A 35-year-old man sustains a closed midshaft tibial fracture. At 6 months post-intramedullary nailing, X-ray shows persistent fracture gap with sclerotic bone ends and no callus bridging. The most appropriate next step is:

• A Continue expectant management for 3 more months
• B External fixation with distraction osteogenesis (Ilizarov)
• C Plate fixation without bone grafting
• D Exchange nailing with a larger diameter nail and bone grafting ✓

Explanation

Atrophic non-union at 6 months post-IM nailing is best managed by exchange nailing (larger diameter nail providing better stability and fresh bone marrow autograft) plus bone grafting to restore biological environment. Exchange nailing improves rotational stability and introduces viable osteogenic cells from the medullary canal. Expectant management is inappropriate for established non-union. Ilizarov is reserved for infected non-union or significant bone loss. Plate fixation alone without biological augmentation is less preferred for atrophic non-union.

Reference: Maheshwari Essential Orthopaedics, 6th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.