Injury, 7, 47-52
47
The results of operative and non-operative management of tibia1 fractures Erkki 0. Karaharju, Antti Alho and Jorma Nieminen Department of Orthopaedics and Traumatology, University Central Hospital, Helsinki Summary
A series of 160 fractures of the tibia in 155 patients is analysed. Eighty patients were operated on; intramedullarv nails were used in 33. A0 _ nlates in 29 and screws in 18 cases. In the final evaluation the result was classified as good in 39, fair in 27, and poor in 14 cases in the nonoperative group, and 40, 25 and 15 in the operative group. Fracture comminution on foot and ankle motion.
had a significant effect
NON-OPERATIVE management
is still the primary therapeutic approach to tibia1 fractures at many hospitals (Slatis and Rokkanen, 1967a; Charnley, 1968). However, the severity of tibia1 fractures has increased in recent years because a rising proportion of the fractures are caused by highvelocity trauma and are consequently often severely comminuted and frequently open. Operative treatment has become more common for these difficult fractures. Opinions differ as to the superiority of the use of the intramedullary nail, screws or A0 plate as the operative method (Mtiller et al., 1970; Zucman and Maurer, 1970; Olerud and Karlstrom, 1972; Solheim and Ber, 1973 ; Karaharju et al., 1974). Hoffman’s double frame external anchorage has proved to be a good method for the treatment of severe complicated tibia1 fractures (Connes, 1973). In order to establish the advantages and disadvantages of operative management, we analysed a series of 80 operatively treated tibia1 fractures and compared it with a corresponding series treated conservatively. During the period of study, about 20 per cent of all tibia1 fractures were treated operatively. PATIENTS AND METHODS The series consists of the 160 tibia1 fractures in 155 patients treated in 1970-1971, 80 of them
operatively and 80 non-operatively. HoffmanVidal double frame external anchorage was applied in 8 cases during the investigation period (Connes, 1973). The indication for the procedure, in every case, was an extensive skin defect and a comminuted fracture. These patients were omitted from the analysis as it was impossible to find controls from the conservatively managed cases. Sixty-two per cent of the patients were men. Fifty-eight per cent were under 40 years of age. The implants used in the 80 operated cases were intramedullary nails in 33, A0 plates in 29, and screws in 18. A control group of 80 patients was chosen from cases with similar wounds and fracture comminution (Table I). The site, pattern and instability of the fractures in the operative and non-operative groups were analysed (Table ZZ). Edwards’ (1965) criteria were employed in the classification. Operative technique All the wounds were closed; primary split-skin grafts were necessary in 7 cases. Of the operative cases, 19 per cent underwent operation within 6 hours of injury, 45 per cent within 12 days, and 36 per cent after 13-20 days. The closed technique of intramedullary nailing was favoured, using a Ktintscher nail and reaming the medullary cavity. A plaster cast was applied in the after-treatment in 10 out of 33 cases. In the A0 plating the principles of the Association for the Study of Internal Fixation were applied (Miiller et al., 1970). Compression was not achieved in 8 cases. Plaster casts were used in 20 out of 29 cases. The A0 principles were also applied in fixation by screws. Plaster casts were used in all 18 cases for postoperative immobilization.
4%
Injury: the British Journal of Accident Surgery Vol. ~/NO. 1
Table 1. Pairing of the groups on the basis of the wound and fracture comminution Non-operative series
Operative series
Wound Minimal (less than 2 cm) Medium (2-5 cm) Large (more than 5 cm)
3 16 6
1 11 6
Fracture comminution Slight or none Moderate Severe
30 35 15
29 34 17
Late examination One hundred and thirty-six patients had a personal follow-up examination. The rest of the information was obtained from the case reports. The follow-up period was 6 months-l year for 32, l-3 years for 63 and over 3 years for 60 patients. In the final evaluation the following findings were recorded using Edwards’ (1965) criteria: pain, working capacity, limp, motion of knee, ankle and foot, swelling, amputation, osteomyelitis and non-union. Further, if the patient had several disabilities, the one that caused the most trouble was recorded. Nine patients with intra-articular fractures (Table ZZ) were omitted from the analysis of joint movements. Seven patients with damage to the ankle or foot of the treated limb were omitted
Tab/e II.
from analysis of ankle and foot movements. The data were processed in the Computer Centre of Helsinki University. The mean and standard deviation (m&d) were stated and the difference between the groups was regarded as statistically significant if PcO.025. RESULTS Full weight-bearing was permitted when 126* 103 days had elapsed from the injury. The patients returned to work 233 h200 days after the injury. There were no significant differences between the series. Of the 77 non-operatively managed patients, 62 returned to their former jobs, 5 took lighter work and 10 were unable to work. The figures for the 78 in the operative group were 62, 7 and 9 respectively.
Location, pattern and instability of 160 lower leg fractures Non-operative series
Operative series
Location Middle thirdthird* Uppermost Lowest thirdt Double Pattern Transverse Longitudinal Comminuted Instability Slight Moderate Severe *l intra-articular
216 46 7
2: 42 9
34 32 14
25 37 18
2
3 37 40
fracture in the non-operative
group, 1 in the operative group.
73 intra-articular fractures in the non-operative group, 4 in the operative group.
Karaharju et al.: Management of Tibia1 Fractures
Time spent in hospital The patients of the non-operative group were in hospital for 30-36 days. The operated patients spent the following average time in hospital: intramedullary nail, 54 days; A0 plate, 40 days; screws, 17-24 days. The only statistically significant difference was between the patients treated with screws and the other therapeutic groups. Late operations Late operations were performed on 15 patients of the operative and 14 of the non-operative series. Fifteen patients needed bone grafts, 11 of which were of the Phemister-Charnley type (Charnley, 1968). Eleven of these 15 bone grafts were performed on patients in the conservative group and 4 on operatively treated patients. Intramedullary nailing was undertaken in 2 cases, 1 from each group. Five patients underwent later skin grafting, 4 debridement and 3 some other operation. The need for a late operation in the operatively managed series was greatest (9 out of 29 cases) after A0 plate fixation. Infections Both superficial and deep infections were recorded (Table III). A closed fracture was infected in 3 of the non-operated and 17 of the operated patients. The latter group showed the highest incidence of infection in the group treated with A0 plates although the fractures were mostly closed (25 out of 28 cases). Union was slower in the infected cases: the average duration of immobilization in plaster was 117f35 days for the non-infected and 164&27 days for the infected cases. The difference is statistically significant. For 2 years after the injury, the infection persisted in 4 cases of the operative and 2 of the non-operative series. Joint mobility after operative and non-operative treatment Loss of ankle motion Table IV shows the limitation of movement in the groups. No differences were established between the operative and non-operative series, or between the different types of operation. Loss of foot motion As can be seen from Table V, disturbances in the range of foot motion were slightly more frequent in the non-operative than in the operative group. The difference, however, was not statistically significant.
49
Table /I/.
Infections
Non-operative series Operative series lntramedullary nail A0 plate Screws
Primary
Late
Total
2 10 2 6 2
5 13 4 5 4
7 23 6 11 6
Loss of knee motion Over 10 degrees extension was lost in only 2 patients in each group. Practically normal flexion was achieved in all cases. As shown in Table VZ, loss of ankle and foot motion was the commonest main late complaint, followed by swelling of the leg. Correlation of joint mobility with fracture comminution Table VZZshows the effect of the degree of fracture comminution on ankle motion, and Table VIII its influence on foot motion. The degree of fracture comminution played a significant role in the loss of ankle and foot motion.
Tab/e IV.
Loss of ankle motion Non-operative series
Loss of dorsiflexion lO” No dorsiflexion Loss of plantarflexion 30”
Operative series
10 10 2
10 9 -
19
15 -
:
3
Tab/e I/. Loss of foot motion Non-operative series
Operative series
Loss of pronation less than one-half one-half no pronation
13 2 5
9 2 4
Loss of supination less than one-half one-half no supination
14 2 5
6
50
Injury: the British Journal of Accident Surgery Vol. ~/NO. 1
Malalignment and shortening Varus deformity of over 5” was seen in 6 conservatively and 2 operatively managed cases. Three patients of the former and 6 of the latter series had a valgus deformity of over 5”. Four of the latter patients belonged to the intramedullary Table VL Main late complaint Non-operative series Loss of ankle or foot motion Loss of knee motion Leg swelling Other
Operative series
19 4 8 4
19 3 6 4
nailing group. Anterior bowing of over 10” was seen in 4 patients of the non-operative and 2 of the operative group and, correspondingly, backward bowing of over 10” in 5 cases of the former but not a single patient of the latter series. Shortening of 2-5 cm was seen in 6 non-operative patients and one operative patient. Leg swelling Of the non-operative series, 13 out of 77 patients suffered from leg swelling; it was marked in 8 of the cases. In the operative series, 16 out of 78 patients had leg swelling, 6 of them to a marked degree (Table VI). There were, therefore, no
Tab/e VII. Influence of fracture comminution
Degree of comminution
None or slight Moderate Severe
Table VIII.
13 11 22
Influence of fracture comminution
Degree of comminution
None or slight Moderate Severe
Evaluation of the end results The classification according to Edwards’ (1965) criteria is ‘ good, fair and poor ‘. Table IX presents the end results. No differences were established between the non-operative and operative groups, nor were any significant differences seen between the different operative groups. DISCUSSION AND CONCLUSIONS The comparability of the fractures in the nonoperative and operative groups was fairly good (Tables I, II) and the results probably warrant conclusions as to the advantages and disadvantages of both methods of treatment. The operative techniques were routine. We regard reaming of the medullary cavity as an important factor increasing stability in intramedullary nailing, although contrary opinions have been recently presented (Zucman and Maurer, 1970). In the group treated with A0 plates, the failures can be attributed in a few cases to unsatisfactory operative technique. The bone-grafting rate in the conservatively treated group (11 out of 80) is obviously higher than the rate in the operated group (4 out of 80). This can be explained by the fact that we consider cancellous bone-grafting of delayed union at 3 months an expected consequence in some cases where primary non-operative treatment has been applied (Charnley, 1968).
on ankle motion
Patients with loss of dorsiflexion (per cent) lO” 13 15 19
significant differences between the series. Nor was there any correlation between the duration of immobilization in plaster and leg swelling.
Patients with loss of plantarflexion er cent) 20” ::
4 3 12
65
on foot motion
Patients with loss of pronation (per cent)
Patients with loss of supination (per cent)
20 23 44
19 18 52
Karaharju et al. : Management of Tibia1 Fractures
51
The operative group suffered distinctly more from infections (Silva, 1973; Alho, 1974; Gallinaro et al., 1974). There were 23 infections in this group, 17 of them in closed fractures. The infection in 3 conservatively managed closed fractures (Tub/e ZZZ) was due to extensive contusion with tissue damage. The infection rate was highest in the group treated with A0 plates
the non-operative group. Malalignment in the operated group was most frequent in the patients treated with intramedullary nails. These radiologically demonstrated malpositions did not generally affect the end result as judged by the patient. To summarize: non-operative treatment proved to be reliable and must still be regarded as the
Tab/e /%. Results of final evaluation
Non-operative group Operative group lntramedullary nail A0 plate Screws
Good
Fair
Poor
39 42 17 15 10
27 26 10 9 7
14 12 6 5 1
and the great risk of infection must in fact be regarded as one of the major drawbacks of this operative method (Olerud and KarlstrGm, 1972; Gallinaro et al., 1974). Our high rates of infection reflect our strict recording of all superficial infections. Persistent drainage occurred in 4 operated and 2 nonoperated cases. Operation did not hasten the patients’ recovery and return to work, as has been previously reported (Slatis and Rokkanen, 1967b). The advantages of operation seem to be offset by the resulting complications. It has often been claimed that operative treatment is the better alternative in that early mobilization of the joints achieves a better result in respect of mobility (Slgtis and Rokkanen, 1967b; Olerud and Karlstrijm, 1972). The reduction of ankle and foot motion was the commonest late complaint in both the operative and non-operative group (Tables V, VZ). The duration of immobilization in plaster did not correlate with the end result. On the other hand the degree of fracture comminution distinctly affected ankle and foot motion (Tables VZZ, VIII). Leg swelling was the next commonest late complaint (Table VZ). Judging by the clinical picture, the swelling was a post-thrombotic syndrome. No venographic examinations were made. The severity of the injury seemed to play a greater role in leg swelling than the method of treatment. Unsatisfactory final positions as shown on the radiograms were somewhat more numerous in
primary method for the management of tibia1 fractures. If non-operative management fails or other indications are present, intramedullary nailing is the best operative method of treatment. The use of the A0 plate is probably the most useful in intra-articular fractures. Certain oblique fractures caused by low-velocity trauma may lend themselves to the use of screws. When the method has been selected with care it does not affect the end result essentially; it is the grade of severity of the fracture that is decisive for the outcome.
REFERENCES ALHO A. (1974) Operative versus non-operative treatment for tibia1 shaft fractures. Acta Orthoo. Scund. (in press). CHARNLEYJ. (1968) The Closed Treatment of Common Fractures. ‘Edinburgh and London, E. & S. Livingstone. CONNESH. (1973) Hoffmann’s Double Frame External Anchorage. Pa& Gead. EDWARDSP. (1965) Fracture of the shaft of the tibia: 492 conkutive cases in adults. Acta Orthop &and. Suppl. 76. GALLINAROP., CROVA M. and DENICOLAIF. (1974) Complications in 64 open fractures of the tibia. Injury 5, 157. KARAHARJUE. O., NIEMINENJ. and ALHO A. (1974) Final results of operatively versus non-operatively treatedfracturesof tibia. AcfaOrthop.Scand. 45,996. MUELLERM. E., ALLG~~WERM. and WILLENEGGERH. (1970) Manual of Internal Fixation-Technique recommended by the A0 Group. Berlin, SpringerVerlag.
52
Injury:
OLERUDS. and KARLSTRGMC. (1972) Tibia1 fractures treated by A0 compression osteosynthesis. Acta Orthop.
Stand.,
Suppl.
of Accident
Surgery
Vol. ~/NO.
1
SL~~TISP. and ROKKANEN P. (1967b) Conservative treatment of tibia1 shaft fractures. Acta Orthop. Scund. 38, 133.
140, 3.
SILVA J. F. (1973) Fractures of the tibia and fibula. J. Trauma 12, 1029. SLATE P. and ROKKANENP. (1967a) Closed intramedullary nailing of tibia1 shaft fractures. Acta Orthop. Stand. 38, 88.
Requests for reprints should be addressed Hospital, Helsinki, Finland.
the British Journal
to:
Erkki
0.
Karaharju,
SOLHHMK. and Bo 0. (1973) lntramedullary nailing of tibia1 shaft fractures. Acta Orthop. Stand. 44,323. ZLJCMAN J. and MAURERP. (1970) Primary medullary nailing of the tibia for fractures of the shaft in adults. Injury 2, 84.
Department
of Orthopaedics
and Traumatology,
University
Central
47
The results of operative and non-operative management of tibia1 fractures Erkki 0. Karaharju, Antti Alho and Jorma Nieminen Department of Orthopaedics and Traumatology, University Central Hospital, Helsinki Summary
A series of 160 fractures of the tibia in 155 patients is analysed. Eighty patients were operated on; intramedullarv nails were used in 33. A0 _ nlates in 29 and screws in 18 cases. In the final evaluation the result was classified as good in 39, fair in 27, and poor in 14 cases in the nonoperative group, and 40, 25 and 15 in the operative group. Fracture comminution on foot and ankle motion.
had a significant effect
NON-OPERATIVE management
is still the primary therapeutic approach to tibia1 fractures at many hospitals (Slatis and Rokkanen, 1967a; Charnley, 1968). However, the severity of tibia1 fractures has increased in recent years because a rising proportion of the fractures are caused by highvelocity trauma and are consequently often severely comminuted and frequently open. Operative treatment has become more common for these difficult fractures. Opinions differ as to the superiority of the use of the intramedullary nail, screws or A0 plate as the operative method (Mtiller et al., 1970; Zucman and Maurer, 1970; Olerud and Karlstrom, 1972; Solheim and Ber, 1973 ; Karaharju et al., 1974). Hoffman’s double frame external anchorage has proved to be a good method for the treatment of severe complicated tibia1 fractures (Connes, 1973). In order to establish the advantages and disadvantages of operative management, we analysed a series of 80 operatively treated tibia1 fractures and compared it with a corresponding series treated conservatively. During the period of study, about 20 per cent of all tibia1 fractures were treated operatively. PATIENTS AND METHODS The series consists of the 160 tibia1 fractures in 155 patients treated in 1970-1971, 80 of them
operatively and 80 non-operatively. HoffmanVidal double frame external anchorage was applied in 8 cases during the investigation period (Connes, 1973). The indication for the procedure, in every case, was an extensive skin defect and a comminuted fracture. These patients were omitted from the analysis as it was impossible to find controls from the conservatively managed cases. Sixty-two per cent of the patients were men. Fifty-eight per cent were under 40 years of age. The implants used in the 80 operated cases were intramedullary nails in 33, A0 plates in 29, and screws in 18. A control group of 80 patients was chosen from cases with similar wounds and fracture comminution (Table I). The site, pattern and instability of the fractures in the operative and non-operative groups were analysed (Table ZZ). Edwards’ (1965) criteria were employed in the classification. Operative technique All the wounds were closed; primary split-skin grafts were necessary in 7 cases. Of the operative cases, 19 per cent underwent operation within 6 hours of injury, 45 per cent within 12 days, and 36 per cent after 13-20 days. The closed technique of intramedullary nailing was favoured, using a Ktintscher nail and reaming the medullary cavity. A plaster cast was applied in the after-treatment in 10 out of 33 cases. In the A0 plating the principles of the Association for the Study of Internal Fixation were applied (Miiller et al., 1970). Compression was not achieved in 8 cases. Plaster casts were used in 20 out of 29 cases. The A0 principles were also applied in fixation by screws. Plaster casts were used in all 18 cases for postoperative immobilization.
4%
Injury: the British Journal of Accident Surgery Vol. ~/NO. 1
Table 1. Pairing of the groups on the basis of the wound and fracture comminution Non-operative series
Operative series
Wound Minimal (less than 2 cm) Medium (2-5 cm) Large (more than 5 cm)
3 16 6
1 11 6
Fracture comminution Slight or none Moderate Severe
30 35 15
29 34 17
Late examination One hundred and thirty-six patients had a personal follow-up examination. The rest of the information was obtained from the case reports. The follow-up period was 6 months-l year for 32, l-3 years for 63 and over 3 years for 60 patients. In the final evaluation the following findings were recorded using Edwards’ (1965) criteria: pain, working capacity, limp, motion of knee, ankle and foot, swelling, amputation, osteomyelitis and non-union. Further, if the patient had several disabilities, the one that caused the most trouble was recorded. Nine patients with intra-articular fractures (Table ZZ) were omitted from the analysis of joint movements. Seven patients with damage to the ankle or foot of the treated limb were omitted
Tab/e II.
from analysis of ankle and foot movements. The data were processed in the Computer Centre of Helsinki University. The mean and standard deviation (m&d) were stated and the difference between the groups was regarded as statistically significant if PcO.025. RESULTS Full weight-bearing was permitted when 126* 103 days had elapsed from the injury. The patients returned to work 233 h200 days after the injury. There were no significant differences between the series. Of the 77 non-operatively managed patients, 62 returned to their former jobs, 5 took lighter work and 10 were unable to work. The figures for the 78 in the operative group were 62, 7 and 9 respectively.
Location, pattern and instability of 160 lower leg fractures Non-operative series
Operative series
Location Middle thirdthird* Uppermost Lowest thirdt Double Pattern Transverse Longitudinal Comminuted Instability Slight Moderate Severe *l intra-articular
216 46 7
2: 42 9
34 32 14
25 37 18
2
3 37 40
fracture in the non-operative
group, 1 in the operative group.
73 intra-articular fractures in the non-operative group, 4 in the operative group.
Karaharju et al.: Management of Tibia1 Fractures
Time spent in hospital The patients of the non-operative group were in hospital for 30-36 days. The operated patients spent the following average time in hospital: intramedullary nail, 54 days; A0 plate, 40 days; screws, 17-24 days. The only statistically significant difference was between the patients treated with screws and the other therapeutic groups. Late operations Late operations were performed on 15 patients of the operative and 14 of the non-operative series. Fifteen patients needed bone grafts, 11 of which were of the Phemister-Charnley type (Charnley, 1968). Eleven of these 15 bone grafts were performed on patients in the conservative group and 4 on operatively treated patients. Intramedullary nailing was undertaken in 2 cases, 1 from each group. Five patients underwent later skin grafting, 4 debridement and 3 some other operation. The need for a late operation in the operatively managed series was greatest (9 out of 29 cases) after A0 plate fixation. Infections Both superficial and deep infections were recorded (Table III). A closed fracture was infected in 3 of the non-operated and 17 of the operated patients. The latter group showed the highest incidence of infection in the group treated with A0 plates although the fractures were mostly closed (25 out of 28 cases). Union was slower in the infected cases: the average duration of immobilization in plaster was 117f35 days for the non-infected and 164&27 days for the infected cases. The difference is statistically significant. For 2 years after the injury, the infection persisted in 4 cases of the operative and 2 of the non-operative series. Joint mobility after operative and non-operative treatment Loss of ankle motion Table IV shows the limitation of movement in the groups. No differences were established between the operative and non-operative series, or between the different types of operation. Loss of foot motion As can be seen from Table V, disturbances in the range of foot motion were slightly more frequent in the non-operative than in the operative group. The difference, however, was not statistically significant.
49
Table /I/.
Infections
Non-operative series Operative series lntramedullary nail A0 plate Screws
Primary
Late
Total
2 10 2 6 2
5 13 4 5 4
7 23 6 11 6
Loss of knee motion Over 10 degrees extension was lost in only 2 patients in each group. Practically normal flexion was achieved in all cases. As shown in Table VZ, loss of ankle and foot motion was the commonest main late complaint, followed by swelling of the leg. Correlation of joint mobility with fracture comminution Table VZZshows the effect of the degree of fracture comminution on ankle motion, and Table VIII its influence on foot motion. The degree of fracture comminution played a significant role in the loss of ankle and foot motion.
Tab/e IV.
Loss of ankle motion Non-operative series
Loss of dorsiflexion lO” No dorsiflexion Loss of plantarflexion 30”
Operative series
10 10 2
10 9 -
19
15 -
:
3
Tab/e I/. Loss of foot motion Non-operative series
Operative series
Loss of pronation less than one-half one-half no pronation
13 2 5
9 2 4
Loss of supination less than one-half one-half no supination
14 2 5
6
50
Injury: the British Journal of Accident Surgery Vol. ~/NO. 1
Malalignment and shortening Varus deformity of over 5” was seen in 6 conservatively and 2 operatively managed cases. Three patients of the former and 6 of the latter series had a valgus deformity of over 5”. Four of the latter patients belonged to the intramedullary Table VL Main late complaint Non-operative series Loss of ankle or foot motion Loss of knee motion Leg swelling Other
Operative series
19 4 8 4
19 3 6 4
nailing group. Anterior bowing of over 10” was seen in 4 patients of the non-operative and 2 of the operative group and, correspondingly, backward bowing of over 10” in 5 cases of the former but not a single patient of the latter series. Shortening of 2-5 cm was seen in 6 non-operative patients and one operative patient. Leg swelling Of the non-operative series, 13 out of 77 patients suffered from leg swelling; it was marked in 8 of the cases. In the operative series, 16 out of 78 patients had leg swelling, 6 of them to a marked degree (Table VI). There were, therefore, no
Tab/e VII. Influence of fracture comminution
Degree of comminution
None or slight Moderate Severe
Table VIII.
13 11 22
Influence of fracture comminution
Degree of comminution
None or slight Moderate Severe
Evaluation of the end results The classification according to Edwards’ (1965) criteria is ‘ good, fair and poor ‘. Table IX presents the end results. No differences were established between the non-operative and operative groups, nor were any significant differences seen between the different operative groups. DISCUSSION AND CONCLUSIONS The comparability of the fractures in the nonoperative and operative groups was fairly good (Tables I, II) and the results probably warrant conclusions as to the advantages and disadvantages of both methods of treatment. The operative techniques were routine. We regard reaming of the medullary cavity as an important factor increasing stability in intramedullary nailing, although contrary opinions have been recently presented (Zucman and Maurer, 1970). In the group treated with A0 plates, the failures can be attributed in a few cases to unsatisfactory operative technique. The bone-grafting rate in the conservatively treated group (11 out of 80) is obviously higher than the rate in the operated group (4 out of 80). This can be explained by the fact that we consider cancellous bone-grafting of delayed union at 3 months an expected consequence in some cases where primary non-operative treatment has been applied (Charnley, 1968).
on ankle motion
Patients with loss of dorsiflexion (per cent) lO” 13 15 19
significant differences between the series. Nor was there any correlation between the duration of immobilization in plaster and leg swelling.
Patients with loss of plantarflexion er cent) 20” ::
4 3 12
65
on foot motion
Patients with loss of pronation (per cent)
Patients with loss of supination (per cent)
20 23 44
19 18 52
Karaharju et al. : Management of Tibia1 Fractures
51
The operative group suffered distinctly more from infections (Silva, 1973; Alho, 1974; Gallinaro et al., 1974). There were 23 infections in this group, 17 of them in closed fractures. The infection in 3 conservatively managed closed fractures (Tub/e ZZZ) was due to extensive contusion with tissue damage. The infection rate was highest in the group treated with A0 plates
the non-operative group. Malalignment in the operated group was most frequent in the patients treated with intramedullary nails. These radiologically demonstrated malpositions did not generally affect the end result as judged by the patient. To summarize: non-operative treatment proved to be reliable and must still be regarded as the
Tab/e /%. Results of final evaluation
Non-operative group Operative group lntramedullary nail A0 plate Screws
Good
Fair
Poor
39 42 17 15 10
27 26 10 9 7
14 12 6 5 1
and the great risk of infection must in fact be regarded as one of the major drawbacks of this operative method (Olerud and KarlstrGm, 1972; Gallinaro et al., 1974). Our high rates of infection reflect our strict recording of all superficial infections. Persistent drainage occurred in 4 operated and 2 nonoperated cases. Operation did not hasten the patients’ recovery and return to work, as has been previously reported (Slatis and Rokkanen, 1967b). The advantages of operation seem to be offset by the resulting complications. It has often been claimed that operative treatment is the better alternative in that early mobilization of the joints achieves a better result in respect of mobility (Slgtis and Rokkanen, 1967b; Olerud and Karlstrijm, 1972). The reduction of ankle and foot motion was the commonest late complaint in both the operative and non-operative group (Tables V, VZ). The duration of immobilization in plaster did not correlate with the end result. On the other hand the degree of fracture comminution distinctly affected ankle and foot motion (Tables VZZ, VIII). Leg swelling was the next commonest late complaint (Table VZ). Judging by the clinical picture, the swelling was a post-thrombotic syndrome. No venographic examinations were made. The severity of the injury seemed to play a greater role in leg swelling than the method of treatment. Unsatisfactory final positions as shown on the radiograms were somewhat more numerous in
primary method for the management of tibia1 fractures. If non-operative management fails or other indications are present, intramedullary nailing is the best operative method of treatment. The use of the A0 plate is probably the most useful in intra-articular fractures. Certain oblique fractures caused by low-velocity trauma may lend themselves to the use of screws. When the method has been selected with care it does not affect the end result essentially; it is the grade of severity of the fracture that is decisive for the outcome.
REFERENCES ALHO A. (1974) Operative versus non-operative treatment for tibia1 shaft fractures. Acta Orthoo. Scund. (in press). CHARNLEYJ. (1968) The Closed Treatment of Common Fractures. ‘Edinburgh and London, E. & S. Livingstone. CONNESH. (1973) Hoffmann’s Double Frame External Anchorage. Pa& Gead. EDWARDSP. (1965) Fracture of the shaft of the tibia: 492 conkutive cases in adults. Acta Orthop &and. Suppl. 76. GALLINAROP., CROVA M. and DENICOLAIF. (1974) Complications in 64 open fractures of the tibia. Injury 5, 157. KARAHARJUE. O., NIEMINENJ. and ALHO A. (1974) Final results of operatively versus non-operatively treatedfracturesof tibia. AcfaOrthop.Scand. 45,996. MUELLERM. E., ALLG~~WERM. and WILLENEGGERH. (1970) Manual of Internal Fixation-Technique recommended by the A0 Group. Berlin, SpringerVerlag.
52
Injury:
OLERUDS. and KARLSTRGMC. (1972) Tibia1 fractures treated by A0 compression osteosynthesis. Acta Orthop.
Stand.,
Suppl.
of Accident
Surgery
Vol. ~/NO.
1
SL~~TISP. and ROKKANEN P. (1967b) Conservative treatment of tibia1 shaft fractures. Acta Orthop. Scund. 38, 133.
140, 3.
SILVA J. F. (1973) Fractures of the tibia and fibula. J. Trauma 12, 1029. SLATE P. and ROKKANENP. (1967a) Closed intramedullary nailing of tibia1 shaft fractures. Acta Orthop. Stand. 38, 88.
Requests for reprints should be addressed Hospital, Helsinki, Finland.
the British Journal
to:
Erkki
0.
Karaharju,
SOLHHMK. and Bo 0. (1973) lntramedullary nailing of tibia1 shaft fractures. Acta Orthop. Stand. 44,323. ZLJCMAN J. and MAURERP. (1970) Primary medullary nailing of the tibia for fractures of the shaft in adults. Injury 2, 84.
Department
of Orthopaedics
and Traumatology,
University
Central
