- Email: [email protected]
Closed medullary nailing for recent fractures of the tibia
Injury (1988)
19, 180-184
Printedin
Great Britain
180
Closed medullary nailing for recent fractures of the tibia C. J. Hindley Department
of Orthopaedics,
Walton Hospital,
Liverpool
Summary This paper reports the results of a series of recent fractures of the tibia treated by closed medullary nailing. The technique is simple and it has been possible to extend the indications for closed nailing. This method of fixation is biomechanically sound and the semi-rigid fixation obtained prevents significant deformity and seems to provide an ideal environment for fracture healing.
INTRODUCTION CLOSED medullary nailing with an incision distant from the fracture site has been shown to yield very much lower rates of deep infection than generally found with open reduction and compression fixation (Alms, 1962; Zucman and Maurer. 1970; Donald and Seligson. 1983). These results equate with the best published report of closed fractures treated by open reduction and compression fixation (Riiedi et al., 1976). The recently introduced technique of closed interlocking nailing for highly comminuted and metaphyseal fracthe tures (Kempf et al., 1978) has further extended indications for what would seem to be a safer operative treatment of these injuries. Whilst the Swiss experience with open reduction and internal fixation of a large number of fractures of the tibia (Riiedi et al., 1976; Oertli et al., 19X4) remains the standard by which all other operations must he judged: not all centres have been able to reproduce these excellent results. A review of three major series of tibia1 fractures treated in this way revealed deep infection rates varying from 4 per cent to 10.5 per cent (Solheim. 1973; Batten et al.. 1978; Fisher and Hamblen, 1978). Primary bone union is the aim in compression plate fixation whereas, after stable medullary nailing, healing occurs by means of periosteal callus with the gradual transfer of stress from the implant to the bone (Olerud and KarlstrGm, 1979). The use of relatively heavy plates for internal fixation results in osteoporosis due to ‘stress protection’ (Striimberg, 1975). Refracture rates of 0.2 per cent to 6 per cent (Solheim, 1973: Thunold et al., 1975; Riiedi et al.. 1976; Batten et al., 197X). have been reported following implant removal, but this complication does not seem to occur after removal of 1962; Weller et al., 1979; medullary nails (Alms, Donald and Seligson, 1983). Since there will always be a need for internal fixation of some fractures of the tibia, it was decided to undertake a prospective clinical trial to see if the apparently good results reported for closed nailing of the tibia (Alms, 1962; Kempf et al., 1978; Weller et al.. 1979; 0 1%+X Butterworth
cci (‘0 (Publisher>) 00~~~13X.I/XX/0~0IX~H~5 $03U)
Lrd
Donald and Seligson, 1983) could district general hospital.
be reproduced
in a
PATIENTS AND METHODS Twenty-four patients with 25 fractures of the tibia have been treated prospectively in this initial series between February 1984 and March 1986. One patient has been lost to follow-up, leaving 24 fractures in 23 patients. There were 21 male (92 per cent) and 2 female patients with a mean age of 28.6 years (range 17-74 years) who sustained 19 closed and 5 open fractures. There was an associated fracture of the fibula in 19 (79 per cent) cases. There were 11 fractures (48 per cent) of the left leg and 13 (54 per cent) of the right leg. Of the five open fractures, four were classified as grade I1 and there was one grade I injury (Miiller et al., 1979). From a total of 26 individual fractures (including two segmental injuries) 23 were located in the diaphysis. The remaining three were within the proximal or distal quarter of the tibia. The fractures were classified according to cause, type (Van der Linden and Larsen 1979), degree of comminution (Winquist and Hansen, 1980) and displacement (Jackson and Macnab, 1959) as shown in Fig. 1. Primary or delayed primary internal fixation was undertaken in 12 fractures (SO per cent) on account of instability or the presence of an open wound. No grade III open fractures were treated in this way. Eight fractures were internally fixed because conservative treatment had failed and four fractures were internally fixed because there were bilateral lower limb fractures. 15
Fracture Type
RTA
Sport
Fall
Transverse
Segmental
I
Longitudinal 15 10 5
Min
Mod
Sev
E‘ig. 1. Classification
0
of the fractures
1
2
314
181
Hindley: Closed medullary nailing for recent fractures of the tibia
Proximal locking screws were required in 5 (21 per cent) fractures and Herzog anti-rotation wires or distal locking screws in 8 (33 per cent) to control rotation. Anti-rotation wires were used in conjunction with the A0 nails. Alternatively two percutaneous distal locking screws were introduced when using the Grosse and Kempf nail. No attempt was made to compress the fractures intraoperatively as dynamic fracture compression occurred with weight bearing.
Table 1. Associated injuries 1
Facial fracture Shoulder injury Fractured clavicle Hand injury Fractured pelvis Fractured femur Knee injury Fractured tibia Simple wounds
2 1
2 1 1 1
2 4
Postoperative
On average each patient had 0.65 associated injuries as detailed in Table I (15 associated injuries). Surgical management
If closed nailing was to be delayed the leg was put on calcaneal traction to maintain length and alignment. For open fractures after initial wound toilet the fractures were nailed at 7-14 days. The majority of closed fractures were nailed within 24 h of injury. A standard fracture table was used and the thigh supported firmly. With the hip and knee flexed to 90”, the foot was placed in the traction boot (Fig. 2). Alternatively, the stirrup attached to the calcaneal pin was used. After an adequate closed reduction a standard closed nailing technique was used gaining access to the upper tibia by splitting the patellar tendon. All patients were given prophylactic antibiotics and no tourniquet was used. After reaming no attempt was made to wash out the medullary canal so that osteogenic antibiotic-laden material remained at the fracture site. The nail length was estimated by using a second guidewire placed along that part of the first guidewire protruding from the entry hole; 10mm was then added to this to allow for the proximal curved part of the tibia1 nail. The largest possible diameter nail (usually 12 mm) was used and a suction drain inserted before wound closure. A plaster back-slab was then applied and retained for 48 h. The A0 tibia1 nail was used in 22 cases and the newer Grosse and Kempf interlocking nail in two cases.
Fig. 2. Illustration the tibia.
of the position
used for closed nailing
management
Mobilization of the ankle was started after 48 h and the patients were allowed home when they were confident on crutches. Most patients were allowed to bear as much weight as they wished after suture removal, but full weight bearing was deliberately delayed in distally placed or highly cornminuted fractures in danger of either shortening or rotation. The nails were usually taken out after 12 months and many of these were removed as day cases. Full activities were permitted after suture removal. RESULTS
The patients were seen and examined at a mean followup time of 17.5 months (range 10-30 months). Subjective symptoms were recorded and a standard clinical assessment was made as shown in Table It. Primary wound healing occurred in 23 (96 per cent) fractures. One superficial wound infection healed within 2 weeks with oral antibiotics. The mean hospital stay for closed unilateral fractures was 13 days (range 8-23 days). This compared with a mean of 18.3 days (range 8-52 days) for the whole group, including those with open fractures and multiple injuries. Full weight bearing was achieved in a mean time of 1.8 months (range 0.5-7.0 months) after operation and patients with closed unilateral fractures achieved full weight bearing after a mean of 1.4 months (range 0.5-7-O). There was no statistically significant difference” between the time to full weight bearing for open and closed unilateral fractures. Fracture union was defined radiologically. The fracture was deemed to be united when there was bridging callus with obliteration of the fracture line over at least three-quarters of the circumference of the bone. The mean time to fracture union was 4.3 months (range 2*5-11.5) and there was no statistically significant difference between the union times in open and closed fractures or for those fractures with or without an associated fracture of the fibula. All the fractures except one united within 6 months and this one united at 11.5 months without any further treatment. The results at the final clinical assessment are shown in Table Ill. None of the fractures showed any angular deformity and only one fracture demonstrated shortening which amounted to 1.5cm. Before removal of the nail five patients had symptoms due to prepatellar irritation, although this did not affect knee movement at the time. Five fractures showed some external rotation. In three cases this was insignificant (5”) and lo”-15” in the remaining two. Knee function was normal in every patient and only
of ‘* Student’s
t-test.
182
Injury: the British Journal of Accident Surgery (1988) Vol. 19/No. 3 Table
II. Final clinical
assessment
Excel/en t
Good
Fair
None O-5
2-5 6-10”
6-10"
O-5
6-10" 6-IOmm
1 I-20 1 I-20
~80% >75% >50%
275% 250% <50% Absent 2-3 cm 2-3 cm Moderate
Poor
Deformity: VarusNalgus Anteversionl Recurvatum Rotation Shortening
Joint
0-5mm
mm
>20” >20 mm
Function:
Knee Ankle Subtalar
Deep Infection Calf Atrophy Malleolar Swelling Foot Contracture”
Normal Normal >75% Absent
* Minimal: Cavus foot, Moderate: Fixed clawing of the toes.
Absent l-2 cm l-2 cm Minimal
<75% <50% ~25% Present >3 cm >3 cm Severe
Clawina of toes, some passive correction possible. Severe:
Table Ill. Results Excellent Good Fair Poor
>lO” >20”
1 I-20”
17 4 2 1
two patients had impaired ankle function. Subtalar motion was measured using McMaster’s method (1976) and compared with the normal side. For the 21 unilateral fractures of the tibia only five patients showed more than a 25 per cent reduction in motion. There was no statistically significant difference between subtalar
Fig. 3. Grade I open fracture of the tibia. An area of skin necrosis ameared over the front of the leg at 5 davs.
function in closed and open fractures treated by closed nailing (Fisher’s exact test). One patient developed a pulmonary embolus but recovered rapidly. One patient suffered an unrecognized compartment syndrome and the fracture did not unite until 11.5 months. Otherwise, one temporary lateral popliteal nerve palsy occurred and one proximal locking screw broke in situ. No cases of nail failure or deep infection occurred. DISCUSSION
The risks of operating on fractures-infection and delayed union-are probably nowhere greater than in the
Fig. 4.
Delayed closed nailing using an A0 tibia1nail without
disturbing
the site of injury.
183
Hindley: Closed medullary nailing for recent fractures of the tibia
Fig. 5. Radiograph incorporation
taken 3 months after of the comminuted fragment
surgery showing and radiological
union.
Fig. 6. Grade II open fracture of the tibia with an associated fracture
of the femur.
Fig. 7. Delayed closed nailing using a Grosse and Kempf tibia1 nail with two proximal locking screws to prevent rotation of the proximal fragment and permit early weight bearing.
Fig. 8. Radiograph radiological union.
taken
4 months
after
surgery
showing
184
Injury: the British Journal of Accident Surgery (1988) Vol. 19/No. 3
tibia. When operative treatment is chosen both of these problems can be minimized by preserving the blood supply and achieving stable fixation. Although a fracture interrupts the continuity of the nutrient artery it has no significant effect on the segmental periosteal supply (Jackson and Macnab, 1959) which is preserved by a closed approach. The largest possible diameter of nail was used to ensure stable semi-rigid fixation, which, in the presence of a closed reduction, facilitates cortical revascularization. Reaming was always carried out slowly through an adequate entry hole to minimize marrow embolization to the intracortical channels which could delay revascularization (Danckwardt-Lilliestr(im, 1969). As with conservative treatment the reduction does not need to be perfectly anatomical and micromovement at the fracture site in conjunction with early weight bearing promotes union. At the final assessment, 21 patients (87.5 per cent) achieved an excellent or good result. The reason for the two fair results were: (i) a rotational deformity of 15” and 1.5 cm shortening in a patient with a short spiral fracture who commenced full weight bearing prematurely; and (ii) one patient whose ankle movement was reduced by 50 per cent. The one poor result was in a patient who suffered an unrecognized compartment syndrome. The incidence of compartment syndrome after closed
nailing is about O-2 per cent (Alms, 1962; Hamza et al., 1971; Weller et al., 1979; Donald and Seligson, 1983). This compares favourably with those treated without operation (Nicoll 1964; Owen and Timbourkis, 1967; Ellis, 1968) and therefore it seems reasonable to continue with closed nailing but to be prepared to carry out a fasciotomy. Treatment of open fractures in this series was not
associated with increased morbidity and the union and rehabilitation rates for these fractures were not significantly different from the closed fracture group. This approach has been continued since reviewing this initial series with equally encouraging results. Acknowledgements
I am grateful to the consultant orthopaedic surgeons of Walton and Broadgreen Hospitals, Liverpool for allowing me to report this experience.
Danckwardt-LilliestrGm G. (1969) Reaming of cavity and its effect on diaphyseal bone. Stand. Suppl. 128. Donald G. and Seligson D. (1983) Treatment fractures by percutaneous Kiintscher nailing.
the medullary Acta Orthop.
of tibia] shaft Clin. Orthop.
178, 64.
Ellis H. (1968) Disabilities after tibia1 shaft fractures. J. Bone Joint Surg. 40B, 190.
Fisher W. D. and Hamblen D. L. (1978) Problems and pitfalls of compression fixation of long bone fractures: a review of results and complications. Injury 10, 99. Hamza K. N.. Dunkerley G. E. and Murray C. M. M. (1971) Fractures of the tibia. A report of fifty patients treated by intramedullary nailing. J. Bone Joint Surg. 57A, 696. Jackson R. W. and Macnab I. (1959) Fractures of the shaft of the tibia. Am. J. Surg. 97, 543. Kempf I., Grosse A. and Lafforgue D. (1978) L’apport du verrouillage dans I’enclouage centro-medullaire des OS longs. Rev. Chir. Orthop. 74, 635. McMaster M. (1976) Disability of the hindfoot after fracture of the tibia1 shaft. J. Bone Joint Surg. SSB. 90. Miiller M. E.. Algiiwer M., Schneider R. et al. (1979) Manual of Internal Fixation, Berlin, Springer-Verlag. Nicoll E. A. (1964) Fractures of the tibia] shaft. J. Bone Joint Surg. 46B. 373.
Oertli D., Matter P., Scharplatz D. et al. (1984) Evaluation of surgically treated shaft fractures: analysis of the Swiss AO/ASIF documentation 1967-1980. A0 Bulletin, June. Olerud S. and KarlstrGm G. (1979) in Recent Advances in Orthopaedics, No. 3, McKibbin B. (ed.) Edinburgh, Churchill Livingstone, 163. Owen R. and Timboukis B. (1967) Ischaemia complicating closed tibia1 and fibular shaft fractures. J. Bone Joint Surg. 49B, 268.
Rhinelander F. W. (1968) The normal microcirculation of diaphyseal cortex and its response to fracture. J. Bone Joint Surg. SOA, 784. Riiedi T., Webb J. K. and AllgGwer M. (1976) Experience with the dynamic compression plate (DCP) in 418 recent fractures of the tibia1 shaft. fnjury 7, 252. Solheim K. (1973) Tibia1 fractures treated according to the A0 method. Injury 4, 213. Strdmberg L. (1975) Diaphyseal bone in rigid internal plate fixation. Acta Chir. Stand. Suppl. 456. Thunold J., Varhaug J. E. and Bjereset T. (1975) Tibia1 shaft fractures treated by rigid internal fixation. Injury 7, 125. Van der Linden W. and Larsen K. (1979) Plate fixation versus conservative treatment of tibia] shaft fractures. J. Bone Joint Surg. 61A, 873.
Weller S.. Kuner E. and Schweikert C. H. (1979) Medullary nailing according to the Swiss study group principles. Clin. Orthop. 138. 45.
REFERENCES
Alms M. (1962) Medullary nailing for fractures of the shaft of the tibia. J. Bone Joint Surg. 44B, 328. Batten R. L., Donaldson L. J. and Aldridge N. J. (1978) Experience with the A0 method of treatment in 142 cases of fresh fracture of the tibia1 shaft treated in the UK.
10, 108.
Winquist R. A. and Hansen Jr., S. T. (1980) Comminuted fractures of the femoral shaft treated by intramedullary nailing. Orthop. C/in. North. Am. 11, 633. Zucman J. and Maurer P. (1970) Primary medullary nailing of the tibia for fractures of the shaft in adults. Injury 2, 84.
fnjury Paper accepted
20 August
19x7.
Reyuesrsfor reprine should be addressed to: Mr C. J. Hindley, 30 Highfield Road, Ormskirk. Lancashire I_,,391NR.
19, 180-184
Printedin
Great Britain
180
Closed medullary nailing for recent fractures of the tibia C. J. Hindley Department
of Orthopaedics,
Walton Hospital,
Liverpool
Summary This paper reports the results of a series of recent fractures of the tibia treated by closed medullary nailing. The technique is simple and it has been possible to extend the indications for closed nailing. This method of fixation is biomechanically sound and the semi-rigid fixation obtained prevents significant deformity and seems to provide an ideal environment for fracture healing.
INTRODUCTION CLOSED medullary nailing with an incision distant from the fracture site has been shown to yield very much lower rates of deep infection than generally found with open reduction and compression fixation (Alms, 1962; Zucman and Maurer. 1970; Donald and Seligson. 1983). These results equate with the best published report of closed fractures treated by open reduction and compression fixation (Riiedi et al., 1976). The recently introduced technique of closed interlocking nailing for highly comminuted and metaphyseal fracthe tures (Kempf et al., 1978) has further extended indications for what would seem to be a safer operative treatment of these injuries. Whilst the Swiss experience with open reduction and internal fixation of a large number of fractures of the tibia (Riiedi et al., 1976; Oertli et al., 19X4) remains the standard by which all other operations must he judged: not all centres have been able to reproduce these excellent results. A review of three major series of tibia1 fractures treated in this way revealed deep infection rates varying from 4 per cent to 10.5 per cent (Solheim. 1973; Batten et al.. 1978; Fisher and Hamblen, 1978). Primary bone union is the aim in compression plate fixation whereas, after stable medullary nailing, healing occurs by means of periosteal callus with the gradual transfer of stress from the implant to the bone (Olerud and KarlstrGm, 1979). The use of relatively heavy plates for internal fixation results in osteoporosis due to ‘stress protection’ (Striimberg, 1975). Refracture rates of 0.2 per cent to 6 per cent (Solheim, 1973: Thunold et al., 1975; Riiedi et al.. 1976; Batten et al., 197X). have been reported following implant removal, but this complication does not seem to occur after removal of 1962; Weller et al., 1979; medullary nails (Alms, Donald and Seligson, 1983). Since there will always be a need for internal fixation of some fractures of the tibia, it was decided to undertake a prospective clinical trial to see if the apparently good results reported for closed nailing of the tibia (Alms, 1962; Kempf et al., 1978; Weller et al.. 1979; 0 1%+X Butterworth
cci (‘0 (Publisher>) 00~~~13X.I/XX/0~0IX~H~5 $03U)
Lrd
Donald and Seligson, 1983) could district general hospital.
be reproduced
in a
PATIENTS AND METHODS Twenty-four patients with 25 fractures of the tibia have been treated prospectively in this initial series between February 1984 and March 1986. One patient has been lost to follow-up, leaving 24 fractures in 23 patients. There were 21 male (92 per cent) and 2 female patients with a mean age of 28.6 years (range 17-74 years) who sustained 19 closed and 5 open fractures. There was an associated fracture of the fibula in 19 (79 per cent) cases. There were 11 fractures (48 per cent) of the left leg and 13 (54 per cent) of the right leg. Of the five open fractures, four were classified as grade I1 and there was one grade I injury (Miiller et al., 1979). From a total of 26 individual fractures (including two segmental injuries) 23 were located in the diaphysis. The remaining three were within the proximal or distal quarter of the tibia. The fractures were classified according to cause, type (Van der Linden and Larsen 1979), degree of comminution (Winquist and Hansen, 1980) and displacement (Jackson and Macnab, 1959) as shown in Fig. 1. Primary or delayed primary internal fixation was undertaken in 12 fractures (SO per cent) on account of instability or the presence of an open wound. No grade III open fractures were treated in this way. Eight fractures were internally fixed because conservative treatment had failed and four fractures were internally fixed because there were bilateral lower limb fractures. 15
Fracture Type
RTA
Sport
Fall
Transverse
Segmental
I
Longitudinal 15 10 5
Min
Mod
Sev
E‘ig. 1. Classification
0
of the fractures
1
2
314
181
Hindley: Closed medullary nailing for recent fractures of the tibia
Proximal locking screws were required in 5 (21 per cent) fractures and Herzog anti-rotation wires or distal locking screws in 8 (33 per cent) to control rotation. Anti-rotation wires were used in conjunction with the A0 nails. Alternatively two percutaneous distal locking screws were introduced when using the Grosse and Kempf nail. No attempt was made to compress the fractures intraoperatively as dynamic fracture compression occurred with weight bearing.
Table 1. Associated injuries 1
Facial fracture Shoulder injury Fractured clavicle Hand injury Fractured pelvis Fractured femur Knee injury Fractured tibia Simple wounds
2 1
2 1 1 1
2 4
Postoperative
On average each patient had 0.65 associated injuries as detailed in Table I (15 associated injuries). Surgical management
If closed nailing was to be delayed the leg was put on calcaneal traction to maintain length and alignment. For open fractures after initial wound toilet the fractures were nailed at 7-14 days. The majority of closed fractures were nailed within 24 h of injury. A standard fracture table was used and the thigh supported firmly. With the hip and knee flexed to 90”, the foot was placed in the traction boot (Fig. 2). Alternatively, the stirrup attached to the calcaneal pin was used. After an adequate closed reduction a standard closed nailing technique was used gaining access to the upper tibia by splitting the patellar tendon. All patients were given prophylactic antibiotics and no tourniquet was used. After reaming no attempt was made to wash out the medullary canal so that osteogenic antibiotic-laden material remained at the fracture site. The nail length was estimated by using a second guidewire placed along that part of the first guidewire protruding from the entry hole; 10mm was then added to this to allow for the proximal curved part of the tibia1 nail. The largest possible diameter nail (usually 12 mm) was used and a suction drain inserted before wound closure. A plaster back-slab was then applied and retained for 48 h. The A0 tibia1 nail was used in 22 cases and the newer Grosse and Kempf interlocking nail in two cases.
Fig. 2. Illustration the tibia.
of the position
used for closed nailing
management
Mobilization of the ankle was started after 48 h and the patients were allowed home when they were confident on crutches. Most patients were allowed to bear as much weight as they wished after suture removal, but full weight bearing was deliberately delayed in distally placed or highly cornminuted fractures in danger of either shortening or rotation. The nails were usually taken out after 12 months and many of these were removed as day cases. Full activities were permitted after suture removal. RESULTS
The patients were seen and examined at a mean followup time of 17.5 months (range 10-30 months). Subjective symptoms were recorded and a standard clinical assessment was made as shown in Table It. Primary wound healing occurred in 23 (96 per cent) fractures. One superficial wound infection healed within 2 weeks with oral antibiotics. The mean hospital stay for closed unilateral fractures was 13 days (range 8-23 days). This compared with a mean of 18.3 days (range 8-52 days) for the whole group, including those with open fractures and multiple injuries. Full weight bearing was achieved in a mean time of 1.8 months (range 0.5-7.0 months) after operation and patients with closed unilateral fractures achieved full weight bearing after a mean of 1.4 months (range 0.5-7-O). There was no statistically significant difference” between the time to full weight bearing for open and closed unilateral fractures. Fracture union was defined radiologically. The fracture was deemed to be united when there was bridging callus with obliteration of the fracture line over at least three-quarters of the circumference of the bone. The mean time to fracture union was 4.3 months (range 2*5-11.5) and there was no statistically significant difference between the union times in open and closed fractures or for those fractures with or without an associated fracture of the fibula. All the fractures except one united within 6 months and this one united at 11.5 months without any further treatment. The results at the final clinical assessment are shown in Table Ill. None of the fractures showed any angular deformity and only one fracture demonstrated shortening which amounted to 1.5cm. Before removal of the nail five patients had symptoms due to prepatellar irritation, although this did not affect knee movement at the time. Five fractures showed some external rotation. In three cases this was insignificant (5”) and lo”-15” in the remaining two. Knee function was normal in every patient and only
of ‘* Student’s
t-test.
182
Injury: the British Journal of Accident Surgery (1988) Vol. 19/No. 3 Table
II. Final clinical
assessment
Excel/en t
Good
Fair
None O-5
2-5 6-10”
6-10"
O-5
6-10" 6-IOmm
1 I-20 1 I-20
~80% >75% >50%
275% 250% <50% Absent 2-3 cm 2-3 cm Moderate
Poor
Deformity: VarusNalgus Anteversionl Recurvatum Rotation Shortening
Joint
0-5mm
mm
>20” >20 mm
Function:
Knee Ankle Subtalar
Deep Infection Calf Atrophy Malleolar Swelling Foot Contracture”
Normal Normal >75% Absent
* Minimal: Cavus foot, Moderate: Fixed clawing of the toes.
Absent l-2 cm l-2 cm Minimal
<75% <50% ~25% Present >3 cm >3 cm Severe
Clawina of toes, some passive correction possible. Severe:
Table Ill. Results Excellent Good Fair Poor
>lO” >20”
1 I-20”
17 4 2 1
two patients had impaired ankle function. Subtalar motion was measured using McMaster’s method (1976) and compared with the normal side. For the 21 unilateral fractures of the tibia only five patients showed more than a 25 per cent reduction in motion. There was no statistically significant difference between subtalar
Fig. 3. Grade I open fracture of the tibia. An area of skin necrosis ameared over the front of the leg at 5 davs.
function in closed and open fractures treated by closed nailing (Fisher’s exact test). One patient developed a pulmonary embolus but recovered rapidly. One patient suffered an unrecognized compartment syndrome and the fracture did not unite until 11.5 months. Otherwise, one temporary lateral popliteal nerve palsy occurred and one proximal locking screw broke in situ. No cases of nail failure or deep infection occurred. DISCUSSION
The risks of operating on fractures-infection and delayed union-are probably nowhere greater than in the
Fig. 4.
Delayed closed nailing using an A0 tibia1nail without
disturbing
the site of injury.
183
Hindley: Closed medullary nailing for recent fractures of the tibia
Fig. 5. Radiograph incorporation
taken 3 months after of the comminuted fragment
surgery showing and radiological
union.
Fig. 6. Grade II open fracture of the tibia with an associated fracture
of the femur.
Fig. 7. Delayed closed nailing using a Grosse and Kempf tibia1 nail with two proximal locking screws to prevent rotation of the proximal fragment and permit early weight bearing.
Fig. 8. Radiograph radiological union.
taken
4 months
after
surgery
showing
184
Injury: the British Journal of Accident Surgery (1988) Vol. 19/No. 3
tibia. When operative treatment is chosen both of these problems can be minimized by preserving the blood supply and achieving stable fixation. Although a fracture interrupts the continuity of the nutrient artery it has no significant effect on the segmental periosteal supply (Jackson and Macnab, 1959) which is preserved by a closed approach. The largest possible diameter of nail was used to ensure stable semi-rigid fixation, which, in the presence of a closed reduction, facilitates cortical revascularization. Reaming was always carried out slowly through an adequate entry hole to minimize marrow embolization to the intracortical channels which could delay revascularization (Danckwardt-Lilliestr(im, 1969). As with conservative treatment the reduction does not need to be perfectly anatomical and micromovement at the fracture site in conjunction with early weight bearing promotes union. At the final assessment, 21 patients (87.5 per cent) achieved an excellent or good result. The reason for the two fair results were: (i) a rotational deformity of 15” and 1.5 cm shortening in a patient with a short spiral fracture who commenced full weight bearing prematurely; and (ii) one patient whose ankle movement was reduced by 50 per cent. The one poor result was in a patient who suffered an unrecognized compartment syndrome. The incidence of compartment syndrome after closed
nailing is about O-2 per cent (Alms, 1962; Hamza et al., 1971; Weller et al., 1979; Donald and Seligson, 1983). This compares favourably with those treated without operation (Nicoll 1964; Owen and Timbourkis, 1967; Ellis, 1968) and therefore it seems reasonable to continue with closed nailing but to be prepared to carry out a fasciotomy. Treatment of open fractures in this series was not
associated with increased morbidity and the union and rehabilitation rates for these fractures were not significantly different from the closed fracture group. This approach has been continued since reviewing this initial series with equally encouraging results. Acknowledgements
I am grateful to the consultant orthopaedic surgeons of Walton and Broadgreen Hospitals, Liverpool for allowing me to report this experience.
Danckwardt-LilliestrGm G. (1969) Reaming of cavity and its effect on diaphyseal bone. Stand. Suppl. 128. Donald G. and Seligson D. (1983) Treatment fractures by percutaneous Kiintscher nailing.
the medullary Acta Orthop.
of tibia] shaft Clin. Orthop.
178, 64.
Ellis H. (1968) Disabilities after tibia1 shaft fractures. J. Bone Joint Surg. 40B, 190.
Fisher W. D. and Hamblen D. L. (1978) Problems and pitfalls of compression fixation of long bone fractures: a review of results and complications. Injury 10, 99. Hamza K. N.. Dunkerley G. E. and Murray C. M. M. (1971) Fractures of the tibia. A report of fifty patients treated by intramedullary nailing. J. Bone Joint Surg. 57A, 696. Jackson R. W. and Macnab I. (1959) Fractures of the shaft of the tibia. Am. J. Surg. 97, 543. Kempf I., Grosse A. and Lafforgue D. (1978) L’apport du verrouillage dans I’enclouage centro-medullaire des OS longs. Rev. Chir. Orthop. 74, 635. McMaster M. (1976) Disability of the hindfoot after fracture of the tibia1 shaft. J. Bone Joint Surg. SSB. 90. Miiller M. E.. Algiiwer M., Schneider R. et al. (1979) Manual of Internal Fixation, Berlin, Springer-Verlag. Nicoll E. A. (1964) Fractures of the tibia] shaft. J. Bone Joint Surg. 46B. 373.
Oertli D., Matter P., Scharplatz D. et al. (1984) Evaluation of surgically treated shaft fractures: analysis of the Swiss AO/ASIF documentation 1967-1980. A0 Bulletin, June. Olerud S. and KarlstrGm G. (1979) in Recent Advances in Orthopaedics, No. 3, McKibbin B. (ed.) Edinburgh, Churchill Livingstone, 163. Owen R. and Timboukis B. (1967) Ischaemia complicating closed tibia1 and fibular shaft fractures. J. Bone Joint Surg. 49B, 268.
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REFERENCES
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Winquist R. A. and Hansen Jr., S. T. (1980) Comminuted fractures of the femoral shaft treated by intramedullary nailing. Orthop. C/in. North. Am. 11, 633. Zucman J. and Maurer P. (1970) Primary medullary nailing of the tibia for fractures of the shaft in adults. Injury 2, 84.
fnjury Paper accepted
20 August
19x7.
Reyuesrsfor reprine should be addressed to: Mr C. J. Hindley, 30 Highfield Road, Ormskirk. Lancashire I_,,391NR.