Ankle Clin. Dec 2008;13(4):725-35. [Medline].

  2. McQueen MM, Christie J, Court-Brown CM. Acute compartment syndrome in tibial diaphyseal fractures. J Bone Joint Surg Br. Jan 1996;78(1):95-8. [Medline].

  3. Audigé L, Griffin D, Bhandari M, Kellam J, Rüedi TP. Path analysis of factors for delayed healing and nonunion in 416 operatively treated tibial shaft fractures. Clin Orthop Relat Res. Sep 2005;438:221-32. [Medline].

  4. Schmitz MA, Finnegan M, Natarajan R. Effect of smoking on tibial shaft fracture healing. Clin Orthop. Aug 1999;184-200. [Medline].

  5. Wiss DA, Stetson WB. Tibial Nonunion: Treatment Alternatives. J Am Acad Orthop Surg. Oct 1996;4(5):249-257. [Medline].

  6. Weber BG, Cech O. Pseudoarthrosis: Pathology, Biomechanics, Therapy, Results. Berne, Switzerland:. Hans Huber Medical Publisher;1976.

  7. Johnston CE, Birch JG. A tale of two tibias: a review of treatment options for congenital pseudarthrosis of the tibia. J Child Orthop. Mar 2008;2(2):133-49. [Medline].

  8. Martus JE, Johnston CE 2nd. Isolated congenital pseudoarthrosis of the fibula: a comparison of fibular osteosynthesis with distal tibiofibular synostosis. J Pediatr Orthop. Dec 2008;28(8):825-30. [Medline].

  9. Vander Have KL, Hensinger RN, Caird M, Johnston C, Farley FA. Congenital pseudarthrosis of the tibia. J Am Acad Orthop Surg. Apr 2008;16(4):228-36. [Medline].

  10. Valdes MA, Thakur NA, Namdari S, Ciombor DM, Palumbo M. Recombinant bone morphogenic protein-2 in orthopaedic surgery: a review. Arch Orthop Trauma Surg. Mar 12 2009;[Medline].

  11. Emara KM, Allam MF. Ilizarov external fixation and then nailing in management of infected nonunions of the tibial shaft. J Trauma. Sep 2008;65(3):685-91. [Medline].

  12. Puskarich CL, Nelson CL, Nusbickel FR. The use of two nutritional indicators in identifying long bone fracture patients who do and do not develop infections. J Orthop Res. Nov 1990;8(6):799-803. [Medline].

  13. Rainey-Macdonald CG, Holliday RL, Wells GA, Donner AP. Validity of a two-variable nutritional index for use in selecting candidates for nutritional support. JPEN J Parenter Enteral Nutr. Jan-Feb 1983;7(1):15-20. [Medline].

  14. Chan YL, Liao HC, Tsay PK. C-reactive protein as an indicator of bacterial infection of adult patients in the emergency department. Chang Gung Med J. Jul 2002;25(7):437-45. [Medline].

  15. Mason MD, Zlatkin MB, Esterhai JL, Dalinka MK, Velchik MG, Kressel HY. Chronic complicated osteomyelitis of the lower extremity: evaluation with MR imaging. Radiology. Nov 1989;173(2):355-9. [Medline].

  16. Nepola JV, Seabold JE, Marsh JL. Diagnosis of infection in ununited fractures. Combined imaging with indium-111-labeled leukocytes and technetium-99m methylene diphosphonate. J Bone Joint Surg Am. Dec 1993;75(12):1816-22. [Medline].

  17. Simpson AH, Wood MK, Athanasou NA. Histological assessment of the presence or absence of infection in fracture non-union. Injury. Mar 2002;33(2):151-5. [Medline].

  18. Sarmiento A, Burkhalter WE, Latta LL. Functional bracing in the treatment of delayed union and nonunion of the tibia. Int Orthop. 2003;27(1):26-9. [Medline].

  19. Brighton CT, Shaman P, Heppenstall RB, et al. Tibial nonunion treated with direct current, capacitive coupling, or bone graft. Clin Orthop. Dec 1995;(321):223-34. [Medline].

  20. Guerkov HH, Lohmann CH, Liu Y, Dean DD, Simon BJ, Heckman JD, et al. Pulsed electromagnetic fields increase growth factor release by nonunion cells. Clin Orthop Relat Res. Mar 2001;265-79. [Medline].

  21. Griffin XL, Warner F, Costa M. The role of electromagnetic stimulation in the management of established non-union of long bone fractures: what is the evidence?. Injury. Apr 2008;39(4):419-29. [Medline].

  22. Khan Y, Laurencin CT. Fracture repair with ultrasound: clinical and cell-based evaluation. J Bone Joint Surg Am. Feb 2008;90 Suppl 1:138-44. [Medline].

  23. Busse JW, Bhandari M, Kulkarni AV. The effect of low-intensity pulsed ultrasound therapy on time to fracture healing: a meta-analysis. CMAJ. Feb 19 2002;166(4):437-41. [Medline].

  24. Sim R, Liang TS, Tay BK. Autologous marrow injection in the treatment of delayed and non-union in long bones. Singapore Med J. Oct 1993;34(5):412-7. [Medline].

  25. Heckman JD, Boyan BD, Aufdemorte TB. The use of bone morphogenetic protein in the treatment of non-union in a canine model. J Bone Joint Surg Am. Jun 1991;73(5):750-64. [Medline].

  26. Vaccaro AR, Chiba K, Heller JG. Bone grafting alternatives in spinal surgery. Spine J. May-Jun 2002;2(3):206-15. [Medline].

  27. Dahabreh Z, Calori GM, Kanakaris NK, Nikolaou VS, Giannoudis PV. A cost analysis of treatment of tibial fracture nonunion by bone grafting or bone morphogenetic protein-7. Int Orthop. Dec 4 2008;[Medline].

  28. Wu CC, Shih CH, Chen WJ, Tai CL. High success rate with exchange nailing to treat a tibial shaft aseptic nonunion. J Orthop Trauma. Jan 1999;13(1):33-8. [Medline].

  29. [Best Evidence] Bhandari M, Guyatt G, Tornetta P 3rd, Schemitsch EH, Swiontkowski M, Sanders D, et al. Randomized trial of reamed and unreamed intramedullary nailing of tibial shaft fractures. J Bone Joint Surg Am. Dec 2008;90(12):2567-78. [Medline].

  30. Wiss DA, Johnson DL, Miao M. Compression plating for non-union after failed external fixation of open tibial fractures. J Bone Joint Surg Am. Oct 1992;74(9):1279-85. [Medline].

  31. Harvey EJ, Henley MB, Swiontkowski MF. The use of a locking custom contoured blade plate for peri-articular nonunions. Injury. Feb 2003;34(2):111-6. [Medline].

  32. Rozbruch SR, Pugsley JS, Fragomen AT, Ilizarov S. Repair of tibial nonunions and bone defects with the Taylor Spatial Frame. J Orthop Trauma. Feb 2008;22(2):88-95. [Medline].

  33. Wu CC, Shih CH. Comparison of dynamic compression plating and reamed intramedullary nailing in the treatment of aseptic tibial shaft nonunions. Contemp Orthop. Jan 1994;28(1):28-33. [Medline].

  34. Törnqvist H. Tibia nonunions treated by interlocked nailing: increased risk of infection after previous external fixation. J Orthop Trauma. 1990;4(2):109-14. [Medline].

  35. Gardner MJ, Toro-Arbelaez JB, Hansen M, Boraiah S, Lorich DG, Helfet DL. Surgical treatment and outcomes of extraarticular proximal tibial nonunions. Arch Orthop Trauma Surg. Aug 2008;128(8):833-9. [Medline].

  36. Court-Brown CM, McQueen MM. High success rate with exchange nailing to treat tibial shaft aseptic nonunion. J Orthop Trauma. May 1999;13(4):274. [Medline].

  37. Dumont AS, Verma S, Dumont RJ, Hurlbert RJ. Nonsteroidal anti-inflammatory drugs and bone metabolism in spinal fusion surgery: a pharmacological quandary. J Pharmacol Toxicol Methods. Jan-Feb 2000;43(1):31-9. [Medline].

  38. Friedlaender GE, Perry CR, Cole JD, et al. Osteogenic protein-1 (bone morphogenetic protein-7) in the treatment of tibial nonunions. J Bone Joint Surg Am. 2001;83-A Suppl 1(Pt 2):S151-8. [Medline].

  39. Kuhlman JE, Fishman EK, Magid D, et al. Fracture nonunion: CT assessment with multiplanar reconstruction. Radiology. May 1988;167(2):483-8. [Medline].

  40. McQueen MM, Christie J, Court-Brown CM. Compartment pressures after intramedullary nailing of the tibia. J Bone Joint Surg Br. May 1990;72(3):395-7. [Medline].

  41. McQueen MM, Court-Brown CM. Compartment monitoring in tibial fractures. The pressure threshold for decompression. J Bone Joint Surg Br. Jan 1996;78(1):99-104. [Medline].

  42. Paley D, Catagni MA, Argnani F, et al. Ilizarov treatment of tibial nonunions with bone loss. Clin Orthop. Apr 1989;(241):146-65. [Medline].

[ CLOSE WINDOW ]

Keywords

tibial nonunion, tibial delayed union, aseptic nonunion, infected nonunion, tibial fractures, fractures of the tibia, fractured tibia, nonunions of the tibia, broken leg, leg fracture, delayed healing, hypertrophic nonunions, atrophic nonunions, normotrophic nonunions, long bone fractures, bone morphogenic protein, bone morphogenetic protein, BMP

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Minoo Patel, MBBS, MD, MS, FRACS, Senior Lecturer, Monash University; Consulting Adult/Pediatric Orthopedic Surgeon, Department of Orthopedic Surgery, Monash Medical Center, Australia
Minoo Patel, MBBS, MD, MS, FRACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, AO Foundation, Australian Association of Surgeons, Australian Medical Association, Australian Orthopaedic Association, Orthopaedic Research Society, Orthopaedics Overseas, Pediatric Orthopaedic Society of North America, and Royal Australasian College of Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

James J McCarthy, MD, FAAOS, FAAP, Associate Professor, Consulting Orthopedic Surgeon, Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health;
James J McCarthy, MD, FAAOS, FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy for Cerebral Palsy and Developmental Medicine, American Academy of Orthopaedic Surgeons, American Academy of Pediatrics, American Orthopaedic Association, Limb Lengthening and Reconstruction Society ASAMI-North America, Orthopaedics Overseas, Pediatric Orthopaedic Society of North America, Pennsylvania Medical Society, Pennsylvania Orthopaedic Society, and Philadelphia County Medical Society
Disclosure: Nothing to disclose.

John Herzenberg, MD, FRCSC, Head of Pediatric Orthopedics, Co-director of International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore
John Herzenberg, MD, FRCSC is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine, American Academy of Orthopaedic Surgeons, Limb Lengthening and Reconstruction Society ASAMI-North America, and Pediatric Orthopaedic Society of North America
Disclosure: Nothing to disclose.

Medical Editor

Charles T Mehlman, DO, MPH, Director, Musculoskeletal Outcomes Research, Associate Professor, Division of Pediatric Orthopedic Surgery, Cincinnati Children's Hospital Medical Center
Charles T Mehlman, DO, MPH is a member of the following medical societies: American Academy of Pediatrics, American Fracture Association, American Medical Association, American Orthopaedic Foot and Ankle Society, American Osteopathic Association, Arthroscopy Association of North America, North American Spine Society, Ohio State Medical Association, Pediatric Orthopaedic Society of North America, and Scoliosis Research Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Thomas M DeBerardino, MD, Director, John A Feagin, Jr, Sports Medicine Fellowship at West Point, Associate Professor of Orthopedic Surgery, Uniformed Services University of the Health Sciences and Keller Army Community Hospital
Thomas M DeBerardino, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, and American Orthopaedic Society for Sports Medicine
Disclosure: Arthrex, Inc. Grant/research funds None; Arthrex, Inc. Honoraria Speaking and teaching; Genzyme Biosurgery. Inc. Grant/research funds Other; Musculoskeletal Transplant Foundation Grant/research funds Other; Histogenics Grant/research funds None

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Carlos J Lavernia, MD, FAAOS, Adjunct Clinical Professor, Department of Orthopedic Surgery, University of Miami School of Medicine; Medical Director, Orthopedic Institute at Mercy Hospital
Carlos J Lavernia, MD, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Hip and Knee Surgeons, Arthritis Foundation, Biomedical Engineering Society, Florida Orthopaedic Society, and Orthopaedic Research Society
Disclosure: Zimmer Stock Implant Designer

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.