Case Report
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Orthop. May 18, 2022; 13(5): 528-537
Published online May 18, 2022. doi: 10.5312/wjo.v13.i5.528
Intramedullary bone pedestal formation contributing to femoral shaft fracture nonunion: A case report and review of the literature
Charles B Pasque, Alexander J Pappas, Chad A Cole Jr
Charles B Pasque, Alexander J Pappas, Department of Orthopaedic Surgery and Rehabilitation, University of Oklahoma College of Medicine, Oklahoma City, OK 73104, United States
Chad A Cole Jr, University of Colorado School of Medicine, Aurora, CO 80045, United States
Author contributions: Pasque CB contributed to the conceptualization, design, data collection, methodology, project administration, supervision, writing, and revising of the manuscript; Pappas AJ contributed to the initial data collection and writing of the manuscript; Cole Jr CA contributed to the data analysis, literature review, and revision of the manuscript; and all authors have read and approved the final manuscript.
Informed consent statement: Informed written consent was obtained from the patient for publication of this report and any accompanying images.
Conflict-of-interest statement: Each of the authors declare no conflict of interest.
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Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Charles B Pasque, MD, Professor, Program Director, Team Physician, Department of Orthopaedic Surgery and Rehabilitation, University of Oklahoma College of Medicine, 800 Stanton L. Young Blvd, AAT-3400, Oklahoma City, OK 73104, United States. charles-pasque@ouhsc.edu
Received: August 28, 2021
Peer-review started: August 28, 2021
First decision: November 17, 2021
Revised: November 28, 2021
Accepted: April 25, 2022
Article in press: April 25, 2022
Published online: May 18, 2022
Processing time: 257 Days and 8 Hours
Abstract
BACKGROUND

Femoral shaft fracture is a commonly encountered orthopedic injury that can be treated operatively with a low overall delayed/nonunion rate. In the case of delayed union after antegrade or retrograde intramedullary nail fixation, fracture dynamization is often attempted first. Nonunion after dynamization has been shown to occur due to infection and other aseptic etiologies. We present a unique case of diaphyseal femoral shaft fracture nonunion after dynamization due to intramedullary cortical bone pedestal formation at the distal tip of the nail.

CASE SUMMARY

A 37-year-old male experienced a high-energy trauma to his left thigh after coming down hard during a motocross jump. Evaluation was consistent with an isolated, closed, left mid-shaft femur fracture. He was initially managed with reamed antegrade intramedullary nail fixation but had continued thigh pain. Radiographs at four months demonstrated no evidence of fracture union and failure of the distal locking screw, and dynamization by distal locking screw removal was performed. The patient continued to have pain eight months after the initial procedure and 4 mo after dynamization with serial radiographs continuing to demonstrate no evidence of fracture healing. The decision was made to proceed with exchange nailing for aseptic fracture nonunion. During the exchange procedure, an obstruction was encountered at the distal tip of the failed nail and was confirmed on magnified fluoroscopy to be a pedestal of cortical bone in the canal. The obstruction required further distal reaming. A longer and larger diameter exchange nail was placed without difficulty and without a distal locking screw to allow for dynamization at the fracture site. Post-operative radiographs showed proper fracture and hardware alignment. There was subsequently radiographic evidence of callus formation at one year with subsequent fracture consolidation and resolution of thigh pain at eighteen months.

CONCLUSION

The risk of fracture nonunion caused by intramedullary bone pedestal formation can be mitigated with the use of maximum length and diameter nails and close follow up.

Keywords: Nonunion; Femoral shaft fracture; Diaphysis; Fracture fixation; Antegrade intramedullary nail; Case report

Core Tip: Femoral shaft fracture nonunion after surgical fixation is a rare complication known to be associated with infection, anatomic abnormalities, hardware failure, and other aseptic etiologies. It is now known that intramedullary bone pedestal formation can also be a cause of nonunion after fracture dynamization. In order to prevent this complication, surgeons should elect to use a maximal length intramedullary nail during initial fixation and follow up closely if the patient is showing signs of delayed union.