A CLINICAL STUDY ON SURGICAL MANAGEMENT OF TIBIA SHAFT
FRACTURES BY INTRAMEDULLARY INTERLOCKING NAIL
M. Nageshwara Rao1, K. B. Vijaya Mohan Reddy2, A. M. Ilias Basha 3, G. Praneeth Kumar Reddy4
HOW TO CITE THIS ARTICLE:
M. Nageshwara Rao, K.B. Vijaya Mohan Reddy, A. M. Ilias Basha, G. Praneeth Kumar Reddy. “A Clinical Study on Surgical Management of Tibia Shaft Fractures by Intramedullary Interlocking Nail”. Journal of Evidence based Medicine and Healthcare; Volume 2, Issue 39, September 28, 2015; Page: 6458-6463, DOI: 10.18410/jebmh/2015/884
ABSTRACT: To assess and study tibial shaft fractures presented to Orthopaedic department at Government General Hospital, Kurnool and to evaluate the final outcome of patients with tibial shaft fracture operated with intramedullary interlocking nailing. The procedure is safe with no morbidity, relatively few complications and helpful in early recovery after surgery.
KEYWORDS: Shaft fractures of tibia, Closed nailing, Interlocking nail.
INTRODUCTION: With the increasing number of vehicles on roads in India, complex trauma cases caused by road traffic accidents have increased progressively. Being sub-cutaneous in location, the tibia is the commonest bone to be fractured and seen commonly in orthopedic practice.
Open fractures are more common, because one third of its surface is subcutaneous throughout most of its length. Furthermore, the blood supply to the tibia is more precarious than that of bones enclosed by heavy muscles. The presence of hinge joints at the knee and ankle allows no adjustment for rotational deformity after a fracture. Delayed union, non-union and infection are relatively frequent complications especially after open fractures of the shaft of tibia. Management of the fractures of the shaft of the tibia remained a controversial subject despite advances in both non-operative and operative care. Several published series regarding treatment of fractures of the shaft of tibia have shown that closed treatment of fractures can have excellent results. Immobilization in a plaster cast has been used most commonly in the past, but it does not always maintain the length of the tibia and it leaves the wound relatively inaccessible.1This has led
to the thought of other modalities of treatment, finally resulting in the use of closed interlocking intramedullary nailing which has given excellent results. Management of the fractured tibia requires the widest experience, greatest wisdom and the best of clinical judgment in order to choose the most appropriate treatment for a particular pattern of injury.2
Now-a-days the well laid principle of biological osteosynthesis is rightly applied in long bone fracture healing and hence the selection of closed intramedullary interlocking nailing in this study. The following study highlights the role of closed interlocking nailing used for treating the fractures of the shaft of tibia.
the study. All the patients had X-ray evaluation of the tibial shaft fractures and any associated fractures. The occupation of the patient was noted, the mode of injury was noted.
After general physical examination and systemic examination to rule out other injuries and co morbidities, local examination is done and provisional diagnosis is made. Required x-rays were taken and regular blood, viral, urine investigations were done, pre operatively patient is put on above knee pop slab. Length of the intramedullary nail is measured from tibial tubercle to medial malleolus. The procedure is planned under C-ARM guidance. All surgeries were done under spinal anaesthesia under tourniquet control on an ordinary fracture table with leg hanging by the side of the table. Draping of leg done, Standard vertical midline incision was used. Some surgeons use a transverse incision placed halfway between the joint line and tibial tubercle.3 Entry portal is made
2 cm proximal in the midline or slightly medial and behind the tibial tubercle. Using curved awl, guide wire, appropriate size reamers tibia prepared, nail size determined by subtracting exposed length or by using another nail of same size and by using C-ARM. Nail mounted on to zig and inserted with distal locking done by C-arm and free hand technique and both proximal and distal are locked using locking screws. Postoperatively, the limb is elevated on a pillow. Post-operative complications like fat embolism, compartment syndrome, vascular injury and wound infection are watched for in the postoperative period. Parenteral antibiotics were given for 3 days and orally till suture removal which was done on 10th post-operative day. Active quadriceps exercises are started
on the first postoperative day with active ankle and toe movement with knee mobilization. Radiograph of the leg is taken to assess the fracture alignment, nail placement and locking screws. The patient is made to walk from the 3rd postoperative day without bearing weight on the operated leg.
FOLLOW UP: Patients were evaluated using Johner and Wruh’s criteria.4 The complaints were
noted and the clinical and radiological assessment of the patients were done, for pain, deformity, shortening, range of motion of knee, ankle and subtalar joints and radiological union.
Pain was noted as none, occasional, moderate and severe.
Deformity was noted as none, anteversion-recurvatum, varus-valgus and rotation deformity in degrees. Shortening was noted in cms or nil if absent.
Range of motion of knee, ankle and subtalar joints were noted in percentage. 100%-normal, >80% for knee, >75% for ankle and >50% for subtalar joint-good. Radiological assessment was done on the basis of presence of callus or union or if fracture is consolidated. Radiological union was noted as consolidated for excellent and good results. Union for fair results and not consolidated for poor results at 6 months. Angular alignment was assessed radiologically. Varus-valgus and Antero posterior alignment were determined, rotations were assessed clinically. Malunion when varus-valgus angulation >50, anteroposterior angulation >100, rotations >100 and
shortening >1cm. Weight bearing was done, initially partial weight bearing at the 4th week
depending on type of fracture and rigidity of fixation. Full weight bearing is allowed after bridging callus is seen and there is solid union, usually at 10-12th week. Late delayed complications like
screw breakage, nail bending, mal-union, non-union, limp, anterior knee pain and infection is noted and any secondary procedure done is noted in the pro forma.
fracture site was not tender on palpation, radiograph showed osseous union in antero-posterior and lateral views. They were graded as excellent, good, fair or poor using Johner &Wruh’s criteria.4
RESULTS: In the present series, the following results are obtained. There were 34 males and 6 females Minimum age of the patient was 18 years and the maximum age was 60 years. Average age of the patient was 34.75 years. The tibial shaft fractures were common in the age group of 31-40 years in our study. In this study, males pre dominate the female sex. The present study has 85% males and 15% females. In this study, right tibia was affected in 75% and the left tibia in 25% of all the patients. In this study, road traffic accidents were the most common nature of injury causing tibial shaft fractures in 34 of all patients and accounted for 85% of tibial fractures. The commonest anatomical location of fracture was at the middle-third of the tibia which constituted for 50% of tibial shaft fractures. In this study 30 fracture were simple (75%) and 10 fractures were Gustilo Grade-I compound fractures (25%). In this study, transverse fractures were seen in 35% of patients, followed by comminuted fractures in 25% of patients, followed by oblique fractures in 20% of patients. Wedge fractures were seen in 10% of patients. In this study, 30 cases (75%) had ipsilateral fibular fractures, 10 cases had intact fibula
Associated Injuries: One patient had fracture of metatarsal (Left) which was fixed with a K-wire. Two patients had fracture of distal radius and were managed by percutaneous k wire fixation.
In this study, partial weight bearing was started at 4th week in 20 patients (50%), at 6th
week in 10 patients (25%) and at 12th week in 10 patients (25%).Full weight bearing was started
at 10th week in 20 patients (50%), at 12th week in 10 patients (25%) and at 14th week in 8
patients (20%). In our study, majority of fractures united within 20 weeks. This is comparable with other series. The average healing time was 19 weeks.
In this study 60% patients had excellent or good functional results and 30 percent had good functional outcome, while only 10 percent had fair functional outcome.
DISCUSSION: Tibial shaft fractures are commonest in day to day orthopedic practice. The optimal management of tibial shaft fractures continues to be a problem with several unanswered questions. Open reduction and internal fixation with plates and screws has yielded unacceptably high rates of infection.5 This method may be selected with more severe or local injuries associated
displaced intra articular fractures of knee and ankle.
External fixation, considered the treatment of choice by many traumatologists, has the disadvantages of bulky frames and frequent pin track infections, non-unions, and malunions.5,6
The intramedullary nailing, locked or unlocked has become an attractive option since image intensifier has made closed intramedullary nailing possible. Nail is a load sharing device and is stiff to both axial and torsional forces. Closed nailing involves least disturbance of soft tissue, fracture haematoma and natural process of bone healing as compared to other forms of internal fixation.
A total of 40 patients with tibial shaft fractures are included in the present study. In our study, males predominated the females. There were 34 male patients (85%) and 6 female patients (15%). The incidence of males is higher because of their more outdoor activities, while women confined themselves to the domestic activities.
Court Brown et al.,7 (1990) in their series noted the male incidence to be around 81.3%,
while the female incidence to be around 18.7%. Hooper et al.,8 (1991) noted male incidence at
82% and female incidence at 18%. In this study, the majority of the patients were in the age group of 31-40 years. There were 16 patients in this age group in our study series. The average of the patient in our study was 34.75 years. Tibial shaft fractures were seen in physically active younger age group. Arne Ekeland et al., (1988) in a study series of 45 patients noted the average age of patients to be around 35 years. Court Brown et al.,7(1990) noted the average age to be
32.4 years. Average age was seen to be around 37 years in a study by Court Brown et al.,7 in
1995. In this series, we have found that majority of the tibial shaft fractures occurred due to road traffic accidents (34 patients). Majority were motorists, remaining were pedestrians or pillion drivers. The incidence of fracture shaft of tibia due to road traffic accidents in Court Brown et al.,7
(1995) was around 37.5%. Hooper et al.,8 (1991) reported a 59% incidence due to road traffic
accidents in his series.
In our series, the anatomical location of the fracture was in the middle-third of the shaft of tibia in 20 (50%) patients, followed by the lower third in 10(25%) of the cases. Hooper et al.,8
(1991), where 48% were middle-third fractures and Court Brown et al7 (1995), where 44% were
middle-third fractures. Our series had an higher incidence of transverse fractures in 35% of cases, oblique fractures made up 20% cases. Oblique and transverse fractures made 55% fractures (22 patients). Court Brown et al.,7 (1995) reported 37.2% of transverse and oblique fractures. The
fibula was fractured along with the shaft of tibia in our series in 25% of cases, in the series of Court Brown et al.,7 (1995), where the fibula was fractured in 77.7% of the cases. The associated
fracture of the fibula, in most cases reflects on the high-velocity injury pattern. Full weight bearing in our series was started at 10th week in 20 patients (50%) at 12th week in 12 patients (30%) and
at 14th week in 8 patients (20%). The appearance of bridging callus was used to assess and allow full weight bearing. The average time was 9 weeks. Full weight bearing delayed in 10 patients as there were comminuted fractures. This is comparable to Lawrence B. Bone et al.,9 (1986), wherein
his study weight bearing has been delayed in unstable fractures. In 4 patients, there was restricted mobility of knee, ankle and subtalar joints. Fracture union was considered when patient was full weight bearing without pain, fracture site was not tender on palpation and radiograph showed osseous union. In our series, majority of fractures united within 20 weeks (32 patients).The average time of union 19 weeks. This is comparable to the study done by Lawrence B. Bone et al.,9 (1986) who reported average union time at 19 weeks. Court Brown et al.,7 (1990)
reported average union time at 16.7 weeks. Arne Ekeland et al., (1988) reported average union time at 16 weeks. In this series, average time of union was 19 weeks.
Complications: Lawrence B. Bone et al.,9 (1986) noted an infection rate of 6.25%. Arne Ekeland
et al., (1988) noted infection rate of 4.4%.Blachut PA et al.,10 (1997) noted an infection rate of
Anterior knee pain was seen in four patients 10%. Due to nail abutting the patellar tendon, causing anterior knee pain and will be relieved after removal of the nail. Anterior knee pain can be compared to Hernigou P et al.,11 (2000), who noted improper entry of nail into medullary canal,
may cause anterior knee pain.
Jarmo AK Toivannen et al.,5 (2002) noted anterior knee pain to be common in tibial
intramedullary nailing. Final assessment in our series was done at 6 months using the Johner and Wruh’s criteria.4In our series, 60% (34 patients) have got excellent, 30% (12 patients) have
good, 10% (4 patients) have fair functional outcome.
Arne Ekeland et al.,(1988) reported 64.4% excellent, 28.8% good and 4.4% as fair.
SUMMARY AND CONCLUSIONS: Majority of the patients was in the age group of 31 to 40 years. Average age of the patient in our series is 34.75 years. Males pre dominated the females in the ratio of 85:15. Right tibia was affected in 75% of the cases. Road traffic accidents were the main mode of injury in 85% of cases. 75% of the fractures were closed and 25% were open (Gustilo-I). Majority of fractures were located in the middle-third (50%) in 20 patients and in lower-third in 10 patients (25%). Transverse and oblique fractures (55%) were common. Fibula was fractured in 25% of cases closed intramedullary interlocking nailing were done in all the 40 cases. Static locking was done in all (40) cases in our series. In our study, partial weight bearing was started at 4th week in 22 patients (55%), at 6th week in 8 patients (20%) and at 8th week in 10
patients (25%). Full weight bearing was started at 10th week in 20 patients (50%), at 12th week in
12 patients (30%) and at 14th week in 8 patients (20%).Final assessment was done after 6months
according to Johner and Wruh’s criteria.4 The average healing time was 19 weeks. There were four
superficial infections and fou patients with anterior knee pain. Four patients had slight shortening. In our study 24 patients (60%) had excellent, 12 patients (30%) had good, 4 patients (10%) had fair functional outcome.
Tibial shaft fractures are common in physically active young people and are commonly due to road traffic accidents. The interlocking nailing combines control of length, alignment and rotation with biological osteosynthesis, lowers the infection and mal union. Patients operated with this technique can be ambulated early and are allowed to resume work early and also reduces the hospital stay. This method of intramedullary interlocking nailing is ideal because of excellent (60%) and good results (30%).With the excellent results and the advantage of rapid rehabilitation and relatively few complications serve to recommend intramedullary interlocking nail for tibial shaft factures for wider use.
REFERENCES:
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2. Watson–Jones: “Injuries of the leg”. Chapter-32 in “Watson-Jones fractures and joint injuries”, 6th ed, Wilson JN (Ed)., B.I. Churchill Livingstone, New Delhi, 1998,1071pp.
3. Court-Brown CM. Fractures of the Tibia and Fibula. In: Bucholz R, Heckman J, Court-Brown C, et al, eds. Rockwood and Green’s Fractures in Adults,6th ed. Philadelphia, PA: Lippincott
4. Johner R, Wruhs O: Classification of tibial shaft fractures and correlation with results after rigid internal fixation. Clin Orthop Relat Res 1983, 178:7-25.
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6. Bach AW., and Hansen Jr. S.T., 1989: “Plates versus external fixation in severe open tibia shaft fractures: A randomized trial”. Clin Orthop. 241: 89-94.
7. Court Brown CM, Christie J, McQueen MM. Closed intramedullary tibial nailing. Journal of Bone & Joint Surgery. 1990; 72B: 605-611.
8. Hooper GJ, Kidell PG, Pennaj ID. Conservative management or closed nailing for tibial shaft fractures – randomized prospective trial. Journal of Bone & Joint Surgery. 1991; 73B: 83-85.
9. Lawrence B Bone, Kenneth D Johnson. Treatment of tibial fractures by reaming and intramedullary nailing. Journal of Bone & Joint Surgery. 1986: 68A: 877-886.
10. Blachut P, A.P.J. O’Brien, R.N.Meek, H.M., Broekhuyse. Interlocking Nailing with or without reaming for the treatment of closed fractures of tibial shaft. Journal of Bone & Joint Surgery, 1997; 79A: 640-646.
11. Hernigou P et al. Proximal entry for intramedullary nailing of tibia. Journal of Bone & Joint Surgery. 2000; 82B: 33-41.
4. Senior Resident, Department of Orthopedics, Kurnool Medical College, Government General Hospital, Kurnool, Andhra Pradesh.
NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:
Dr. M.Nageshwara Rao, Assistant Professor,
Department of Orthopedics, Kurnool Medical College, Government General Hospital, Kurnool, Andhra Pradesh. E-mail: drmnrms@yahoo.co.in
Date of Submission: 16/09/2015. Date of Peer Review: 17/09/2015. Date of Acceptance: 22/09/2015. Date of Publishing: 25/09/2015.
AUTHORS:
1. M.Nageshwara Rao 2. K.B.Vijaya Mohan Reddy 3. A.M.Ilias Basha
4. G.Praneeth Kumar Reddy
PARTICULARS OF CONTRIBUTORS:
1. Assistant Professor, Department of Orthopedics, Kurnool Medical College, Government General Hospital, Kurnool, Andhra Pradesh.
2. Assistant Professor, Department of Orthopedics, Kurnool Medical College, Government General Hospital, Kurnool, Andhra Pradesh.
