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TRAUMATOLOGY Table of Contents   
Year : 2005  |  Volume : 39  |  Issue : 1  |  Page : 30-32
Primary unreamed intramedullary locked nailing in open fractures of tibia


Department of Orthopaedics, M.A.M.C. and associated L.N. Hospital, N. Delhi, India

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   Abstract 

Background: Fractures of tibia are among the commonest fractures sustained in road traffic accidents. They are frequently open and contaminated. Unreamed nails are considered superior to external fixator in the management of open fractures of tibia.
Method: Forty patients with open fractures of tibia, grade I, II, IIIa, IIIb were included in the study. They were managed by primary unreamed intramedullary nailing with adequate soft tissue management.
Results: Functional results were excellent in 26 cases, good in 10 cases and fair in 4 cases. Four cases had delayed union. Average time of union was 16.9 weeks.
Conclusion: Primary unreamed intramedullary nailing offers advantage of rigid fixation, low incidence of infection, non-union, good functional results and early return to work. An adequate soft tissue management is mandatory in treatment of these fractures.

Keywords: Open fracture tibia; Unreamed intramedullary nailing.

How to cite this article:
Jain V, Aggarwal A, Mehtani A, Jain P, Garg V, Dhaon B K. Primary unreamed intramedullary locked nailing in open fractures of tibia. Indian J Orthop 2005;39:30-2

How to cite this URL:
Jain V, Aggarwal A, Mehtani A, Jain P, Garg V, Dhaon B K. Primary unreamed intramedullary locked nailing in open fractures of tibia. Indian J Orthop [serial online] 2005 [cited 2020 Feb 21];39:30-2. Available from: http://www.ijoonline.com/text.asp?2005/39/1/30/36892

   Introduction Top


There has been a rapid increase in the traffic volume over past one decade. Fractures of tibia are among the commonest fractures sustained in road traffic accidents. They are frequently open and contaminated [1] . Due to poor blood supply [2] and poor soft tissue coverage these fractures are frequently complicated by delayed union, mal union, non-union and infection [3].

Controversy exists over optimal method of stabilization of open fractures of tibia. External fixation devices have been quite popular in the management of these fractures. But recently unreamed intramedullary nailing, as initial definitive management of these fractures, has been gaining acceptance.

Studies had shown that reaming disturbs cortical blood flow to a greater extent than unreamed nails,[4] possibly increasing susceptibility to infection. Few studies suggested that unreamed nails are superior to external fixator or reamed nail in management of open fractures of tibia [5],[6] while others didn't find any significant difference between reamed and unreamed intramedullary nailing.

We conducted a prospective study at our institution to evaluate clinical, functional and radiological results of primary unreamed intramedullary locked nailing with adequate soft tissue management in management of open fractures of tibia.


   Materials and methods Top


A prospective study was done in on 45 patients presenting with open fractures of tibia within 24 hours of injury [Figure - 1].

Exclusion criterions for the patients were : Fractures lying proximal to tibial tuberosity and distal to 4 cm from the ankle joint, pathological fractures, intraarticular extension of fracture, grade IIIc fracture, patients less than 20 years of age, patients requiring a nail of less than 9 mm diameter, and refusal for inclusion in the study.

Assessment of patient was done with regards to vital parameters, associated orthopaedic and systemic injuries. Stabilization of vitals and initial immobilization of limb was done immediately. Wound was washed with 3-5 liters of saline. Intravenous third generation cephlosporins, gentamicin and metronidazole were immediately administered and continued for minimum of 3 days. Radiological assessment was done to ascertain the type of fracture.

Management protocol included adequate wound debridement, stabilization with primary unreamed intramedullary locked nailing and soft tissue reconstruction. A provisional wound coverage plan was formulated before debridement. All nonviable tissues with avascular bone fragments not contributing to bony stability was removed. In lesser grade of open fractures primary wound coverage was done with tensionless sutures. Traditional bone coverage methods like musculocutaneous flaps were used in cases of extensive soft tissue reconstruction. The degree of contamination decided the need of repeat debridement within 36-72 hours of surgery followed by repeated debridement as and when required.

Size and diameter of nails were preselected. Nail used had a cross section of hollow cylinder with anterior angulation of 15 degrees in proximal end and a tapered distal end. A nail size of 9 mm was considered the minimum acceptable diameter for treating tibial shaft fracture. Nails were inserted with the help of insertion handle, which had an attached distal locking assembly, in view of absence of image intensifier in our emergency setting.

Knee and ankle mobilization, quadriceps exercises and non-weight bearing crutch walking was allowed on subsidence of pain. Post operatively patient was followed up clinically, functionally; radiologically every 3 weeks for 3 months, monthly for 3 months and thereafter 3 monthly for maximum of 2 years. Partial weight bearing was allowed after 6 weeks. It was progressively increased to full weight bearing on evidence of fracture union on antero-posterior and lateral view X-rays. In case of minimal callus formation at 7 - 8 weeks, dynamization was done and patient mobilized with a patellar tendon bearing cast. In case of poor bridging callus formation even after 4 weeks of dynamization, autologous bone grafting was done.

Patients were observed for time of bony union, complications like infection, compartment syndrome, implant failure, delayed union, malunion and non union. Ultimate goal was to return the patient to pre injury status as quickly as possible.


   Results Top


Forty patients were followed up for minimum of 6 months and maximum of 2 year. Five patients were lost to follow-up. Thirty seven patients were males while 3 were females. Average age of patients was 40.3 years. Thirty five patients sustained injury in a road traffic accident. Associated injury in form of head injury was the found in 7 cases, facial injury in 2 while fracture of ribs was found in one case.

There were 20 cases of grade I, 9 grade II, 7 grade IIIa and 4 cases of grade IIIb open tibial fractures. Site of injury was upper 1/3 rd in 14, middle 1/3 rd in 21, lower 1/3 rd in two cases. Segmental fracture was found in three cases. Two patients had ipsilateral medial malleolus fracture. Two patients had impending compartment syndrome managed with nailing and fasciotomy.

Thirty two cases were operated within 12 hours of injury with a minimum time of 3 hours. All cases were operated under regional anaesthesia. In 26 cases a nail of 9mm diameter was used while in 14 cases a 10mm diameter nail was used. There was no case of fracture at site of entry or at posterior cortex. Failure of the distal locking assembly occurred in three cases. Distal locking was done under image intensifier in routine operation theatre in these cases.

Primary wound closure was done in 24 cases. Primary muscle pedicle graft was done in four cases. Medial gastrocnemius flap was done in two cases, tibialis posterior flap was done in one case while soleal flap was done in one case. Skin grafting was required in six cases.

Non-weight bearing crutch walking with knee and ankle exercises were commenced at an average interval of 1.5 days. In one case of grade II compounding there was superficial infection. It was managed with regular debridement and aseptic dressing. Wound healed and secondary closure was done with a posterior releasing incision 2 weeks after surgery. In one case of compound grade IIIb fracture there was deep infection. It resulted in an infected delayed union. Thereafter nail was removed, ultimately leading to subsidence of infection. Both the cases were operated within 12 hours of injury.

Dynamization was required in 9 cases and in three cases bone grafting was required. There was no case of non-union. Four cases had delayed union. Average time of union was 16.9 weeks. In 6 patients varus angulation of <5 degrees was found while 0.5 cm of shortening was found in 6 cases. In 2 patients there was loss of 10 degree of knee flexion. In 4 patients there was loss of 10-15 degree of ankle dorsiflexion. Functional results were excellent in 26 cases, good in 10 cases and fair in 4 cases [Figure - 2].

Three cases had knee pain due to nail. There was no case of deep vein thrombosis, fat embolism, and compartment syndrome. No case of failure of nailing, implant breakage was seen. Average loss of working days was 15 weeks.


   Discussion Top


Tibia fractures are one of the commonest fractures encountered in high velocity trauma. Variables such as communition, displacement, severity of soft tissue injury, infection, and multiple injuries are important prognostic factors in treatment of these fractures.

Throughout 1980's external fixators had been the treatment of choice in open fractures as they provided stabilization with adequate wound management and soft tissue care. But they had been associated with complications of pin tract infection, pin loosening [7] , malunion, delayed union, and non-union [8]. Plating as devised by AO group is associated with increased risk of infection and skin necrosis [9] .

Henley et al [10] in a study to compare results of manage­ment of open fracture of tibia with external fixator and unreamed intramedullary nailing found that malunion was higher in cases treated with external fixator. Bhandari and associates [11] in a metaanalysis of studies found that unreamed nail in comparison to external fixator led to fewer reoperation, less incidence of superficial infection and malunion. Lottes [12] reported a union rate of 98% and infection rate of only 5% in 50 cases of open fracture of tibia treated with his unreamed nail. Hamza and Murray [13] reported unacceptably high infection rate in patients treated with reamed nailing leading to belief that reaming is not advisable in open fractures. This led to development of unreamed intramedullary nailing as alternative in open fracture of tibia. Whittle et al [14] on trial of unreamed intramedullary nailing of open fracture of tibia reported a infection rate of only 5% in grade III, 25% in grade IIIb with 96% union rate and no malunion.

Our study showed that unreamed intramedullary nailing with adequate soft tissue management offers advantage of rigid fixation, low incidence of infection, non-union, good functional results and early return to work. A proper soft tissue management is mandatory in treatment of these fractures.

 
   References Top

1.Merritt K. Factors increasing the rate of infection in patients with open fractures. J Trauma. 1988;28,823-827.  Back to cited text no. 1    
2.Rhinelander FW. Tibial blood supply in relation to fracture healing. Clin. Orthop.1974;105,34-81.  Back to cited text no. 2    
3.Rosenthal RE, Mac Phail JA, Ortiz JE. Nonunion in open tibial fractures. Analysis of reasons for failure of treatment. J Bone Joint Surg (Am). 1977;59, 244-248.  Back to cited text no. 3    
4.Klein M, Frigg R, Kessler S. Reaming versus non reaming in medul­lary nailing. Interferance with cortical circulation of the canine tibia. Arch Orthop Trauma Surg.1990; 109,314-316.  Back to cited text no. 4    
5.Totnetta P et al. Treatment of grade IIIb open tibial fractures. J Bone Joint Surg (Br).1994;76, 13-17.  Back to cited text no. 5    
6.Dean JC, Lori J. A sequential protocol for management of severe open tibial fractures. Clin Orthop. 1995;315,84-103.  Back to cited text no. 6    
7.Sisk TD. External fixation. Historic review, advantages, disadvantages, complications and indications. Clin Orthop.1983;180,15-22.  Back to cited text no. 7    
8.Heiser MT, Jacobs RR. Complicated extremity fractures: The relation between external fixation and non-union. Clin. Orthop. 1983;178,89-95.  Back to cited text no. 8    
9.Beck AW, Henson ST. Plates versus external fixation in severe open tibial fractures: A randomized trial. Clin Orthop. 1989;241.29-34.  Back to cited text no. 9    
10.Henley MB, Chapman JR. Comparison of unreamed tibial nails and external fixator in the treatment of grade II and grade III open tibial fractures. J Orthop Trauma. 1994;19,143-144.  Back to cited text no. 10    
11.Bhandari M, Gordon H, Guyatt, Swiontkowski MF, Sheimitch EH. Treatment of open fractures of the shaft of the tibia. J Bone Joint Surg (Br). 2001;83,62-68.  Back to cited text no. 11    
12.Lottes JW. Medullary nailing of the tibia with the triflange nail. Clin Orthop. 1974;105,1253-66.  Back to cited text no. 12    
13.Sanders RJ, Murray H. Reamed intramedullary locked nailing in twenty three open ftactures of tibia. Clin Orthop.1982;212,122-132.  Back to cited text no. 13    
14.Whittle AP, Taylor CJ. Treatment of open fractures of the tibial shaft with the use of interlocking nailing without reaming. J Bone Joint Surg (Am). 1992;74,1162-1171.  Back to cited text no. 14    

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Correspondence Address:
Vineet Jain
House No. 194, Sector 21-C, Faridabad, Haryana
India
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Source of Support: None, Conflict of Interest: None


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    Abstract
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    Materials and me...
    Results
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