J Orthop Trauma, Vol 21, No.8, Sept 2007
Author: Mark R. Brinker, MD, Daniel P. O'Connor, PhD, Yomna T. Monla, MD,
and Thomas P. Earthman, MD
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published article by Dr Brinker
Objectives: To determine whether patients with unexplained
nonunions, patients with a history of multiple low-energy fractures
with at least one progressing to a nonunion, and patients with a
nonunion of a nondisplaced pubic rami or sacral ala fracture would
have an underlying metabolic or endocrine abnormality that had not
been previously diagnosed.
Design: Case series.
Setting: Tertiary referral center.
Patients and Intervention: From a larger series of 683 consecutive
patients with nonunion seen by us between January 1998 and
December 2005, 37 patients were referred to 1 of 2 clinically practicing
endocrinologists to undergo an evaluation for metabolic and endocrine
abnormalities. The screening criteriawere: 1) an unexplained nonunion
that occurred despite adequate reduction and stabilization (and
debridement in initially infected cases) without obvious technical
error and without any other obvious etiology; 2) a history of multiple
low-energy fractures with at least one progressing to a nonunion; or
3) a nonunion of a nondisplaced pubic rami or sacral ala fracture.
Results: In all, 31 of the 37 patients (83.8%, 95% CI: 71.3% to
93.8%) who met our screening criteria had one or more new diagnoses
of metabolic or endocrine abnormalities. The most common newly
diagnosed abnormality was vitamin D deficiency (25 of 37 patients;
68%). Other newly diagnosed abnormalities included calcium
imbalances, central hypogonadism, thyroid disorders, and parathyroid
hormone disorders. All newly diagnosed abnormalities were treated
medically. Eight patients who underwent no operative intervention
following the diagnosis and treatment of a new metabolic or endocrine
abnormality achieved bony union in an average of 7.6 months (range,
3 to 12 months) following their first visit to the endocrinologist.
Conclusions: Although our study does not prove a causal link
between metabolic and endocrine abnormalities and either the development
or healing of nonunions, 84% of the patients who met our
screening criteria were found to have metabolic or endocrine abnormalities,
and eight of our patients achieved bony union following
medical treatment alone. All patients with nonunion who meet our
screening criteria should be referred to an endocrinologist for
evaluation because they are likely to have undiagnosed metabolic
or endocrine abnormalities that may be interfering with bone healing.
KeyWords: fractures, ununited, bone, hormone, calcium, vitamin D,