A Question a day (W2D4)

1. Chronic infected atrophic non-union of distal 3rd of tibia

2. A. An open wound with pus discharge, slight hyperemic at one end, with surrounding
hyperpigmentation and chapped skin suggesting infected wound. Plus it's at previous surgical site.

B. Intramedullary nail fixing fracture. Fracture gap was noted suggesting non-union after 4 years.

3. Systemic factors: Heavy smoker

Local factors: Open fracture, location at distal 1/3rd of tibia, intramedullary nailing

4. Stabilize patient, wound debridement, removal of intramedullary nail, osteostomy then bone graft

How to stabilize the fracture since there is non union? Is it safe to bone graft? Can we bone graft the
site with chronic OM?

Please Identify the underlying cause of the non-union first then tackle the underlying cause
accordingly. If the non-union is atrophic then the 2 major causes should be considered; 1st lack of
blood supply 2nd is severe infection or combination of both. Replacing a nail with plate will further
devitalize the bone because of external periosteum stripping on a bone which endosteum already
being stripped during the previous IM nailing. So exchange of internal fixation from nail to plate is
not a good idea. Can the bone get rid of the bacteria totally? the chances of potential of flaring up
of OM after cancellous bone graft is very high. Think about resection of infected bone which can be
followed by bone transportation with Ilizarov method. "remove the IM nail first and attach a larger
plate at the site of nonunion" is the method to treat hypertrophic non-unions which are mostly due
to hypermobility from inadequate immobilization.

Rolled edge “volcano crater wound”

Undermined edge