Introduction

Diaphyseal tibial fractures account for approximately 1.9% of adult fractures. Studies have demonstrated a high proportion have ipsilateral occult posterior malleolus fractures. We hypothesize that this rotational element will be highlighted using the Mason & Molloy Classification.

1. A series of 705 fractures of the tibia is reviewed, 674 of which were treated conservatively.

2. The factors most conducive to delayed or non-union are initial displacement, comminution, associated soft-tissue wound and infection. The extent to which these are combined in any fracture determines its "personality" and its inherent propensity for union.

3. Eight fracture types are differentiated based on the above "personality rating." The incidence of delayed union or non-union varies from 9 per cent in the most favourable type to 39 per cent in the least favourable. Infection raises the incidence to 60 per cent. Comparative statistics which fail to recognise these differences can be entirely misleading.

4. Continuous traction does not retard union.

5. The results of conservative treatment are analysed with regard to union, deformity, stiff joints and contractures and the conclusion is reached that no case has yet been made out for internal fixation as the method of choice in the treatment of this fracture.

1. The probable greatest bending moment applied to a plated or nailed fracture of the tibia during restricted weight-bearing is estimated to be, in men, up to about 79 Newton metres (58 poundsforce feet). The maximum twisting moment is estimated to be about 29 Newton metres (22 poundsforce feet).

2. Twenty-two human tibiae were loaded in three-point bending and broke at bending moments of from 57·9 to 294 Newton metres (42·7 to 216 poundsforce feet) if they had not previously been drilled; tibiae which had holes made through both cortices with a c. 3-millimetre (⅛-inch) drill broke at from 32·4 to 144 Newton metres (23·8 to 106 poundsforce feet). Tibiae loaded in torsion broke at twisting moments of from 27·5 to 892 Newton metres (20·2 to 65·8 poundsforce feet) when not drilled, 23·6 to 77·5 Newton metres (l7·3 to 57·1 poundsforce feet) when drilled.

3. When bent so as to open the fracture site, the 14-centimetre Stamm was the strongest of all the single plates tested (reaching its elastic limit at a bending moment of 17·6 Newton metres (13 poundsforce feet) and 5 degrees total angulation at 22·6 Newton metres (16·6 poundsforce feet)), while the Venable was the weakest (elastic limit 4·9 Newton metres (3·6 poundsforce feet) and 5 degrees at 7·9 Newton metres (5·8 poundsforce feet)). A 13-millimetre Küntscher nail reached its elastic limit at 42·2 Newton metres (31·1 poundsforce feet) and 5 degrees total angulation at 49 Newton metres (36 poundsforce feet).

4. In torsion the 15-centimetre Hicks was the strongest ofthe plates (elastic limit 27·5 Newton metres (20·2 poundsforce feet) and 5 degrees rotation at 16·7 Newton metres (l2·3 poundsforce feet)).

5. Küntscher nails in bones provided no dependable strength in torsion.

6. In both bending and torsion, a preparation of one Venable plate on each of the two anterior surfaces was stronger than any single plate, and was as strong as the weaker drilled tibiae.

7. The three currently available metallic materials (stainless steel, cobalt-chrome and titanium) have static mechanical properties so similar that the choice between them can be made on other grounds.

8. The highest load applied to a screw during bending tests was about half that needed to pull a screw out of even a thin-walled tibia.

9. Screws beyond four for one plate are mechanically redundant at the moment of implantation but may be necessary as an insurance against subsequent deterioration in strength.

10. Countersinks in plates are a source of significant weakness, and should preferably be as shallow as possible.

11. An unoccupied screw hole in the centre of a plate is a source of serious weakness.

12. Only the strongest implants tested were strong enough to withstand the bending or twisting moments to be expected in restricted weight-bearing. In two-plate preparations a danger is introduced by the fact that these moments are similar to those required to Ireak a drilled tibia.

1. Eighty consecutive open fractures of the tibial shaft were treated by primary internal fixation and wound closure. Wound healing was complicated by deep infection in eight patients (10 per cent) and by skin loss of varying degree in ten (l2·5 per cent).

2. Careful selection of patients on the basis of associated soft-tissue injuries is urged. A simple method of grading open fractures by the appearance of the wound and adjacent skin and the effectiveness of wound closure is suggested. If internal fixation is indicated on mechanical grounds, the nature of the soft-tissue injury should be the deciding factor in the choice of the method of treatment. In the less severe (Grade 1) fractures internal fixation and wound closure may be safely employed. In the severe (Grade 3) injuries, primary wound closure with or without internal fixation should be avoided. Moderately severe (Grade 2) fractures should be carefully assessed and treated by internal fixation and wound closure only if primary wound healing is confidently expected.

3. Wound healing by first intention requires, in addition to adequate debridement of the deep layers of the wound, careful approximation of healthy wound edges without excessive tension. An adequate knowledge of skin-plastic procedures is essential to achieve this.

4. A combination of systemic penicillin and streptomycin in adequate doses is a safe and effective prophylactic antibiotic for use in the treatment of open fractures.

The purpose is to present our experiences with the conversion of external fixation to an intramedullary nail in the treatment of open fractures and fractures in polytraumatised patients. These are traumatological cases where primary use of an intramedullary nail is difficult or impossible.

References in the world literature to the two-stage treatment of the fractures of the tibial shaft are more than 2O years old and are considered as unsuccessful. However, later papers presented conversion as an advantageous procedure. A higher stability of the fracture and better comfort of the patient are acquired by the use of conversion.

From 1995 to 1999 in the Orthopedic Clinic Bulovka in Prague, Czech Republic, ten patients (8 male, 2 female) were treated by the method of conversion of external fixation to an intramedullary nail. The group of patients was composed of eight open fractures: one Gustillo-Anderson 1, two Gustillo-Anderson 2, three Gustillo-Anderson 3A, two Gustillo-Anderson 3B, one closed fracture Tscherne CIII, and one closed fracture Tscherne CII in a polytraumatised patient. Conversion was performed from 6 to 48 days after primary stabilisation by external fixation (mean 21.2 days). We currently use the UNI-fix clamp external fixator. Conversion by standard procedure is performed up to the 21st day to the 28th day after primary stabilisation. Injury of soft tissues and skin covering must be solved at the time of conversion.

Analysis of the results in the ten cases was made from three months to 4.5 years. All of the cases were subjectively classified as excellent or very good. There were no deep infections. In three cases there was prolonged secretion from the screw holes of the external fixator. For one patient, bone grafting into a fracture bone defect was necessary after six months. ROM of the knee and ankle joint was without reduction of function. When the period of follow-up was more than one year, all patients had perfect healing of the fractures.

This method gives very satisfactory therapeutic results with a minimum of complications, and covers the spectrum of the treatment of complicated fractures of the tibial shaft. However, the indications are very strict. If conversion is not able to be performed before the 21st to the 28th day after primary stabilisation, it is more advantageous to continue with treatment by external fixation because of the risk of deep infection. After the 28th day following primary stabilisation, conversion to an intramedullary nail is not indicated.

Purpose: The evaluation of the results of intramedullary nailing of open fractures of tibial shaft, which have been initially treated with external fixation.

Material & Method: Between 1997–2003, in 58 open fractures of tibial shaft (Gustillo type II & IIIa), the initially applied external fixation was replaced by an intramedullary nail type Russell-Taylor or Grosse-Kempf, either due to delay in union progress or due to frame‘s loosening. The conversion of external fixation to intramedullary nail was performed between 12th–15th week (average: 14th week), in two stages (1st stage: removal of EX.FIX, 2nd stage: insertion of I..N); with 13–22 days interval between the stages. In all cases, no elements of infection were noticed. In 45% of the patients bone grafting was performed at the time of nail‘s insertion. 37 patients were men and 21 were women, aged 19–52 years old (average: 31,7yrs). All patients were treated by the same surgical team and followed-up routinely.

Results: Union was achieved in 85% of the fractures, usually between 16–23 weeks (average: 18,7 weeks) from nail‘s insertion. In 7 cases, another operation was needed. Bone grafting in five, exchange of nail in two. Neither infection nor DVT was noticed. 82% of patients started sociallizing within 4 weeks, while 79% returned to pre-injury activities.

Conclusions: In cases that the union progress of the externally fixed open fractures of tibial shaft is not satisfactory; the conversion of external fixation to intramedullary nail seems to be a reliable option. The key points for the success of the method are timing and conditions of that conversion.

Aim

One of the most common patient-reported complaints following intramedullary nailing (IMN) of tibial shaft fractures is anterior knee pain reported by 10% to 80% of patients. The present study aimed to compare the 12-month Knee injury and Osteoarthritis Outcome Score (KOOS) sport and recreation activities subscale (sport/rec) scores after IMN with external ring fixation (RF) to adult patients with tibial shaft fractures.

1. The thesis is advanced that in the treatment of fractures of the adult tibia rigid fixation is desirable.

2. The mechanical factors are discussed and a technique is described which provides a high degree of fixation without exposing more than one surface of the bone.

3. The process of healing of such fractures is described and the results in thirty-three unselected patients are given.

Fractures of the tibial shaft are common injuries, but there are no long-term outcome data in the era of increased surgical management. The aim of this prospective study was to assess the clinical and functional outcome of this injury at 12 to 22 years. Secondary aims were to determine the short- and long-term mortality, and if there were any predictors of clinical or functional outcome or mortality. From a prospective trauma database of 1502 tibial shaft fractures in 1474 consecutive adult patients, we identified a cohort of 1431 tibial diaphyseal fractures in 1403 patients, who fitted our inclusion criteria. There were 1024 men, and mean age at injury was 40.6 years. Fractures were classified according to the AO system, and open fractures graded after Gustilo and Anderson. Requirement of fasciotomy, time to fracture union, complications, incidence of knee and ankle pain at long-term follow-up, changes in employment and the patients’ social deprivation status were recorded. Function was assessed at 12 to 22 years post-injury using the Short Musculoskeletal Function Assessment and short form-12 questionnaires. Long-term functional outcome data was available for 568 of the surviving patients, 389 were deceased and 346 were lost to follow-up. Most fractures (90.7%, n = 1363) united without further intervention. Fasciotomies were performed in 11.5% of patients; this did not correlate with poorer functional outcome in the long term. Social deprivation was associated with a higher incidence of injury but had no impact on long-term function. The one-year mortality in those over 75 years of age was 29 (42%). At long-term follow-up, pain and function scores were good. However, 147 (26%) reported ongoing knee pain, 62 (10%) reported ankle pain and 97 (17%) reported both. Such joint pain correlated with poorer functional outcome. Cite this article: Bone Joint J 2014;96-B:1370–7