Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for evaluation of persistent pain and functional limitation at the site of a previous left tibial shaft fracture. Fracture occurred [Date], treated initially with [ORIF/IMN/Cast]. Patient reports localized tenderness, inability to bear full weight without discomfort, and lack of clinical or radiographic progression toward union over the past [Number] months. No systemic symptoms of infection (fever, chills, night sweats) reported.
Clinical Examination Findings
Left lower extremity examination reveals localized tenderness at the fracture site. No erythema, warmth, or sinus tract formation noted. Range of motion at the knee and ankle is [Full/Restricted]. Neurovascular status is intact with palpable dorsalis pedis and posterior tibial pulses; capillary refill < 2 seconds. Radiographic assessment demonstrates persistent fracture gap, lack of bridging callus, and sclerotic bone ends consistent with nonunion.
Treatment Protocol
Plan: 1. Obtain inflammatory markers (ESR, CRP) to rule out occult infection. 2. Discuss surgical revision options, including exchange nailing, bone grafting (autograft/allograft), or compression plating. 3. Consider adjunctive therapies such as low-intensity pulsed ultrasound (LIPUS) or bone stimulators. 4. Maintain protected weight-bearing as tolerated with assistive devices. 5. Follow-up in [Number] weeks for repeat imaging.