A healthy 65 year old women was at an auto race when she fell off a bleacher and sustained an open distal tibial fracture. The wound was irrigated, closed primarily, and an external fixator was applied by the initial treating physician.
She was seen in follow-up by a second physician who removed the external fixator and placed her into a long leg cast at 3 weeks post injury. Three weeks later the long leg cast was converted to a short leg cast. Nine weeks later the short leg cast was changed to a short leg brace and a electrical bone stimulator was used. Four weeks later the patient complained of pain. (Radiographs: Figure 1) The brace was continued.
Nineteen weeks later the patient continued to have pain and on physical exam had gross motion at the fracture site. The patient was returned to the operating room where 1.5 cm of fibula were removed, the fibula was reduced, and a Rush rod was inserted across the fibular osteotomy. The tibial non-union was taken down, grafted and internally fixed with a single lag screw (Radiographs: Figure 2). A short leg weight bearing cast was applied for 4 weeks. This was followed by bracing for 4 weeks. The brace was weaned and the patient was weight bearing as tolerated.
Five months after the bone graft the patient continued to have pain and swelling at the fracture site (Radiographs: Figure 3). One year after the bone graft and lag screw fixation the patient presented to a third physician complaining of persistent pain for an evaluation (Radiographs: Figure 4 Figure 5). The patient was referred with the diagnosis of an aseptic distal tibial nonunion.
The patient complained of persistent pain in the leg with activity but was weight bearing as tolerated. The past medical history, past family history, and social history were non-contributory. The review of systems was negative for tobacco and infection at the open fracture site. The physical examination demonstrated near normal ankle motion, slightly decreased pulses, normal hair pattern, intact sensation, a healed scar along the distal medial tibia, a healed scar along the fibula, a varus deformity of the distal tibia, and pain with manual stress of the distal tibia. The overall condition of the skin was very good to excellent. Radiographs and CT scan were reviewed (Radiographs: Figure 4 Figure 5).
The diagnosis of a non-infected hypertrophic non-union of the distal 6th of the tibia two years after an open distal tibial fracture in a healthy 65 year old woman was made.