From the Guidelines
I strongly recommend an immediate orthopedic consultation for this fracture that shows incomplete healing and excessive bone formation around the injury site, as indicated by the lack of complete bony ankylosis and exuberant periosteal new bone formation, suggesting potential lack of adequate fixation. The findings of incomplete bony ankylosis (meaning the fracture hasn't fully fused together) combined with exuberant periosteal new bone formation suggest the current fixation method is inadequate. This situation requires specialized evaluation by an orthopedic surgeon who can assess whether surgical intervention is needed, such as revision surgery with more stable fixation using plates, screws, or other hardware appropriate for the specific fracture location, as suggested by the American College of Radiology in their 2021 update on inflammatory back pain 1.
The excessive bone formation (callus) around the fracture site is the body's attempt to stabilize an unstable fracture, which can lead to malunion or nonunion if not addressed. Proper fixation is crucial because it provides the stability needed for appropriate bone healing, minimizes excessive callus formation, and helps prevent long-term complications like chronic pain, limited function, or arthritis. According to the 2021 update, CT and MRI are the imaging techniques of choice for definitive evaluation of the patient with ankylosis and suspected fracture, with CT being typically the preferred modality in the acute posttraumatic setting 1.
While waiting for the orthopedic consultation, the patient should follow weight-bearing restrictions for the affected area and continue any prescribed pain management regimen. It is also important to note that if neurologic symptoms are present, MRI without contrast would be recommended for the evaluation for spinal cord, nerve root, and ligamentous injuries, as stated in the ACR Appropriateness Criteria for chronic back pain suspected sacroiliitis-spondyloarthropathy 1.
Key considerations for the orthopedic consultation include:
- Assessing the need for surgical intervention to achieve stable fixation
- Evaluating the potential for malunion or nonunion and its implications for long-term outcomes
- Discussing the role of imaging modalities like CT and MRI in guiding treatment decisions
- Developing a plan for pain management and rehabilitation to optimize the patient's quality of life.
From the Research
Orthopedic Consultation Indications
The lack of complete bony ankylosis at the fracture site and exuberant periosteal new bone formation may suggest a potential lack of adequate fixation, indicating the need for orthopedic consultation.
Relevant Studies
- The study by 2 suggests that atrophic nonunion fractures are caused by severe damage to the periosteal mesenchymal progenitors and are accompanied by an extraskeletal, fibro-cellular response.
- Another study by 3 discusses the mechanisms of pathologic new bone formation, which can interfere with the normal function of the joint and contribute to disability in inflammatory joint diseases.
- The study by 4 reviews the molecular biology and physiology of bone development and fracture healing, highlighting the importance of understanding these processes in reconstructing critical sized bony defects.
Key Findings
- The formation of new bone can be a complex process, involving various molecular mechanisms and pathways 5, 6.
- In some cases, new bone formation can lead to ankylosis, resulting in joint or spine fusion 3, 6.
- The use of biologics, such as TNF-α blockers, may help slow radiographic progression in patients with ankylosing spondylitis, but its impact on slowing structural damage is still a matter of debate 5.
Implications for Orthopedic Consultation
- Orthopedic consultation may be necessary to assess the adequacy of fixation and to develop a treatment plan to promote proper bone healing and prevent further complications.
- Understanding the molecular mechanisms of new bone formation and ankylosis can help inform treatment decisions and optimize patient outcomes 2, 4.