Hi gaelic i broke my right tibia on nov. 6 2012 in a
motorcycle accident (open fracture type 3a or 3b not
really sure) note with bone loss and a gap of 1 or 1.5
inch. My 1st surgery was on nov 7 were they put ex
fix. I've been on ex fix for 2 months and on 6th of
jan. 2nd surgery IM nail and bone graft which my OS
took bones at both of my hips.. my first xray was at 5
weeks (feb 11, 2013) my OS told me that the fracture
was now consolidating he told me to come back after
45 days.my 2nd xray (march 23 2013) looks not much
different from my previous one i didn't notice any
callus formation but my OS is not worried at all he
said there are little positive changes at my my xray
but less than what he is expecting..I ask my OS if im
on a delayed union he said no..Im afraid im not
healing its been 5 months since the accident..how
long it will take for my bone grafted fracture to unite?
my next appt is on april 30...13 weeks of no
weightbearing is so frustrating.Im totally disappointed
that i didn't see any callus formation..how long it will
take to see a callus?I thought the bone graft will jump
start the healing process?I don't have any pain at the
fracture site even at my hips i don't have any
pain..thank u in advance
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replied April 7th, 2013
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kalixren,

Sorry you are having such problems. But, glad you are doing well pain wise.


With that much actual bone loss, you have have had a 3B, by definition, according to the Guistilo-Anderson classification. (The only thing worse is a 3C.)


As to not seeing any callus formation at your first visit after the bone grafting, try not to worry too much about that. You have to remember that, after a cancellous bone grafting, it is not like right after a fresh fracture, where you would want to see some whisps of callus formation, around the fracture site. In a fresh fracture site, there is bleeding around the bone (hematoma formation), and it is within this hematoma that the whisps of callus start to form.

But, in a callcellous bone grafting situation, the healing is starting in, and going on in, the cancellous bone graft. So, you most likely will not see a whole lot of callus formation going on. The cancellous bone graft will start to get denser and will start to look more and more like cortical bone.


You have the IM nail in place, to help with the structural support, and the cancellous bone graft to bring in the osteoproginetor cells to jump start the healing and to also provide some structural scaffolding upon which to grow new bone.


As long as you are following your surgeon's instructions and do not have any pain at the fracture site, you are probably just fine.


I understand that it is frustrating, that you would like to have gotten back to riding a motorcycle months ago. But, by the same token, just a few years ago, you could have easily ended up with a primary amputation with that type of injury. Once this is healed, and you have your own foot, and everything is said and done, it will be worth it. You just have to hang in there a little while longer.


Again, the fact that you do not have any pain is a good sign. Just do not push it too much. Follow your surgeon's instructions. Don't go an' blow it now.


Good luck.

Wishing you the best.
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replied April 8th, 2013
Thank you so much Gaelic, you're very helpful and informative. I took a pic of my xrays coz I want to know your opinion about my xrays.Does my xrays show's
signs of healing?Here's the URL to the pics.
http://i1282.photobucket.com/albums/a529/k alixren/tibia%20xray/xray4_zps315ad1cb.jpg
http://i1282.photobucket.com/albums/a529/k alixren/tibia%20xray/xray3_zps92e703bd.jpg
http://i1282.photobucket.com/albums/a529/k alixren/tibia%20xray/xray2_zpsb21bd444.jpg
http://i1282.photobucket.com/albums/a529/k alixren/tibia%20xray/xray1_zps823244e2.jpg
The 1st 2 images was my xray 5 weeks after bone grafting (feb 11, 2013) and the last 2 images was my xray on march 23 2012 (11 weeks after bone grafting).
Once again thank you for all your efforts.
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replied April 9th, 2013
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kalixren

Sorry about your injury.

You have had a very significant loss of bone. The only good thing in this accident, is that it is located in the proximal tibia, just at the proximal metaphyseal flare.

Bone loss like this, were it to occur in the distal tibia, would be very bad indeed. But, luckily, in the proximal tibia, the bone loss is under the muscle mass, so there is good blood supply to the bone.


The overall alignment of the fracture, with the IM nail in place is very good. From the pictures shown, the fibula is intact, which will help to strut the bone during healing.


There appears to be very good consolidation of the bone graft beginning, especially notable on the AP view. There appears to be a connection of the distal fragment to some new bone formation, on the medial side. The changes are going to be very subtle at this point. It will probably be more noticeable when you get your next set of x-rays, and compare them to the first ones.


But, considering what you started with, this looks like it is going pretty well. I understand it can be very frustrating. However, at least you are now out of the ex fix, with an IM nail and bone grafting done. So, healing can get on with it.

Follow your surgeon’s instructions, especially in regard to weight bearing. Eat a proper diet. Do not smoke. Maintain your weight. Maintain a good aerobic conditioning program.

If your wounds are healed, you might want to look into getting into a pool for some therapy. In chest deep water, the buoyancy makes the exercises nonweight bearing. The warmth of the water makes the tissues more pliable. The exercises are safe, as you cannot fall down in the water. And, it is nice to get out of the house once in a while.


So, again, with only those two sets of x-rays to compare to, it actually looks pretty good. Try to hang in there.

Good luck.
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replied April 27th, 2013
tibia bone graft
Hi Gaelic,
Just an update, this morning was my 16th week appointment.im still not allowed to bear weight..Anyway Im happy about the result of my new sets of xrays callus formation are now visible specially at ap view...Gaelic I just want to know your opinion why is it Im still not allowed to bear weight?does my fracture is unstable?Here is the url to the pics
http://s1282.photobucket.com/user/kalixren /media/xray3_zps7bd7d474.jpg.html?sort=3&o =5
http://s1282.photobucket.com/user/kalixren /media/xray2_zps152b7838.jpg.html?sort=3&o =6
Thank you Gaelic your advices and opinions help me a lot..
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replied May 9th, 2013
Hi Gaelic

I had a small soft lump at my wound now which started 2 weks ago i don't know what it is and there is a yellowish pus coming out of the lump.Please give me an advice i don't know what to do i want to see my surgeon but he is out of the country right now.
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replied May 10th, 2013
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kalixren,

Unfortunately, this does not sound too good. You might be developing as abscess, especially since you have purulent drainage.

You should probably contact your surgeon's office and ask who is "covering" for him. You may need to have something done sooner rather than later.

You do not want to get a deep infection in the bone (osteomyelitis), as it is very difficult to treat.

So, again, contact your surgeon's office. He should have another surgeon covering his patients while he is out of the country.

Sorry you are having problems. Good luck.
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replied May 10th, 2013
Hi Gaelic I had my check up today..My new OS said that the lump is an early sign of infection he told me that there might be some foreign objects still left inside of my leg that is finding a way to come out of my leg thats the cause of my soft lump or it might be osteomyelitis.He prescribed me antibiotics (ciprofloxacin and clindamycin) hopefully the antibiotics will do the healing if not i have to undergo debridement surgery..This new development was a big setback..Gaelic I've noticed that there's a hole at the center of the lump, do you think it is abscess?Can you explain to me what is abscess?what do you think about my infection?is it worse?Im sorry for my english im not good at communicating in english please understand me it is just my 2nd langauage..Thank you very much for your help and quick reply I really appreciate your help.
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replied May 10th, 2013
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Kalixren,

Your english is very good.

An abscess is a pocket of pus (pus is dead cells and debris, also called purulant material). It forms when there is an infection under the skin.

If there is a hole in the lump, it could be a spot where the abscess is draining from.

Hopefully, the antibiotics will take care of the abscess (infection). If not, like the surgeon stated, you will have to have it opened and drained (cleaned out).

Unfortunately, any time one does surgery, there is a chance of infection developing. In orthopedic surgery, sometimes it can take a while to show up.

Sorry you are having problems. Hang in there.

Good luck.
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replied May 10th, 2013
Thank you for your quick reply Gaelic. By the way I've done some research about abscess I don't have the symptoms of abscess like pain, tenderness and swelling.The pus that coming out of the lump seems subsided hopefully it will stop.I also done some research about osteomyelitis and Im scared of that infection I've been through a lot of problems about this injury hopefully this is not osteomyelitis im keeping my finger cross.Do you think the antibiotics will take care of the infection?Base on what i have read in other thread you mention that antibiotics alone will not do the healing.Is it true?If my lump is abscess do you think it wil become ostemyelitis?
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replied May 10th, 2013
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kalixren,

It may be that you have a superficial infection (away from the bone), which is in its early stages. In those cases, sometimes antibiotics will take care of the problem.

Once an infection develops into an abscess, with the formation of the pocket of pus, antibiotics alone will usually not take care of the problem. The abscess has to be surgically drained and any nonviavble tissue debrided.

Osteomyelitis is a bad thing to have. It is very difficult to treat. That is why it is important to get any inflammation or infection taken care of quickly, before the bone can become involved.

Hope the antibiotics take care of the problem. If the draining is going down, and you do not have any pain or systemic symptoms (fever, chills, malaise, etc), you are probably doing okay. But, do keep on top of the situation.

Good luck.
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replied May 10th, 2013
Gaelic does this infection affect the healing process of my bone graft?Do i need to clean the lump everyday with povidone iodine and hydrogen peroxide?The draining sometimes goes down and sometimes it continues.Hopefully I will overcome this problem.

Thank you Gaelic I'll keep you updated from time to time.5
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replied May 11th, 2013
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kalixren,

If you have an open wound (even if it is very small), yes, it should be kept clean and covered with a small dressing. The best way to clean the wound is to just get in the shower and clean it thoroughly under the running water with just plain soap. Then, after the shower, just put a small guaze dressing over the opening.

If you want to use a topical antibiotic ointment, that is fine. But, you still need to wash it off and clean the wound thoroughly everyday. Patients, when they use the ointment, often forget to clean the wound and just keep applying the ointment. That is not a good thing to do, as the wound needs to be washed with soap and water everyday.


As long as the infection does not get down to the bone, it will not affect the healing of the bone graft.

It is interesting, that it has been found in cases of slight infection, that the bone actually heals faster. But, in cases of a significant infection, it prevents the healing. So, it is best to prevent infection from occuring, because you never can tell if the infection is little and going to help, of if it is going to increase and become a problem.


Keep an eye on the wound and your symptoms. If you start to develop pain and systemic symptoms, get in touch with your surgeon as soon as possible.


Good luck.
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replied May 11th, 2013
Thank you very much Gaelic for keeping my spirit high. I will follow all your advice to me regarding cleaning my wound hopefully this is just a slight infection..I'll keep you posted if there is a new development.

Once again thank you I really appreciate all your help and advice.
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replied May 12th, 2013
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kalixren,

No problem. Keep us informed an how you are doing.

Good luck.
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replied June 7th, 2013
Hi Gaelic I had another lump this time it is located where the distal screw was inserted..It looks like there is a pus inside the lump..Gaelic this is the 2nd time in a month that a lump came out of my leg the 1st one was located at my wound (1 inch below proximal screw).Do you have any idea what is the cause of this lump?
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replied June 7th, 2013
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kalixren,

Unfortunately, no I do not know what is causing the lumps. But, if it is an abscess, with pus in it, it needs to be opened so it can drain.

You may have an indolent infection around your leg, and it shows up occasionally. The pus in the abscess needs to be sent to pathology, so it can be examined, to see what organisms are in it. That way the surgeon can order the right antibiotic for the organism.

Have you seen your surgeon? Again, if it is an abscess, it needs to be treated.

Sorry you are having problems.

Wishing you the best.
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replied June 8th, 2013
Hi Gaelic
I went to my OS this morning and I did mention to him that this is the 2nd time in a month that a lump with a pus came out of my leg.He just check the lump and press it and ask me if it is painful I answer him no because the lump doesn't hurt that much so he told me that maybe it is superficial infection like what you told me..He just gave me antibiotic prescription..By the way my OS ordered me to have my CBC test here is the result of my CBC test

TEST RESULT NORMAL RANGE S.I.UNITS
Hemoglobin 150.0 M:140 - 180 g/dl
Hematocrit 0.45 M:0.42 - 0.54
WBC Count 7.0 4.0 - 11.0 x 9/L
Segmenters 0.85 0.36-0.70
Lymphocytes 0.13 0.22 - 0.40
Eosinophils 0.02 0.01 - 0.04
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replied June 8th, 2013
Hi Gaelic
I went to my OS this morning and I did mention to him that this is the 2nd time in a month that a lump with a pus came out of my leg.He just check the lump and press it and ask me if it is painful I answer him no because the lump doesn't hurt that much so he told me that maybe it is superficial infection like what you told me..He just gave me antibiotic prescription..By the way my OS ordered me to have my CBC test here is the result of my CBC test

TEST RESULT NORMAL RANGE S.I.UNITS
Hemoglobin 150.0 M:140 - 180 g/dl
Hematocrit 0.45 M:0.42 - 0.54
WBC Count 7.0 4.0 - 11.0 x 9/L
Segmenters 0.85 0.36-0.70
Lymphocytes 0.13 0.22 - 0.40
Eosinophils 0.02 0.01 - 0.04
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replied June 8th, 2013
Hi Gaelic
I went to my OS this morning and I did mention to him that this is the 2nd time in a month that a lump with a pus came out of my leg.He just check the lump and press it and ask me if it is painful I answer him no because the lump doesn't hurt that much so he told me that maybe it is superficial infection like what you told me..He just gave me antibiotic prescription..By the way my OS ordered me to have my CBC test here is the result of my CBC test

TEST RESULT NORMAL RANGE S.I.UNITS
Hemoglobin 150.0 M:140 - 180 g/dl
Hematocrit 0.45 M:0.42 - 0.54
WBC Count 7.0 4.0 - 11.0 x 9/L
Segmenters 0.85 0.36-0.70
Lymphocytes 0.13 0.22 - 0.40
Eosinophils 0.02 0.01 - 0.04
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replied June 8th, 2013
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kalixren,

Your CBC looks fine, the WBC count is within normal limits.

Did your orthopedic surgeon order any of the inflammatory markers? Such as a ESR or a CRP? These are more sensitive to the presence of an infection.

But, hopefully, the antibiotics will take care of the superficial infection.

Good luck.
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replied July 1st, 2013
Hi Gaelic I went to my OS this morning for follow up check up and he ordered me to go the lab for wound culture because my lump which became a wound was not healing I will know the result after 5 to 7 days..I just want to ask you why is it that my wound is not healing?If the result of the wound culture is positive for bacteria or infection what will be the next step of my OS?By the way my ESR result 3 weeks ago was 19.0mm/hr (NORMAL: MALE= 0-10 mm/hr.)It's been 6 moths since my bone graft surgery why is it that i'm not still allowed to bear weight?I already read all of the thread here in your forum and much of the patients was allowed to bear weight after a short period of time but in my case it's been 6 months and yet i'm not allowed tobear weight?
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replied July 10th, 2013
Hi Gaelic the result of my wound culture and gram stain are negative of bacteria according to my OS but my wound is healing slow..Gaelic it's been 26 weeks since my bone graft surgery but still im not allowed to bear weight how long do i need to wait to finally start bearing weight?please help me Gaelic your the only one answering all my questions..thank you in advance gaelic
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replied July 12th, 2013
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kalixren,

It is a bit strange to keep a patient nonweight bearing for such a long period of time. Usually, if the bone is just not healing, then something has to be done. It is not a great idea to continue nonweight bearing status for extended time. This leads to significant ostroporosis.


Sounds like you need to discuss the situation with your surgeon. Again, something needs to be done.


Good luck.
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