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A comparison of plating and traction in the treatment of tibial shaft fractures
Injury (1986) 17, 91-94
91
Printedin Great Britain
A comparison of plating and traction in the treatment of tibial shaft fractures J. M. Harley, M. J. Campbell and R. K. Jackson Southampton General Hospital Summary A consecutive series of fractures of the tibial shaft was studied over a 4-year period. A total of 115 fractures in 115 patients were found to be unstable and therefore unsuitable for immediate treatment in a plaster cast. Sixty-three fractures were treated by internal fixation using AO dynamic compression plates and 52 patients were treated by calcaneal traction. The two treatment groups were compared and it was found that overall each spent a similar time in hospital but the surgically treated group required a minimum of two admissions. The surgically treated group healed 6 weeks sooner than the conservatively treated group but there was an overall complication rate of 30 per cent related to the internal fixation. One hundred and three patients were seen for clinical review, and the incidence of joint stiffness is discussed.
INTRODUCTION THERE are m a n y methods of treating fractures of the tibial shaft but one of the more difficult fractures to treat is that which by virtue of soft tissue swelling or fracture shape is impossible to hold securely in an acceptable position by plaster-of-Paris. The method of treatment of these unstable tibial fractures remains open for debate and while previous authors have advocated conservative treatment in the m a n a g e m e n t of all tibial fractures (Nicoll, 1964) and others have m o r e recently demonstrated the efficiency of rigid internal fixation as a method of treatment (Riiedi et al., 1976), no previous study has compared conservative with surgical m a n a g e m e n t in the treatment of the select group of fractures which prove to be unstable and therefore unsuitable for immediate treatment in plaster-of-Paris. This p a p e r compares rigid internal fixation with calcaneal traction in the treatment of unstable fractures of the tibial shaft.
PATIENTS The case notes and radiographs of all adult patients with fractures of the tibia and fibula occurring over a 4-year period and treated at Southampton General Hospital were studied. There was a minimum follow-up time of 3 years since the date of the injury. Those patients treated wholly in plaster-of-Paris or by external fixation were excluded from the present study. Segmental fractures and fractures which were bone grafted at the time of primary internal fixation were also excluded. A total of 115 patients were identified as having unstable fractures of the tibia and fibula which had been treated by either calcaneal traction or rigid internal fixation. These patients had a fracture of the
tibia and fibula which did not involve a joint surface and attempts at m a n a g e m e n t in plaster-of-Paris had been unsuccessful. The majority of the fractures studied were comminuted. The day of the week on which a patient wi~s admitted governed which surgeon would be in charge of each individual case, and this in turn dictated the method of treatment that would be used. In this way it can be said that the selection of patients for each treatment group was made arbitrarily. In two patients an attempt was m a d e at conservative managem e n t but the fractures proved impossible to reduce by closed methods and were therefore treated by open reduction and internal fixation and so have been included in the plated group. A total of 63 patients were treated by rigid internal fixation while 52 patients were treated by calcaneal traction.
METHOD Plated fractures were rigidly fixed using A O dynamic compression plates. Postoperatively the patients were rested with the leg elevated until the surgical wound healed and once satisfactory healing had occurred an a b o v e - k n e e plaster cast was applied. The patient then walked with crutches and went home. The patients treated by traction had a D e n h a m pin pushed through the calcaneum and the fracture reduced under general anaesthesia. The patients were then managed on a Braun frame with a traction weight of 3.6 kg (8 lb). This was maintained until the fracture was felt to be sticky. This was when the patient could lift the leg straight, free from the supporting frame, while the traction was maintained. The D e n h a m pin was then removed and a full-leg plaster cast was applied. The patient then walked with crutches and was discharged from inpatient hospital care. All the patients with open fractures received antibiotics and most of those with closed fractures which were plated also received antibiotics. The characteristics considered for each patient were the time spent in hospital, the time taken to satisfactory healing and the occurrence of complications. The patients were studied first as a single group to identify factors other than the m e t h o d of treatment which affected these characteristics. Although it is difficult to ensure that similar fractures are c o m p a r e d in such a study the severity of each fracture was graded by giving each fracture a 'personality type' as described by Nicoll (1964); so dividing them into open or closed and slightly or severely displaced fractures. While this means that
Injury: the British Journal of Accident Surgery (1986) Vol. 17/No. 2
92
each individual group is small in numbers they remain sufficient for statistical analysis. Satisfactory union was considered to have occurred in the plated group when obliteration of the fracture line was seen radiographically. In the conservatively treated group union was considered to have occurred when there was sufficient callus to allow the patient to take full weight on the limb free of any external support. Analysis of the healing time for each group of fractures was conducted using the Mann-Whitney U test as implemented on the M I N I T A B system. The patients were called to a special clinic, where they were reviewed with regard to symptoms and clinical evidence of stiffness subsequent to their injury.
RESULTS Time in hospital
Table L Time in hospital Type of fracture
Primary plating Delayed plating Traction
Displacement Treatment Plating Traction
Closed
Open
26 days 29 days 32 days
44 days 46 days 32 days
Healing time There were 69 closed fractures with 37 treated surgically and 32 treated conservatively. The remaining 46 fractures were open and 26 of these were treated surgically while 20 were treated conservatively. The median healing time for the 69 closed fractures was 18 weeks while the median healing time for the 46 open fractures was 26 weeks. This 8-week difference was found to be highly significant (P<0-01). Sixty-four fractures had a displacement on the initial radiograph of less than two-thirds of the tibial shaft's diameter and the median healing time for these fractures was 17 weeks. Fractures with a displacement of two-thirds or more of the tibial shaft diameter on the initial X-ray film had a median healing time of 28 weeks. The l l - w e e k difference between these two groups of fractures was found to be highly significant (P<0.01). Therefore each treatment group was subdivided into
<2/3
> 2/3
14 weeks 18 weeks
21 weeks 28 weeks
Table III. Median healing time for open fractures Displacement Treatment
The average time spent in hospital was 32 days for the conservatively treated group and 34 days for the surgically treated group. The conservatively treated group spent an average of 28 days on traction. Patients in the plated group of fractures required a second hospital admission for removal of the metal. The average inpatient time required for this was 5 days, and this has been included in the above times. Table 1 shows that in the surgically treated group patients with closed fractures spent less time in hospital than those with open fractures. The average difference in time in hospital between primary and delayed plated fractures was approximately 3 days, while the average interval before delayed plating of fractures was 12 days (minimum 5 days) for closed and 18 days (minimum 10 days) for open fractures. All patients in the traction group spent a similar period in hospital regardless of the type of fracture.
Method of treatment
Table IL Median healing time for closed fractures
Plating Traction
<2/3
>2/3
16 weeks 24 weeks
38 weeks 36 weeks
open and closed and slightly or severely displaced fractures to ensure that similar fracture types were studied in each group. Table I1 shows the healing time for closed fractures, comparing the surgically and conservatively treated groups. It can be seen that in both the lesser and the greater displaced fractures the traction treated group required a longer time for healing, with the difference being 4 weeks and 7 weeks. These differences were highly significant (P<0.01). Table III shows a similar comparison for open fractures demonstrating that in the lesser displaced fractures the traction group takes 8 weeks longer to healing than the plated group. This difference was found to be highly significant (P<0.01) while there was no significant difference in the severely displaced open fractures. Figure 1 shows that the median difference in healing time between plated fractures and traction treated fractures when all fracture types are considered is 6 weeks. This difference was found to be highly significant (P<0-01). The definition of the term 'delayed union' varies with different authors but the use of this cumulative percentage curve, as recommended by Austin (1977), allows direct comparison of the healing rate in each treatment group. An individual definition of time to delayed union can be read directly from the graph, so allowing comparison with other reported series. Although the graph stops at 52 weeks all fractures had healed at the time of review but the plated group took until 110 weeks to reach 100 per cent healed. Bone grafting was necessary in five patients (10 per cent) of the traction group and in 10 patients (25 per cent) of the primary plated group. The average time for grafting was 30 weeks from date of injury. No patient in the group treated by delayed plating required a bone graft.
Complications Complications in closed and open fractures were compared. Malunion was defined as more than 8° of medial or lateral angulation or 10° of anterior or posterior angulation in the final radiograph. The overall complication rate of each treatment group is shown in Table IV. Tables V and VI show the nature of the complications in each treatment group. The number of complications exceeds the number of patients because
Harley et al. : Unstable tibial shaft fractures
93
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time fo healing(weeks)
Fig. 1. Median difference in healing time between plated fractures and those treated by traction. Table IV. Complication rate after fracture of the tibial shaft No. o f complications
Total no. o f fractures
Complication rate (%)
11 0 4
26 11 32
42.0% 0 12.5%
10 2 5
13 13 20
77.0% 15.0% 25.0%
Closed fractures Primary plating Delayed plating Traction Open fractures Primary plating Delayed plating Traction Table V. Complications of closed tibial fractures Primary plating
Bone graft required Malunion Pulmonary embolism Refractu re Fracture through a screw-hole Wound infection Delayed wound healing Chronic osteomyelitis Painful plate
Traction
3 3 3 3 6 1 1 4
several patients had more than one complication. The complication rate attributable to internal fixation was 30 per cent.
Clinical result One hundred and three patients were seen for clinical review; 47 had been treated conservatively and 56 surgically. Six patients in the traction treated group had clinical evidence of stiffness of the ankle joint. Two of these patients had only slight stiffness and were asymptomatic. The other four had less than one-third of the normal range of ankle joint movement, and this stiffness was symptomatic. Two of these patients had also
Table VI. Complications of open tibial fractures Primary plating
Bone graft required Malunion Pulmonary embolism Refracture Delayed wound healing Wound infection Painful plate Toe clawing and metatarsalgia
7 1 1 2 1 3 1
Traction
Delayed plating
94 suffered a fracture of the malleolus as well as of the tibial shaft. Three patients in the surgically treated group had stiff ankles. Each of these patients had less than one-third of the normal range of m o v e m e n t when c o m p a r e d with the other side. This stiffness was symptomatic in each patient, one of w h o m had suffered fracture of the malleolus as well as of the tibial shaft. Subtalar stiffness occurred in eight of the patients treated on traction and in six of the patients treated by plating. All of these patients were symptomatic and had less than one-third of the normal movement. There was no instance of persisting stiffness of the knee. The occurrence of stiffness of the ankle and subtalar joint did not a p p e a r to be related to the severity of the fracture but all patients who suffered fracture of the malleolus as well as of the tibial shaft developed symptomatic stiffness of the ankle and subtalar joints, in both treatment groups.
DISCUSSION The conservative m a n a g e m e n t of large numbers of tibial shaft fractures has been well documented in the literature (Nicoll, 1964), as have large numbers of patients treated by rigid internal fixation (R/iedi et al., 1976). There have been a few reports comparing conservative treatment with internal fixation (Jensen et al., 1977; Van der Linden and Larson, 1979), but no previous p a p e r has considered exclusively the unstable fractures of the tibial shaft and their treatment. The results of this study show that the time spent in hospital by patients with surgically or conservatively treated fractures was the same. Patients with closed fractures spent less time in hospital when treated surgically than when treated conservatively but the opposite was true of those with open fractures. Patients with fractures plated at once also spent less time in hospital than those with fractures plated after a delay, but the difference of 3 days in the total time spent in hospital was considerably less than the delay which occurred before the operation. This apparently anomalous finding is accounted for by the fact that a high complication rate in the primarily plated fractures necessitated extra time in hospital. This concurs with other published work (Smith, 1974). In all fracture groups the surgically treated patients healed more quickly, apart from those with severely displaced open fractures. No arbitrary time was taken in this study to denote delayed or nonunion but bone grafting had been carried out when there was lack of satisfactory clinical or radiological progress. The bone grafting rate was approximately 10 per cent of all cases, except for primarily plated open fractures in which the bone grafting rate was over 50
Injury: the British Journal of Accident Surgery (1986) Vol. 17/No. 2
per cent. This was not seen after delayed plating. Stiffness of the ankle or subtalar joints occurred more commonly in the conservatively treated group but not all were symptomatic. However, when there was an ipsilateral disruption of the ankle joint as well as a fracture of the tibial shaft neither conservative management nor internal fixation achieved satisfactory ankle or subtalar function. It has been previously stated that the shorter time to regain function after internal fixation (Watson-Jones and Coltart, 1943) made this method preferable to the conservative m a n a g e m e n t of fractures of the tibial shaft. However, it can be seen from this study that while m a n y of the troubles are not severe, there is a high complication rate associated with surgical intervention which must be set against this. In conclusion, therefore, while neither treatment group can be said to be superior to the other in all respects, it can be said that despite the introduction of sound engineering techniques into internal fixation, traction remains a satisfactory method in the treatment of unstable tibial fractures.
Acknowledgements We would like to thank Mr J. A. Wilkinson FRCS, Mr J. A. Robertson FRCS and Mr J. A. Fitzgerald FRCS for permission to study their patients and Jayne Hill for typing the manuscript.
REFERENCES
Austin R. T. (1977) Fractures of the tibial shaft: is medical audit possible? Injury 9, 93. Jensen J. S., Hansen F. W. and Johansen J. (1977) Tibial shaft fractures: a comparison of conservative treatment and internal fixation with conventional plates or AO compression plates. Acta Orthop. Scan& 48,204. Nicoll E. A. (1964) Fractures of the tibial shaft. J. Bone Joint Surg. 46B, 373. R/iedi T., Webb J. K. and Allgower M. (1976) Experience with the dynamic compression plate in 418 recent fractures of the tibial shaft. Injury 7(4), 252. Smith J. E. M. (1974) Results of early and delayed internal fixation for tibial shaft fractures. J. Bone Joint Surg. 56B, 469. Van der Linden W. and Larson K. (1979) Plate fixation versus conservative treatment of tibial shaft fractures. J. Bone Joint Surg. 61A, 873. Watson-Jones R. and Coltart W. D. (1943) Slow union of fractures with a study of 804 fractures of the shafts of the tibia and femur. Br. J. Surg. 30, 260. Paper accepted 31 July 1985.
Requests for reprints should be addressed to: Mr J. M. Harley VRCS,Lord Mayor Treloar Hospital, Alton, Hants GU34 1RJ.
91
Printedin Great Britain
A comparison of plating and traction in the treatment of tibial shaft fractures J. M. Harley, M. J. Campbell and R. K. Jackson Southampton General Hospital Summary A consecutive series of fractures of the tibial shaft was studied over a 4-year period. A total of 115 fractures in 115 patients were found to be unstable and therefore unsuitable for immediate treatment in a plaster cast. Sixty-three fractures were treated by internal fixation using AO dynamic compression plates and 52 patients were treated by calcaneal traction. The two treatment groups were compared and it was found that overall each spent a similar time in hospital but the surgically treated group required a minimum of two admissions. The surgically treated group healed 6 weeks sooner than the conservatively treated group but there was an overall complication rate of 30 per cent related to the internal fixation. One hundred and three patients were seen for clinical review, and the incidence of joint stiffness is discussed.
INTRODUCTION THERE are m a n y methods of treating fractures of the tibial shaft but one of the more difficult fractures to treat is that which by virtue of soft tissue swelling or fracture shape is impossible to hold securely in an acceptable position by plaster-of-Paris. The method of treatment of these unstable tibial fractures remains open for debate and while previous authors have advocated conservative treatment in the m a n a g e m e n t of all tibial fractures (Nicoll, 1964) and others have m o r e recently demonstrated the efficiency of rigid internal fixation as a method of treatment (Riiedi et al., 1976), no previous study has compared conservative with surgical m a n a g e m e n t in the treatment of the select group of fractures which prove to be unstable and therefore unsuitable for immediate treatment in plaster-of-Paris. This p a p e r compares rigid internal fixation with calcaneal traction in the treatment of unstable fractures of the tibial shaft.
PATIENTS The case notes and radiographs of all adult patients with fractures of the tibia and fibula occurring over a 4-year period and treated at Southampton General Hospital were studied. There was a minimum follow-up time of 3 years since the date of the injury. Those patients treated wholly in plaster-of-Paris or by external fixation were excluded from the present study. Segmental fractures and fractures which were bone grafted at the time of primary internal fixation were also excluded. A total of 115 patients were identified as having unstable fractures of the tibia and fibula which had been treated by either calcaneal traction or rigid internal fixation. These patients had a fracture of the
tibia and fibula which did not involve a joint surface and attempts at m a n a g e m e n t in plaster-of-Paris had been unsuccessful. The majority of the fractures studied were comminuted. The day of the week on which a patient wi~s admitted governed which surgeon would be in charge of each individual case, and this in turn dictated the method of treatment that would be used. In this way it can be said that the selection of patients for each treatment group was made arbitrarily. In two patients an attempt was m a d e at conservative managem e n t but the fractures proved impossible to reduce by closed methods and were therefore treated by open reduction and internal fixation and so have been included in the plated group. A total of 63 patients were treated by rigid internal fixation while 52 patients were treated by calcaneal traction.
METHOD Plated fractures were rigidly fixed using A O dynamic compression plates. Postoperatively the patients were rested with the leg elevated until the surgical wound healed and once satisfactory healing had occurred an a b o v e - k n e e plaster cast was applied. The patient then walked with crutches and went home. The patients treated by traction had a D e n h a m pin pushed through the calcaneum and the fracture reduced under general anaesthesia. The patients were then managed on a Braun frame with a traction weight of 3.6 kg (8 lb). This was maintained until the fracture was felt to be sticky. This was when the patient could lift the leg straight, free from the supporting frame, while the traction was maintained. The D e n h a m pin was then removed and a full-leg plaster cast was applied. The patient then walked with crutches and was discharged from inpatient hospital care. All the patients with open fractures received antibiotics and most of those with closed fractures which were plated also received antibiotics. The characteristics considered for each patient were the time spent in hospital, the time taken to satisfactory healing and the occurrence of complications. The patients were studied first as a single group to identify factors other than the m e t h o d of treatment which affected these characteristics. Although it is difficult to ensure that similar fractures are c o m p a r e d in such a study the severity of each fracture was graded by giving each fracture a 'personality type' as described by Nicoll (1964); so dividing them into open or closed and slightly or severely displaced fractures. While this means that
Injury: the British Journal of Accident Surgery (1986) Vol. 17/No. 2
92
each individual group is small in numbers they remain sufficient for statistical analysis. Satisfactory union was considered to have occurred in the plated group when obliteration of the fracture line was seen radiographically. In the conservatively treated group union was considered to have occurred when there was sufficient callus to allow the patient to take full weight on the limb free of any external support. Analysis of the healing time for each group of fractures was conducted using the Mann-Whitney U test as implemented on the M I N I T A B system. The patients were called to a special clinic, where they were reviewed with regard to symptoms and clinical evidence of stiffness subsequent to their injury.
RESULTS Time in hospital
Table L Time in hospital Type of fracture
Primary plating Delayed plating Traction
Displacement Treatment Plating Traction
Closed
Open
26 days 29 days 32 days
44 days 46 days 32 days
Healing time There were 69 closed fractures with 37 treated surgically and 32 treated conservatively. The remaining 46 fractures were open and 26 of these were treated surgically while 20 were treated conservatively. The median healing time for the 69 closed fractures was 18 weeks while the median healing time for the 46 open fractures was 26 weeks. This 8-week difference was found to be highly significant (P<0-01). Sixty-four fractures had a displacement on the initial radiograph of less than two-thirds of the tibial shaft's diameter and the median healing time for these fractures was 17 weeks. Fractures with a displacement of two-thirds or more of the tibial shaft diameter on the initial X-ray film had a median healing time of 28 weeks. The l l - w e e k difference between these two groups of fractures was found to be highly significant (P<0.01). Therefore each treatment group was subdivided into
<2/3
> 2/3
14 weeks 18 weeks
21 weeks 28 weeks
Table III. Median healing time for open fractures Displacement Treatment
The average time spent in hospital was 32 days for the conservatively treated group and 34 days for the surgically treated group. The conservatively treated group spent an average of 28 days on traction. Patients in the plated group of fractures required a second hospital admission for removal of the metal. The average inpatient time required for this was 5 days, and this has been included in the above times. Table 1 shows that in the surgically treated group patients with closed fractures spent less time in hospital than those with open fractures. The average difference in time in hospital between primary and delayed plated fractures was approximately 3 days, while the average interval before delayed plating of fractures was 12 days (minimum 5 days) for closed and 18 days (minimum 10 days) for open fractures. All patients in the traction group spent a similar period in hospital regardless of the type of fracture.
Method of treatment
Table IL Median healing time for closed fractures
Plating Traction
<2/3
>2/3
16 weeks 24 weeks
38 weeks 36 weeks
open and closed and slightly or severely displaced fractures to ensure that similar fracture types were studied in each group. Table I1 shows the healing time for closed fractures, comparing the surgically and conservatively treated groups. It can be seen that in both the lesser and the greater displaced fractures the traction treated group required a longer time for healing, with the difference being 4 weeks and 7 weeks. These differences were highly significant (P<0.01). Table III shows a similar comparison for open fractures demonstrating that in the lesser displaced fractures the traction group takes 8 weeks longer to healing than the plated group. This difference was found to be highly significant (P<0.01) while there was no significant difference in the severely displaced open fractures. Figure 1 shows that the median difference in healing time between plated fractures and traction treated fractures when all fracture types are considered is 6 weeks. This difference was found to be highly significant (P<0-01). The definition of the term 'delayed union' varies with different authors but the use of this cumulative percentage curve, as recommended by Austin (1977), allows direct comparison of the healing rate in each treatment group. An individual definition of time to delayed union can be read directly from the graph, so allowing comparison with other reported series. Although the graph stops at 52 weeks all fractures had healed at the time of review but the plated group took until 110 weeks to reach 100 per cent healed. Bone grafting was necessary in five patients (10 per cent) of the traction group and in 10 patients (25 per cent) of the primary plated group. The average time for grafting was 30 weeks from date of injury. No patient in the group treated by delayed plating required a bone graft.
Complications Complications in closed and open fractures were compared. Malunion was defined as more than 8° of medial or lateral angulation or 10° of anterior or posterior angulation in the final radiograph. The overall complication rate of each treatment group is shown in Table IV. Tables V and VI show the nature of the complications in each treatment group. The number of complications exceeds the number of patients because
Harley et al. : Unstable tibial shaft fractures
93
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20
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time fo healing(weeks)
Fig. 1. Median difference in healing time between plated fractures and those treated by traction. Table IV. Complication rate after fracture of the tibial shaft No. o f complications
Total no. o f fractures
Complication rate (%)
11 0 4
26 11 32
42.0% 0 12.5%
10 2 5
13 13 20
77.0% 15.0% 25.0%
Closed fractures Primary plating Delayed plating Traction Open fractures Primary plating Delayed plating Traction Table V. Complications of closed tibial fractures Primary plating
Bone graft required Malunion Pulmonary embolism Refractu re Fracture through a screw-hole Wound infection Delayed wound healing Chronic osteomyelitis Painful plate
Traction
3 3 3 3 6 1 1 4
several patients had more than one complication. The complication rate attributable to internal fixation was 30 per cent.
Clinical result One hundred and three patients were seen for clinical review; 47 had been treated conservatively and 56 surgically. Six patients in the traction treated group had clinical evidence of stiffness of the ankle joint. Two of these patients had only slight stiffness and were asymptomatic. The other four had less than one-third of the normal range of ankle joint movement, and this stiffness was symptomatic. Two of these patients had also
Table VI. Complications of open tibial fractures Primary plating
Bone graft required Malunion Pulmonary embolism Refracture Delayed wound healing Wound infection Painful plate Toe clawing and metatarsalgia
7 1 1 2 1 3 1
Traction
Delayed plating
94 suffered a fracture of the malleolus as well as of the tibial shaft. Three patients in the surgically treated group had stiff ankles. Each of these patients had less than one-third of the normal range of m o v e m e n t when c o m p a r e d with the other side. This stiffness was symptomatic in each patient, one of w h o m had suffered fracture of the malleolus as well as of the tibial shaft. Subtalar stiffness occurred in eight of the patients treated on traction and in six of the patients treated by plating. All of these patients were symptomatic and had less than one-third of the normal movement. There was no instance of persisting stiffness of the knee. The occurrence of stiffness of the ankle and subtalar joint did not a p p e a r to be related to the severity of the fracture but all patients who suffered fracture of the malleolus as well as of the tibial shaft developed symptomatic stiffness of the ankle and subtalar joints, in both treatment groups.
DISCUSSION The conservative m a n a g e m e n t of large numbers of tibial shaft fractures has been well documented in the literature (Nicoll, 1964), as have large numbers of patients treated by rigid internal fixation (R/iedi et al., 1976). There have been a few reports comparing conservative treatment with internal fixation (Jensen et al., 1977; Van der Linden and Larson, 1979), but no previous p a p e r has considered exclusively the unstable fractures of the tibial shaft and their treatment. The results of this study show that the time spent in hospital by patients with surgically or conservatively treated fractures was the same. Patients with closed fractures spent less time in hospital when treated surgically than when treated conservatively but the opposite was true of those with open fractures. Patients with fractures plated at once also spent less time in hospital than those with fractures plated after a delay, but the difference of 3 days in the total time spent in hospital was considerably less than the delay which occurred before the operation. This apparently anomalous finding is accounted for by the fact that a high complication rate in the primarily plated fractures necessitated extra time in hospital. This concurs with other published work (Smith, 1974). In all fracture groups the surgically treated patients healed more quickly, apart from those with severely displaced open fractures. No arbitrary time was taken in this study to denote delayed or nonunion but bone grafting had been carried out when there was lack of satisfactory clinical or radiological progress. The bone grafting rate was approximately 10 per cent of all cases, except for primarily plated open fractures in which the bone grafting rate was over 50
Injury: the British Journal of Accident Surgery (1986) Vol. 17/No. 2
per cent. This was not seen after delayed plating. Stiffness of the ankle or subtalar joints occurred more commonly in the conservatively treated group but not all were symptomatic. However, when there was an ipsilateral disruption of the ankle joint as well as a fracture of the tibial shaft neither conservative management nor internal fixation achieved satisfactory ankle or subtalar function. It has been previously stated that the shorter time to regain function after internal fixation (Watson-Jones and Coltart, 1943) made this method preferable to the conservative m a n a g e m e n t of fractures of the tibial shaft. However, it can be seen from this study that while m a n y of the troubles are not severe, there is a high complication rate associated with surgical intervention which must be set against this. In conclusion, therefore, while neither treatment group can be said to be superior to the other in all respects, it can be said that despite the introduction of sound engineering techniques into internal fixation, traction remains a satisfactory method in the treatment of unstable tibial fractures.
Acknowledgements We would like to thank Mr J. A. Wilkinson FRCS, Mr J. A. Robertson FRCS and Mr J. A. Fitzgerald FRCS for permission to study their patients and Jayne Hill for typing the manuscript.
REFERENCES
Austin R. T. (1977) Fractures of the tibial shaft: is medical audit possible? Injury 9, 93. Jensen J. S., Hansen F. W. and Johansen J. (1977) Tibial shaft fractures: a comparison of conservative treatment and internal fixation with conventional plates or AO compression plates. Acta Orthop. Scan& 48,204. Nicoll E. A. (1964) Fractures of the tibial shaft. J. Bone Joint Surg. 46B, 373. R/iedi T., Webb J. K. and Allgower M. (1976) Experience with the dynamic compression plate in 418 recent fractures of the tibial shaft. Injury 7(4), 252. Smith J. E. M. (1974) Results of early and delayed internal fixation for tibial shaft fractures. J. Bone Joint Surg. 56B, 469. Van der Linden W. and Larson K. (1979) Plate fixation versus conservative treatment of tibial shaft fractures. J. Bone Joint Surg. 61A, 873. Watson-Jones R. and Coltart W. D. (1943) Slow union of fractures with a study of 804 fractures of the shafts of the tibia and femur. Br. J. Surg. 30, 260. Paper accepted 31 July 1985.
Requests for reprints should be addressed to: Mr J. M. Harley VRCS,Lord Mayor Treloar Hospital, Alton, Hants GU34 1RJ.