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Tibial Nonunions Workup

  • Author: Minoo Patel, MBBS, PhD, MS, FRACS; Chief Editor: Thomas M DeBerardino, MD  more...
Updated: Jun 10, 2016

Approach Considerations

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.


Laboratory Studies

The role of the diagnostic workup is threefold, as follows:

  • To determine whether the patient is able to undergo successful surgery
  • To evaluate the patient for any signs of infection
  • To assess the fracture deformity (see Imaging Studies)

Evaluation of suitability for surgery obviously implies a routine preoperative assessment, but more specific laboratory tests may be indicated to determine whether any systemic factors are contributing 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.[13, 14]

In looking for signs of infection, evaluation with a routine complete blood count (CBC), erythrocyte sedimentation rate (ESR), 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.[15] Cultures may be helpful, but findings are often negative, especially if the patient has been treated with antibiotics.


Imaging Studies

For assessing 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 (see the images below).

Tibial nonunions. Anteroposterior radiograph of ps Tibial nonunions. Anteroposterior radiograph of pseudarthrosis with nonunion.
Tibial nonunions. Lateral radiograph of pseudarthr Tibial nonunions. Lateral radiograph of pseudarthrosis with nonunion.

Any rotational component must be assessed either clinically or with computed tomography (CT). 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, or tomography may be helpful. Assessment of the fibula is important to determine whether it is preventing tibial union.

Magnetic resonance imaging (MRI) is probably the most sensitive and specific study for osteomyelitis, with an accuracy greater than 90%.[16] 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%.[17]


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.[18]

Contributor Information and Disclosures

Minoo Patel, MBBS, PhD, MS, FRACS Senior Lecturer, Monash University; Director, Centre for Limb Reconstruction and Deformities, Epworth Centre; Chairman, Cabrini Hospital Orthopaedic Surgery Specialty Group; Orthopaedic Adult/Pediatric Surgeon, Epworth Hospital; Fellowship Director, Epworth Kleos Upper Limb and Limb Reconstruction Fellowship; Consulting Adult/Pediatric Orthopedic Surgeon, Department of Orthopedic Surgery, Monash Medical Center, Australia

Minoo Patel, MBBS, PhD, MS, FRACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Australian Association of Surgeons, Australian Medical Association, Australian Orthopaedic Association, Royal Australasian College of Surgeons, Orthopaedic Research Society, AO Foundation, Orthopaedics Overseas, Indian Orthopedic Association, Bombay Orthopedic Society, Shoulder and Elbow Society of Australia, Australian Paediatric Orthopaedic Society, Australian Limb Lengthening and Reconstruction Society, Victorian Hand Surgery Society, Victorian Shoulder and Elbow Society

Disclosure: Nothing to disclose.


John Herzenberg, MD, FRCSC Head of Pediatric Orthopedics, 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, Pediatric Orthopaedic Society of North America, Limb Lengthening and Reconstruction Society, American Academy of Orthopaedic Surgeons

Disclosure: Received educational grant from Smith and Nephew, EBI, Orthofix for none.

James J McCarthy, MD, FAAOS, FAAP Director, Division of Orthopedic Surgery, Cincinnati Children's Hospital; Professor, Department of Orthopedic Surgery, University of Cincinnati College of Medicine

James J McCarthy, MD, FAAOS, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Orthopaedic Association, Pennsylvania Medical Society, Philadelphia County Medical Society, Pennsylvania Orthopaedic Society, Pediatric Orthopaedic Society of North America, Orthopaedics Overseas, Limb Lengthening and Reconstruction Society, Alpha Omega Alpha, American Academy for Cerebral Palsy and Developmental Medicine, American Academy of Orthopaedic Surgeons

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Orthopediatrics, Phillips Healthcare, POSNA<br/>Serve(d) as a speaker or a member of a speakers bureau for: Synthes<br/>Received research grant from: University of Cincinnati<br/>Received royalty from Lippincott Williams and WIcins for editing textbook; Received none from POSNA for board membership; Received none from LLRS for board membership; Received consulting fee from Synthes for none.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Thomas M DeBerardino, MD Associate Professor, Department of Orthopedic Surgery, Consulting Surgeon, Sports Medicine, Arthroscopy and Reconstruction of the Knee, Hip and Shoulder, Team Physician, Orthopedic Consultant to UConn Department of Athletics, University of Connecticut Health Center

Thomas M DeBerardino, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Arthrex, Inc.; Ivy Sports Medicine; MTF; Aesculap; The Foundry, Cotera; ABMT<br/>Received research grant from: Histogenics; Cotera; Arthrex.

Additional Contributors

Charles T Mehlman, DO, MPH Professor of Pediatrics and Pediatric Orthopedic Surgery, Division of Pediatric Orthopedic Surgery, Director, Musculoskeletal Outcomes Research, 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, Scoliosis Research Society, Pediatric Orthopaedic Society of North America, 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

Disclosure: Nothing to disclose.

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Treatment algorithm for tibial nonunions.
Tibial nonunions. Anteroposterior radiograph of pseudarthrosis with nonunion.
Tibial nonunions. Lateral radiograph of pseudarthrosis with nonunion.
Tibial nonunions. Patient with pseudarthrosis after failure of internal fixation and bone stimulation.
Tibial nonunions. Anteroposterior radiograph of tibial fracture after provisional fixation.
Tibial nonunions. Oblique view of tibial fracture after provisional fixation (note the fracture gap is not visible on the anteroposterior and lateral radiographs).
Tibial nonunions. Lateral radiograph of tibial fracture after provisional fixation.
Tibial nonunions. Close-up view of antibiotic bone cement beads.
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