Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for follow-up of fracture nonunion. Reports persistent localized pain, functional impairment, and inability to bear weight/use extremity as expected for duration of injury. Denies recent trauma, fever, or chills. Previous interventions include [ORIF/casting/external fixation] performed on [Date]. Current pain level is [X]/10, exacerbated by movement and loading.
Clinical Examination Findings
Inspection reveals [atrophy/swelling/deformity] at the fracture site. Palpation demonstrates localized tenderness, abnormal mobility at the fracture site, and absence of clinical callus formation. Neurovascular status is intact distally with palpable pulses and normal capillary refill. Range of motion is limited by pain and mechanical instability.
Treatment Protocol
Plan: 1. Obtain repeat imaging (X-rays/CT) to assess for biological vs. mechanical nonunion. 2. Discuss revision surgery (bone grafting, hardware exchange, or compression plating). 3. Consider adjunctive therapies (bone stimulator). 4. Maintain activity modifications as directed. 5. Follow up in [X] weeks for review of imaging and surgical planning.