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Fractures of the tibial shaft treated in a patellar-tendon-bearing cast
124 Injury, 10, 124-127
Printedin Great Britain
Fractures of the tibial shaft treated in a patellar-tendon-bearing cast R. A. B. Mollan and B. Bradley Royal Victoria Hospital, Belfast Summary
A retrospective review of fractures of the tibial shaft treated in patellar-tendon-bearing (PTB) casts shows that a high rate of union, in respect of both time required and numbers, and a low morbidity can be expected. The method is easy to apply. In those patients who had the casts applied early, once swelling had settled down, the fractures united more quickly.
INTRODUCTION FRACTURES Of the tibial shaft are very common but the methods of treatment remain diverse and controversial, owing to the unpredictable results of the various methods of treatment and the frequent complications. In recent years the traditional conservative methods of treatment in Western Europe have been overshadowed by an aggressive surgical approach. The principles involved in rigid internal fixation are mechanically sound, the hardware is beautifully produced and the method is aesthetically pleasing to the surgical mind. Unfortunately these advantages are not without appreciable risk to the patient. Charnley's warning is worth repeating, 'Failures of operative and conservative treatment are not equally salvageable by secondary procedures' (Charnley, 1970). The ideal treatment should be designed to counter known complications of the fracture and to have minimal inherent complications. Open reduction and internal fixation does not always meet these criteria. The infection rate in closed tibial fractures treated by internal fixation is at best 4 per cent (Karlstrom and Olerud, 1974) and in less ideal circumstances we know the rate to be very much higher. Another danger is that, because of lack of expertise and
the failure to appreciate the mechanical problems or technical difficulties with the high velocity type of fracture, mechanical principles are not always adhered to surgically. Unstable fixation aggravates an already disadvantageous environment for early bone union. Mechanical instability was a feature of 26 per cent of cases in one series (Karlstrom and Olerud, 1974) and 14 per cent in another (Thunold et al., 1975). Both series showed correspondingly high rates of non-union. Classic conservative treatment does not carry the danger of surgically induced infection, but two other complications are associated with this method: a very slow rate of union in a high proportion of cases (Darder and Gomar, 1975) and the difficulty of holding the bones in an acceptable position until healing occurs with a minimum of soft tissue complication. Long immobilization of the patient, slow recovery of function and a far from negligible need for secondary operative procedures to achieve union have led to a search for other methods in order to reduce these complications and improve the chances of achieving union. Two methods have shown great promise: the patellar-tendonbearing (PTB) cast devised by Sarmiento (1967) and the total-contact long-leg cast devised by Dehne et al. (1961). Subsequent reports of both methods have been extremely encouraging (Brown, 1974; Dehne, 1974; Sarmiento, 1974; King, 1975). The purpose of this study was to review fractures of the tibial shaft treated at this hospital between 1975 and 1976 to see if the aims of treatment were achieved and to examine any complications and shortcomings of the method used. Particular attention was paid to those fractures treated with a PTB cast.
125
Mollan and Bradley: Patellar-tendon-bearing Cast PATIENTS AND METHODS A total of I06 patients had PTB casts applied for fractures of the tibial shaft during 1975 and 1976. The details of treatment differed and the various subgroups were studied separately (Table I). In the study of time to union, comparison was made with matched groups of patients with identical
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injuries treated without PTBs in the same hospital during 1974. They were matched for sex, age, grade and type of injury and were treated by the same group of surgeons. Union was considered to have occurred when a plaster cast was removed, thus 'cast time' is synonymous with time to union.
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~J P r i m a r y a p p l i c a t i o n of a PTB cast Twenty-nine patients had PTB casts applied within 1 week of injury. The cast was identical to that described by Sarmiento (1967). Ages ranged from 12 to 79 years with an average of 41 years. Four of these fractures were open. The fractures were classified according to Edwards (1965): there were 16 type l, 5 type 2 and 8 type 3. The cast times varied from 6 to 18 weeks with an average of l0 weeks. Fourteen patients (l 0 type l, 3 type 2, and l type 3) had cast times of under 12 weeks and 7 of these had a cast time of only 6 weeks. On average, patients in this group had resumed their normal occupation at 15 weeks with a range of 8-28 weeks. There was only one complication in this group; this patient, a 31-year-old with a type 3 fracture, developed pain over the patella and radiographs revealed periostitis. This settled without treatment when the cast was removed.
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S e c o n d a r y a p p l i c a t i o n of a PTB cast Fifty-two patients had PTB casts applied after 1 week according to the method described by Sarmiento 0967). Ages ranged from 18 to 80 years with an average of 38 years. Twenty-seven fractures were open and there were 19 type l, 10 type 2, and 23 type 3. Ten patients in this group were treated in longleg casts for a prolonged period and were considered to have delayed union. These patients were being considered for operation when the PTB casts were applied. All the fractures subsequently united in the PTB casts: the average cast time was 10 weeks, with a range of 4-18 weeks. The other 42 patients who had PTB casts applied according to Sarmiento's recommendations had cast times ranging from 9 to 27 weeks with an average of 15 weeks. These patients returned to their previous activities after an average of 29 weeks, with a range of 12-52 weeks.
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126
Injury: the British Journal of Accident Surgery Vol. 1 O/No. 2
When PTB cast times alone were studied for the whole group, the range was from 2 to 18 weeks with an average of 8 weeks. It did not seem to matter at what stage the PTB cast was applied, union of the fracture occurred within a cast time of only 10-14 weeks and in no case did this time exceed 18 weeks. Complications in this group included one case of mild Volkmann's contracture and one patient who had a final shortening of 2"5 cm which had been present before treatment and did not increase during the time in the PTB cast. There were no other cases of malunion. A matched group of 52 patients treated in long-leg casts alone during 1974 had an average cast time of 19 weeks with a range of 6-59 weeks.
Application of a PTB cast after internal fixation Twenty-five patients had a PTB cast applied after conventional internal fixation. Ages ranged from 16 to 70 years with an average of 36 years. Six fractures were initially open and there were 11 type 1, 5 type 2 and 9 type 3 fractures. Cast times ranged from 9 to 52 weeks with an average of 15 weeks. On average, patients returned to their previous activities 26 weeks after injury, with a range of 10-52 weeks. Complications in this group included 4 cases of secondary infection and 1 case of non-union, which responded to bone grafting. A matched group of 25 patients who had had internal fixation and long-leg casts applied had an average cast time of 22 weeks with a range of 8-42 weeks.
DISCUSSION The results of treatment of fracture of the shaft of the tibia with a PTB cast show this form of treatment to be the method of choice. Cast times of 6-8 weeks were recorded in the primary application group and the results showed a fast rate of union with a minimum of complications in all types of fracture. This study corroborates other reports (Sarmiento, 1967; Suman, 1977), but goes further in that an accelerated rate of union was observed in the group treated primarily with the PTB cast. Shortening of the leg in the cast, malunion, infection and non-union were not encountered. Those fractures treated in a long-leg cast followed by a PTB cast had acceptable cast times on average and these compare well with reports of other methods of conservative treatment (Burkhalter and Protzman, 1975; Darder and Gomar, 1975). It is interesting that those patients with non-union subsequently treated in
the PTB cast aU showed union within less than 10 weeks on average. These patients again indicate that the method is associated with rapid union. Karlstrom and Olerud (1974) concluded an excellent review of the treatment of the fractured shaft of the tibia with the words, 'there was always a place for conservative therapy'. The literature and personal experience abound with the complications of internal fixation, chief among which are induced infection and nonunion. Any surgeon who treats a fractured tibial shaft by an open method should have very good reasons for doing so when conservative ambulatory treatment is so acceptable and free from complications. There is no case that osteogenesis is solely induced by rigid fixation. The accelerated union seen in the PTB cast occurs between bone ends that are mobile and held only by the fibroelastic properties of the tissue encased in the total-contact cast (Sarmiento et al., 1974). The walking patient, especially when treated primarily with a cast, showed a low morbidity with a high rate of union and full knee movement. There is rapid restoration of function and, therefore, early and more complete rehabilitation. Treatment in the PTB cast means minimal time in hospital and also removes the danger of knee stiffness completely. The method requires understanding and some skill, but the materials are always available and we recommend this ambulatory method as the treatment of choice for fractures of the tibial shaft.
REFERENCES Brown P. W. (1974) The early weight bearing treatment of tibial shaft fractures. C/in. Orthop. 105, 167. Burkha]ter W. E. and Protzman R. (1975) The tibial shaft fracture. J. Trauma 15, 785.
Charnley J. (1970) The Closed Treatment of Common Fractures, 4th ed. Edinburgh, Churchill Livingstone. Darder A. and Gomar F. (1975) A series of tibial fractures treated conservatively. Injury 6, 225. Dehne E. (1974) Ambulatory treatment of the fractured tibia. Clin. Orthop. 105, 192. Dehne E., Metz C. W., Defter P. A. et al. (1961) Nonoperative treatment of the fractured tibia by immediate weight bearing. J. Trauma 1, 514. Edwards P. (1965) Fracture of the shaft of tibia: 492 consecutive cases in adults. Acta. Orthop. Scand. Suppl. 76. Karlstrom G. and Olerud S. (1974) Fractures of the tibial shaft. Clin. Orthop. 105, 82. King D. M. (1975) Experience with the below knee total contact cast in the management of tibial fractures. Aust. N Z J. Surg. 45, 54. Sarmiento A. (1967) A functional below the knee cast for tibial fractures. J. Bone Joint Surg. 49A, 85:
Mollan and Bradley: Patellar-tendon-bearing Cast
Sarmiento A. (1974) Functional bracing of tibial fractures. Clin. Orthop. 108, 202. Sarmiento A., Latta L., Zilioli A. et al. (1974) The role of soft tissues in the stabilization of tibial fractures. Clin. Orthop. 105, 116. Suman R. K. (1977) The management of tibial shaft fractures by early weight bearing in a patellar tendon bearing cast. J. Trauma. 17, 97.
127,
Thunold J., Varhaug J. E. and Bjerkeset T. (1975) Tibial shaft fractures treated by rigid internal fixation. The early results in a 4-year series. Injury
4, 125.
Requests for reprints should be addressed to: Mr R. A. B. Mollan, Royal Victoria Hospital, Belfast, N. Ireland.
Printedin Great Britain
Fractures of the tibial shaft treated in a patellar-tendon-bearing cast R. A. B. Mollan and B. Bradley Royal Victoria Hospital, Belfast Summary
A retrospective review of fractures of the tibial shaft treated in patellar-tendon-bearing (PTB) casts shows that a high rate of union, in respect of both time required and numbers, and a low morbidity can be expected. The method is easy to apply. In those patients who had the casts applied early, once swelling had settled down, the fractures united more quickly.
INTRODUCTION FRACTURES Of the tibial shaft are very common but the methods of treatment remain diverse and controversial, owing to the unpredictable results of the various methods of treatment and the frequent complications. In recent years the traditional conservative methods of treatment in Western Europe have been overshadowed by an aggressive surgical approach. The principles involved in rigid internal fixation are mechanically sound, the hardware is beautifully produced and the method is aesthetically pleasing to the surgical mind. Unfortunately these advantages are not without appreciable risk to the patient. Charnley's warning is worth repeating, 'Failures of operative and conservative treatment are not equally salvageable by secondary procedures' (Charnley, 1970). The ideal treatment should be designed to counter known complications of the fracture and to have minimal inherent complications. Open reduction and internal fixation does not always meet these criteria. The infection rate in closed tibial fractures treated by internal fixation is at best 4 per cent (Karlstrom and Olerud, 1974) and in less ideal circumstances we know the rate to be very much higher. Another danger is that, because of lack of expertise and
the failure to appreciate the mechanical problems or technical difficulties with the high velocity type of fracture, mechanical principles are not always adhered to surgically. Unstable fixation aggravates an already disadvantageous environment for early bone union. Mechanical instability was a feature of 26 per cent of cases in one series (Karlstrom and Olerud, 1974) and 14 per cent in another (Thunold et al., 1975). Both series showed correspondingly high rates of non-union. Classic conservative treatment does not carry the danger of surgically induced infection, but two other complications are associated with this method: a very slow rate of union in a high proportion of cases (Darder and Gomar, 1975) and the difficulty of holding the bones in an acceptable position until healing occurs with a minimum of soft tissue complication. Long immobilization of the patient, slow recovery of function and a far from negligible need for secondary operative procedures to achieve union have led to a search for other methods in order to reduce these complications and improve the chances of achieving union. Two methods have shown great promise: the patellar-tendonbearing (PTB) cast devised by Sarmiento (1967) and the total-contact long-leg cast devised by Dehne et al. (1961). Subsequent reports of both methods have been extremely encouraging (Brown, 1974; Dehne, 1974; Sarmiento, 1974; King, 1975). The purpose of this study was to review fractures of the tibial shaft treated at this hospital between 1975 and 1976 to see if the aims of treatment were achieved and to examine any complications and shortcomings of the method used. Particular attention was paid to those fractures treated with a PTB cast.
125
Mollan and Bradley: Patellar-tendon-bearing Cast PATIENTS AND METHODS A total of I06 patients had PTB casts applied for fractures of the tibial shaft during 1975 and 1976. The details of treatment differed and the various subgroups were studied separately (Table I). In the study of time to union, comparison was made with matched groups of patients with identical
o3
o
o0
I
I I I
injuries treated without PTBs in the same hospital during 1974. They were matched for sex, age, grade and type of injury and were treated by the same group of surgeons. Union was considered to have occurred when a plaster cast was removed, thus 'cast time' is synonymous with time to union.
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~J P r i m a r y a p p l i c a t i o n of a PTB cast Twenty-nine patients had PTB casts applied within 1 week of injury. The cast was identical to that described by Sarmiento (1967). Ages ranged from 12 to 79 years with an average of 41 years. Four of these fractures were open. The fractures were classified according to Edwards (1965): there were 16 type l, 5 type 2 and 8 type 3. The cast times varied from 6 to 18 weeks with an average of l0 weeks. Fourteen patients (l 0 type l, 3 type 2, and l type 3) had cast times of under 12 weeks and 7 of these had a cast time of only 6 weeks. On average, patients in this group had resumed their normal occupation at 15 weeks with a range of 8-28 weeks. There was only one complication in this group; this patient, a 31-year-old with a type 3 fracture, developed pain over the patella and radiographs revealed periostitis. This settled without treatment when the cast was removed.
03
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S e c o n d a r y a p p l i c a t i o n of a PTB cast Fifty-two patients had PTB casts applied after 1 week according to the method described by Sarmiento 0967). Ages ranged from 18 to 80 years with an average of 38 years. Twenty-seven fractures were open and there were 19 type l, 10 type 2, and 23 type 3. Ten patients in this group were treated in longleg casts for a prolonged period and were considered to have delayed union. These patients were being considered for operation when the PTB casts were applied. All the fractures subsequently united in the PTB casts: the average cast time was 10 weeks, with a range of 4-18 weeks. The other 42 patients who had PTB casts applied according to Sarmiento's recommendations had cast times ranging from 9 to 27 weeks with an average of 15 weeks. These patients returned to their previous activities after an average of 29 weeks, with a range of 12-52 weeks.
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126
Injury: the British Journal of Accident Surgery Vol. 1 O/No. 2
When PTB cast times alone were studied for the whole group, the range was from 2 to 18 weeks with an average of 8 weeks. It did not seem to matter at what stage the PTB cast was applied, union of the fracture occurred within a cast time of only 10-14 weeks and in no case did this time exceed 18 weeks. Complications in this group included one case of mild Volkmann's contracture and one patient who had a final shortening of 2"5 cm which had been present before treatment and did not increase during the time in the PTB cast. There were no other cases of malunion. A matched group of 52 patients treated in long-leg casts alone during 1974 had an average cast time of 19 weeks with a range of 6-59 weeks.
Application of a PTB cast after internal fixation Twenty-five patients had a PTB cast applied after conventional internal fixation. Ages ranged from 16 to 70 years with an average of 36 years. Six fractures were initially open and there were 11 type 1, 5 type 2 and 9 type 3 fractures. Cast times ranged from 9 to 52 weeks with an average of 15 weeks. On average, patients returned to their previous activities 26 weeks after injury, with a range of 10-52 weeks. Complications in this group included 4 cases of secondary infection and 1 case of non-union, which responded to bone grafting. A matched group of 25 patients who had had internal fixation and long-leg casts applied had an average cast time of 22 weeks with a range of 8-42 weeks.
DISCUSSION The results of treatment of fracture of the shaft of the tibia with a PTB cast show this form of treatment to be the method of choice. Cast times of 6-8 weeks were recorded in the primary application group and the results showed a fast rate of union with a minimum of complications in all types of fracture. This study corroborates other reports (Sarmiento, 1967; Suman, 1977), but goes further in that an accelerated rate of union was observed in the group treated primarily with the PTB cast. Shortening of the leg in the cast, malunion, infection and non-union were not encountered. Those fractures treated in a long-leg cast followed by a PTB cast had acceptable cast times on average and these compare well with reports of other methods of conservative treatment (Burkhalter and Protzman, 1975; Darder and Gomar, 1975). It is interesting that those patients with non-union subsequently treated in
the PTB cast aU showed union within less than 10 weeks on average. These patients again indicate that the method is associated with rapid union. Karlstrom and Olerud (1974) concluded an excellent review of the treatment of the fractured shaft of the tibia with the words, 'there was always a place for conservative therapy'. The literature and personal experience abound with the complications of internal fixation, chief among which are induced infection and nonunion. Any surgeon who treats a fractured tibial shaft by an open method should have very good reasons for doing so when conservative ambulatory treatment is so acceptable and free from complications. There is no case that osteogenesis is solely induced by rigid fixation. The accelerated union seen in the PTB cast occurs between bone ends that are mobile and held only by the fibroelastic properties of the tissue encased in the total-contact cast (Sarmiento et al., 1974). The walking patient, especially when treated primarily with a cast, showed a low morbidity with a high rate of union and full knee movement. There is rapid restoration of function and, therefore, early and more complete rehabilitation. Treatment in the PTB cast means minimal time in hospital and also removes the danger of knee stiffness completely. The method requires understanding and some skill, but the materials are always available and we recommend this ambulatory method as the treatment of choice for fractures of the tibial shaft.
REFERENCES Brown P. W. (1974) The early weight bearing treatment of tibial shaft fractures. C/in. Orthop. 105, 167. Burkha]ter W. E. and Protzman R. (1975) The tibial shaft fracture. J. Trauma 15, 785.
Charnley J. (1970) The Closed Treatment of Common Fractures, 4th ed. Edinburgh, Churchill Livingstone. Darder A. and Gomar F. (1975) A series of tibial fractures treated conservatively. Injury 6, 225. Dehne E. (1974) Ambulatory treatment of the fractured tibia. Clin. Orthop. 105, 192. Dehne E., Metz C. W., Defter P. A. et al. (1961) Nonoperative treatment of the fractured tibia by immediate weight bearing. J. Trauma 1, 514. Edwards P. (1965) Fracture of the shaft of tibia: 492 consecutive cases in adults. Acta. Orthop. Scand. Suppl. 76. Karlstrom G. and Olerud S. (1974) Fractures of the tibial shaft. Clin. Orthop. 105, 82. King D. M. (1975) Experience with the below knee total contact cast in the management of tibial fractures. Aust. N Z J. Surg. 45, 54. Sarmiento A. (1967) A functional below the knee cast for tibial fractures. J. Bone Joint Surg. 49A, 85:
Mollan and Bradley: Patellar-tendon-bearing Cast
Sarmiento A. (1974) Functional bracing of tibial fractures. Clin. Orthop. 108, 202. Sarmiento A., Latta L., Zilioli A. et al. (1974) The role of soft tissues in the stabilization of tibial fractures. Clin. Orthop. 105, 116. Suman R. K. (1977) The management of tibial shaft fractures by early weight bearing in a patellar tendon bearing cast. J. Trauma. 17, 97.
127,
Thunold J., Varhaug J. E. and Bjerkeset T. (1975) Tibial shaft fractures treated by rigid internal fixation. The early results in a 4-year series. Injury
4, 125.
Requests for reprints should be addressed to: Mr R. A. B. Mollan, Royal Victoria Hospital, Belfast, N. Ireland.