A CLINICAL STUDY ON SURGICAL MANAGEMENT OF DIAPHYSEAL FRACTURES

OF TIBIA BY INTRAMEDULLARY INTERLOCKING NAIL

By Dr.BASU VENKATRAMAIAH

Dissertation Submitted to the Rajiv Gandhi University of Health Sciences, Karnataka,

Bangalore

In partial fulfillment of the requirements for the degree of

MASTER OF SURGERY in

ORTHOPAEDICS

Under the Guidance of Dr.PRAMOD B.ITAGI

M.S. (Ortho)

Associate Professor

DEPARTMENT OF ORTHOPAEDICS

i

M.R. MEDICAL COLLEGE, GULBARGA-585 105

ii

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE

DECLARATION BY THE CANDIDATE

I here by declare that this dissertation/ thesis entitled “A

CLINICAL STUDY ON SURGICAL MANAGEMENT OF

DIAPHYSEAL FRACTURES OF TIBIA BY

INTRAMEDULLARY INTERLOCKING NAIL” is a

bonafide and genuine research work carried out by me under

the guidance of Dr.PRAMOD B.ITAGI, M.S., (Ortho),

Associate Professor, Dept. of Orthopaedics.

Date:

Place: GULBARGA Dr.BASU VENKATRAMAIAH

iii

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE

CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled “A

CLINICAL STUDY ON SURGICAL MANAGEMENT OF

DIAPHYSEAL FRACTURES OF TIBIA BY

INTRAMEDULLARY INTERLOCKING NAIL” is a bonafide

research work done by Dr.BASU VENKATRAMAIAH in partial

fulfillment of the requirement for the degree of MASTER OF

SURGERY in ORTHOPAEDICS.

Date:

Place: GULBARGA Dr.PRAMOD B.ITAGI M.S. (Ortho)

Associate Professor Department of Orthopaedics M.R. Medical College, Gulbarga

iv

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE

ENDORSEMENT BY THE HOD, PRINCIPAL/

HEAD OF THE INSTITUTION

This is to certify that the dissertation entitled “A

CLINICAL STUDY ON SURGICAL MANAGEMENT OF

DIAPHYSEAL FRACTURES OF TIBIA BY

INTRAMEDULLARY INTERLOCKING NAIL” is a bonafide

research work done by Dr.BASU VENKATRAMAIAH under the

guidance of Dr.PRAMOD B.ITAGI, M.S. (Ortho) Associae

Professor, Department of Orthopaedics.

Dr.B.C.Patil Dr.Mallikarjun B. D.Ortho., M.S. (Ortho) M.D. (Paed) Head of the Dept. Principal Dept. of Orthopaedics M.R. Medical College, Gulbarga M.R. Medical College, Gulbarga Date: Date:

Place: GULBARGA Place: GULBARGA

v

COPYRIGHT

DECLARATION BY THE CANDIDATE

I here by declare that the Rajiv Gandhi University of Health

Sciences, Karnataka shall have the rights to preserve, use

and disseminate this dissertation/ thesis in print or

electronic format for academic/ research purpose.

Date:

Place: GULBARGA Dr.BASU VENKATRAMAIAH

© Rajiv Gandhi University of Health Sciences, Karnataka.

vi

ACKNOWLEDGEMENT

I dedicate this dissertation to my parents and brother for

providing the strength, time, unconditional love, care and especially

for cushioning all my falls in my life and directed me to the path of

success.

I avail this opportunity to express my profound earnest

gratitude to my beloved teacher guide Dr.Pramod Itagi, M.S.

(Ortho), Associate Professor of Orthopaedics, for his esteemed

guidance, unflinching support, keen surveillance, in estimable aid

and continued inspiration, at the same time who has been a source of

sustained illumination to me, whose valuable guidance and generous

support facilitated me to accomplish this dissertation.

I owe my sincere and grateful acknowledgement to

Dr.B.C.Patil, M.S. (Ortho), D.Ortho., Professor and H.O.D.,

Department of Orthopaedics, for his valuable guidance and

encouragement.

My sincere thanks are to Dr.Sanjeev Reddy, M.S. (Ortho),

D.Ortho. and Dr.S.S.Gubbi, M.S.(Ortho), Associate Professors of

Orthopaedics for their constant help and encouragement during the

period of study and while preparing this dissertation.

I also take this opportunity to express my sincere gratitude to

Dr.S.B.Kamareddy, M.S.(Ortho), Assistant Professor,

Dr.Arunkumar Kulkarni, D.Ortho., Senior Registrar, Department of

Orthopaedics, for their help and guidance.

vii

I owe my sincere gratitude to Dr.B.Mallikarjun, M.D. (Paed),

Principal & Dean, M.R.Medical College, for his guidance and

encouragement.

I am very thankful to Dr.Dilip Rampure, M.D.(Med), Medical

Superintendent, Basaveshwar Teaching & General Hospital attached

to M.R.Medical College, for permitting me to utilize the clinical

material for this dissertation.

I gratefully acknowledge the patients, who cooperated to

submit themselves for this study, without whom, this dissertation

would not have been possible.

I would not do justice if I don’t express my sincere and warm

gratitude to my colleagues Dr.Ramesh, Dr.Nishanth, Dr.Akash,

Dr.Prakash, Dr.Naga, Dr.Somshekhar, Dr.Himakanth, Dr.Sudeep,

Dr.Harsha, Dr.Kiran, Dr.Shivkumar, Dr.Veeresh, Dr.Vijay,

Dr.Chaitanya, Dr.Shyam and Dr.Arun for their valuable hints and

timely help ensuring that this dissertation saw the light of the day.

I am also thankful to my friends Dr.Shankar, Dr.Vijay,

Dr.Rajeev, Dr.Sanjeev, Dr.Hari and Dr.Suneel for their moral

support.

I thank all my colleagues and friends for their valuable help

in completing this dissertation.

Date:

Place: Dr.BASU VENKATRAMAIAH

viii

LIST OF ABBREVIATIONS USED

AO................... Arbeitsgemeinschaft fur osteosynthesefragen

ASIF................ Association for the Study of Internal Fixation

ESIN................ Elastic stable intramedullary nail

IM nail............. Intramedullary nail

OTA ................Orthopaedic Trauma Association

POP ................. Plaster of paris

ix

ABSTRACT

Background & Objectives: To assess and study diaphyseal fractures of tibia and to evaluate the functional outcome of patients with tibial shaft fracture treated with locked intramedullary nailing. Materials & Methods: Patients: Patients of both sexes belonging to adult age group presenting with fracture shaft tibia to orthopedic department of Basaveshwar Teaching & General Hospital, Gulbarga attached to M.R.Medical College, Gulbarga are admitted from October 2006 to March 2008 and evaluated. Those satisfying our inclusion criteria and are surgically fit are included in this study. Intervention: All enrolled patients were treated with locked intramedullary nailing of their tibia. Main Outcome Measurements: All enrolled patients were evaluated with Johner & Wruh’s criteria. Final assessment in our series was done at 6 months taking into account of the following objective and subjective symptoms of gait, pain, deformity, range of motion of knee, angle and sub-talar joints, shortening, neurovascular disturbances, ability to do strenuous activities, radiological union and presence or absence of non-union. Functional outcome was graded into excellent, good, fair and poor. Results: The results of interlocking fracture shaft tibia were excellent in 12 patients (60%), good in patients (30%) and fair in 2 patients (10%). The average healing time was 19.1 weeks. There were 2 superficial infections (10%) and 2 patients with anterior knee pain (10%). Conclusion: The method of treatment employing closed intramedullary interlocking nailing to stabilize diaphyseal fractures of tibia is ideal because of its excellent and good results. The method has a long learning curve but with the excellent results. The advantage of rapid rehabilitation and relatively few complications serve to recommend it for wider use. Key Words: Diaphyseal fractures of tibia; Interlocking; Closed nailing.

x

LIST OF CONTENTS

1. Introduction..........................................................................................01

2. Objectives ............................................................................................03

3. Review of Literature ............................................................................04

• Historical Review...........................................................................04

• Review of Literature on Intramedullary Nailing ...........................13

• Surgical Anatomy ..........................................................................26

• Classification of Tibial Shaft Fractures .........................................39

• Fracture Mechanics........................................................................44

• Biomechanics of Intramedullary Locked Nail ...............................47

• Biology of Fracture and Fracture Healing with Intramedullary Locked Nail...........................................................51

• Advantages, Disadvantages and Complications of Intramedullary Interlocking Nailing ..............................................54

• Approaches ....................................................................................57

4. Materials & Methods ...........................................................................59

5. Observations and Results.....................................................................77

6. Discussion............................................................................................98

7. Summary ............................................................................................106

8. Conclusion .........................................................................................108

9. Bibliography ......................................................................................110

10. Annexures ..........................................................................................118

Proforma

Master Chart

Key to Master Chart

xi

LIST OF TABLES

Sl. No. Title Page

No.

1. Age Incidence 77

2. Sex Incidence 78

3. Involved Limb 79

4. Mode of Injury 80

5. Anatomical Location of the Fracture 81

6. Type of Injury 82

7. Type of Fracture 83

8. Weight-bearing 85

9. Fracture Union 86

10. Complications 87

11. Functional Outcome 89

xii

LIST OF FIGURES

Sl. No. Title Page

No. 1. Muscles of Leg – Anterior View 26 2. Muscles of Leg – Posterior View 29 3. Bones of the Leg – Tibia and Fibula 31 4. Anterior tibial and dorsalis pedis arteries 35 5. Posterior Tibial and Peroneal Arteries 37 6. Instrumentation Set for Tibia Intramedullary Locking Nail 74 7. Surgical Technique of Interlocking Tibia 75 8. Age Incidence 77 9. Sex Incidence 78 10. Involved Limb 79 11. Mode of Injury 80 12. Anatomical Location of the Fracture 81 13. Type of Injury 82 14. Type of Fracture 83 15. Weight-bearing 85 16. Fracture Union 86 17. Complications 87 18. Functional Outcome 89 19. Case No. 1: Clinical Photographs of the Patient at Six Months

showing Full Weight Bearing and Movements of Knee & Ankle 90

20. Case No. 1: Radiographs - A/P & Lateral 91 21. Case No. 4: Clinical Photographs of the Patient at 6 months showing

full weight bearing and movements of Knee and Ankle 92

22. Case No. 4: Radiographs - A/P & Lateral 93 23. Case No. 15: Clinical Photographs of the Patient at 6 months

showing full weight bearing and movement of Knee and Ankle 94

24. Case No. 15: Radiographs - A/P & Lateral 95 25. Case No. 16: Clinical photographs of the patient at 6 months

showing full weight bearing and movements of Knee and Ankle 96

26. Case No. 16: Radiographs - A/P & Lateral 97

xiii

INTRODUCTION

With the increasing number of vehicles on roads in India, complex

trauma cases caused by road traffic accidents have increased progressively.

Being sub-cutaneous in location, the tibia is the commonest bone to be

fractured and seen commonly in orthopedic practice.

Open fractures are more common, because one third of its surface is

subcutaneous throughout most of its length. Furthermore, the blood supply to

the tibia is more precarious than that of bones enclosed by heavy muscles.

The presence of hinge joints at the knee and ankle allows no adjustment for

rotatory deformity after a fracture. Delayed union, non-union and infection

are relatively frequent complications especially after open fractures of the

shaft of tibia.

Due to its frequency, topography and mode of injury it has become a

major source of temporary disability and morbidity.

Hence special care and expertise is necessary when treating such

fractures. It requires the widest experience, the greatest wisdom and the nicest

of the clinical judgement in order to choose the most appropriate treatment for

a particular pattern of injury.

1

The major goal in the treatment of fracture tibia is achieving

functionally useful and stable extremity. Yet the spectrum of injuries to tibia

is so great that no single method of treatment is applicable to all fractures.

Management of the fractures of the shaft of the tibia remained a

controversial subject despite advances in both non-operative and operative

care. Sir John Charnley stated that, “we have still a long-way to go before the

best method of treating a fracture of the shaft of tibia can be stated with

finality” in 1961. Several published series regarding treatment of fractures of

the shaft of tibia have shown that closed treatment of fractures can have

excellent results. But the drawbacks of prolonged healing time, fracture

disease, malalignment and non-compliance of the patient has led to the

thought of other modalities of treatment, finally resulting in the use of closed

interlocking intramedullary nailing which has given excellent results.

Now-a-days the well laid principle of biological osteosynthesis is

rightly applied in long bone fracture healing and hence the selection of closed

intramedullary interlocking nailing in this study.

The following study highlights the role of closed interlocking nailing

used for treating the fractures of the shaft of tibia.

2

AIMS AND OBJECTIVES

The tibial diaphyseal fracture is the commonest fracture encountered,

and the locked intramedullary interlocking nailing has revolutionized the

management of tibial diaphyseal fractures.

The use of interlocking nails means that virtually all tibial diaphyseal

fractures can be stabilized with an intramedullary nail, and the well laid

principle of biological osteosynthesis is rightly followed here.

The objectives of the study are:

1. To assess and study diaphyseal fractures of tibia with special

reference to fracture anatomy, pattern and status of stability.

2. To study fracture healing and the union rates with intra-

medullary interlocking nail.

3. To study the functional outcome with regard to knee, ankle and

subtalar joint movements.

4. To prevent angulation, deformity and to maintain limb length

equality.

5. To mobilize the patient as early as possible.

3

REVIEW OF LITERATURE

Historical Review:

The history of intramedullary nailing for the treatment of long bone

fractures and nonunions is long and storied. From the earliest recorded

examples in 16th century Mexico to the current procedures of today, there has

been an evolution of design, materials, and basic science principles, which has

resulted in a well accepted and successful technique for the past several

decades. Interestingly, throughout the early history of intramedullary nailing,

these advances in method, principle, and design appear to parallel advances in

anesthetic and aseptic techniques, allowing for routine operative care of

fractures to emerge. Although intramedullary nailing is now the standard of

care for the treatment of most diaphyseal lower extremity fractures,

introduction of the technique was met with a great deal of skepticism in both

Europe and North America during the first half of the 20th century. In the

latter half of the 20th century, intramedullary nailing of long bone fractures

revolutionized the care of the multiply injured patient.

The Beginnings

Bernardino de Sahagun, a 16th century anthropologist who traveled to

Mexico with Hernando Cortes, recorded the first account of the use of an

intramedullary device.1 De Sahagun witnessed Aztec physicians placing

wooden sticks into the medullary canals of patients with long bone nonunions.

4

Other pre-Twentieth century intramedullary techniques also seemed to

be conducted in patients with nonunions and not in patients with acute long

bone fractures. During the mid 1800s through the first decade of the 1900s,

most of the work in intramedullary nailing of nonunions appear to revolve

around the use of ivory pegs. It had been observed that ivory pegs would

reabsorb in the human body compared to metallic implants, which became

encapsulated with fibrous material. The majority of this work was reported at

the time in the German literature.2,3 During the 1890s, Gluck recorded the first

description of an interlocked intramedullary device.4 The device consisted of

an ivory intramedullary nail that contained holes at the end, through which

ivory interlocking pins could be passed. Around the same time period,

Nicolaysen of Norway described the biomechanical principles of

intramedullary devices in the treatment of proximal femur fractures.5

Nicolaysen proposed that the length of intramedullary implants be maximized

to provide for the best biomechanical advantage. While ivory seemed to be the

material of choice reported in the German literature, Hoglund of the United

States reported the use of autogenous bone as an intramedullary implant in

1917.6

He described a technique in which a span of the cortex was cut out and

then passed up the medullary cavity across the fracture site. During World

War I, Hey Groves of England reported the use of metallic rods for the

treatment of gunshot wounds.7 These rods were passed into the medullary

cavity through an incision made over the fracture site. This technique appeared

5

to have a high infection rate and was not universally accepted. It was not until

Smith-Petersen’s 1931 report of the successful use of stainless steel nails for

the treatment of femoral neck fractures, that the application of metallic

intramedullary implants began to expand rapidly.8 In the United States, Rush

and Rush described the use of metallic Steinman pins placed in the medullary

canal to treat frac-tures of the proximal ulna and proximal femur.9 While these

techniques provided a foundation of principles for the treatment of fractures

with intramedullary fixation, there would be an explosion of principles and

methods in the decades to come.

Origins and Evolution of Küntscher Nailing

Gerhard Küntscher was born in Germany in 1900. His early interest in

intramedullary devices resulted from his work with the Smith-Petersen nail in

the treatment of femoral neck fractures. Küntscher believed the same basic

science principles would be applicable in the treatment of diaphyseal fractures.

During development of his “marrow nail,” he conducted cadaveric and animal

studies. His original intramedullary nail was a V-shaped stainless steel nail

that was inserted antegrade. Küntscher first reported use of the V-shaped nail

in 1940 and proposed the nail would act as an internal splint that created an

elastic union with the inner medullary cavity.10 It appears that early in the

development of his technique, he recommended inserting the nail into the bone

distant to the fracture site, thus, avoiding any disturbance of the zone of injury.

Intraoperative reductions were achieved with the use of multiple slings; while

head worn fluoroscopy was used for bony visualization. Küntscher believed

6

that proper insertion of his nail would allow for immediate functional

mobilization of the patient. Küntscher’s early work was not well received in

Germany, and early in World War II he was sent to the northern Finnish front.

There he collaborated with Finnish surgeons, which resulted in a report, in

1947, of 105 cases using the V-shaped nail.11 By the late 1940s, Küntscher had

begun to abandon use of the V-shaped nail design in favor of another

Küntscher design, the cloverleaf nail. While there was some interest in the use

of Küntscher’s technique in Europe during World War II, his method was

essentially unknown in the US. The use of the Küntscher nail was first

described in the US in a March 12, 1945, Time Magazine article, entitled

“Amazing Thighbone.”

This article discusses the skepticism displayed by American surgeons

on discovering the metallic rods implanted in US servicemen by German

doctors. It would be several more years until the first report of the Küntscher

nail would appear in the English medical literature.11 During the 1940s,

various other intramedullary designs were introduced. Westerborn reported his

experience with a V-shaped nail in the Scandinavian literature in 1944.12 In

1946, Soeur reported on his use of a U-shaped nail in the femur, tibia and

humerus.13

In the US, the Hansen-Street nail was introduced in 1947.14 This was a

solid diamond-shaped nail, designed to resist fracture rotation via its

compressive fit within the cancellous bone. These nails were originally

7

inserted using a closed method in order to avoid the high infection rate

reported earlier by Hey Groves. However, with the utilization of penicillin,

Street transitioned to open retrograde nailing to avoid side effects of the

radiographic techniques of the day.

1950s

During the 1950s, two important techniques were developed and

introduced. In 1942, Fischer had reported, in the German literature, the use of

intramedullary reamers to increase the contact area between the nail and host

bone, with the hope of improving stability of the fracture.15 However, it took

another decade with Küntscher’s introduction of flexible reamers for the

concept to take hold. Fischer also believed that reaming in combination with a

larger diameter nail would enhance the stability of fractures by increasing the

contact area. He felt that, although the intramedullary vascular supply was

obliterated through this technique, the periosteum and surrounding tissues

would promote adequate bone formation for healing. Another currently used

technique introduced in the 1950s was the application of interlocking screws

to enhance stability of the construct. Modny and Bambara introduced the

transfixion intramedullary nail in 1953.16 This nail was cruciate-shaped, with

multiple holes the length of the nail to allow for placement of screws at 90°

angles from each other. Modny and Lewert later reported excellent results in a

series of 261 femur fractures treated with this nail.17

8

1960s

Enthusiasm for compression plating of long bone fractures exploded

during the 1960s, and general advancement in the use of intramedullary nails

“went on hiatus.” Despite the emergence of compression plating, there were

several advancements that changed the future practice of intramedullary

nailing. Cephalomedullary nails were first introduced in the 1960s, highlighted

by the development of the Zickel nail in 1967.18 The Zickel nail contained a

hole in the proximal portion in order that a separate nail could be placed

through the lateral cortex of the proximal femur into the neck and head. A set

screw, which continues to be found on some current cephalomedullary

designs, could be inserted through the proximal portion of the shaft nail to

prevent backout of the head and neck nail.

During the 1940s and 1950s, many surgeons abandoned early

radiological techniques, such as head worn fluoroscopy, because of the

potential side effects to both surgeon and patient. This forced these surgeons

to adopt an open nailing technique. The development of radiological image

intensification, in the 1960s, allowed surgeons to readopt closed nailing

techniques with a much lower risk to patient and surgeon alike.

1970s and 1980s

The exuberance that accompanied the advent of compression plating

for tibias and femurs in the 1960s quickly diminished in the 1970s and, thus, a

renewed interest in refining closed nailing techniques appeared. This

9

reemergence of closed nailing has led to many of today’s current techniques.

As the use of reamed nailing gained more traction, undreamed nailing became

reserved for open fractures. Also during this time, a rapid gain in experience

occurred using reamed nails for treating tibial shaft fractures. The dominant

design during this time period was the slotted cloverleaf-shaped interlocked

nail, e.g., the AO and Grosse-Kempf nails.

As surgical techniques continued to expand during this time, there was

a surge in clinical data regarding the use of reamed interlocking nails of both

the femur and tibia. This was culminated by a three-part study of reamed

interlocked femoral nails by Brumback and colleagues.19-21 This work reported

a 98% (85/87) initial healing rate with statically locked, reamed

intramedullary nails in 87 femur fractures. Union was reported in the

remaining two fractures after dynamization.

1990s and the 21st Century

While there was certain progress as far as nail design and materials is

concerned during the 1990s, the major advancements came with the expansion

of indications for undreamed and reamed intramedullary nailing. Open tibial

shaft fractures were now being treated with intramedullary fixation with good

results. Likewise, open femur fractures that previously were managed with

unreamed nails, were now being treated with reamed nails. In addition, very

proximal and distal tibia and femur fractures, once thought to be unsuitable for

nailing, were benefiting from intramedullary fixation.

10

Design achievements of the 1990s included the introduction of new

titanium nails, cephalomedullary devices such as the Gamma nail, and

retrograde supracondylar intramedullary nails such as the GSH (Green-

Seligson-Henry) nail.22,23

In addition, slotted cloverleaf cross-sectional designs were being

replaced by nonslotted designs that provided greater torsional rigidity. In

1999, Brumback and associates reported a two-part study looking at

immediate weightbearing in patients with comminuted femoral shaft fractures

that were treated with intramedullary nailing.24 These investigators concluded

that immediate weightbearing is advisable in patients who had their femur

fractures fixed with larger diameter nails with high fatigue strength, as this

allows for more rapid mobilization for the trauma patient with multiple

injuries of the extremities.

Future Advancements

While today’s experience with intramedullary fixation for tibial and

femur fractures has been quite good, there will most certainly be continued

research to improve the technique. The most likely two areas of future

research will revolve around different biomaterials and biologically active

agents to promote bone healing. Two types of biomaterials that may hold

promise include biodegradable polymers and shape memory alloys.

Biologically active agents, such as bone morphogenic protein-2 and -7, have

been used with good success in the promotion of bone healing in both animal

11

models and humans. How to combine these bioactive agents with implants in a

cost effective manner is yet to be determined.

Conclusion

Intramedullary nailing has a long and interesting history that dates

back, at least, to the 16th century. Modern intramedullary techniques were

developed by Küntscher in Germany during the 1940s and were originally met

with much skepticism. Despite these early doubters, intramedullary nailing has

become the standard of care for the treatment of femoral shaft fractures and

tibial fractures that require operative stabilization.

12

REVIEW OF LITERATURE ON INTRAMEDULLARY NAILING

Gerhard B.G.Kuntscher25 (1958) opined that intramedullary nailing

represents the ideal treatment of fractures and requires no external fixation or

special postoperative care. The basic principle in this method is stable

osteosynthesis through flexible impingement of nail in the bone.

J.Zucman et al26 (1969) treated 36 two-level tibial fractures by

intramedullary nailing. The results showed that intramedullary nailing in two-

level tibial fractures allows walking with full weight bearing in an average of

3 to 4 months. It decreases the rate of non-union, malunion and it should

decrease the rate of infection, in closed fractures compared with other types of

internal fixation.

Compound tibial fractures treated by nailing are still complicated by

infection, but there are no other studies to conclude that other methods could

lower significantly the infection.

Merle d’Aubigne et al27 (1974) studied the outcome of tibial shaft

fractures treated with plates and screws and intramedullary nailing. Between

1960 and 1972, 849 tibial fractures were treated by intramedullary nailing and

58 by other methods. 23 patients were treated with plates and screws. They

showed more rate of non-union (69.6%) in the fractures by the plates and

screws. The infection rate was 28% including compound and simple fractures.

13

In case of intramedullary nailing non-union was 3.44% and infection was

7.2%.

Johner and Wruh28 (1983) classified tibial fractures based on etiology,

morphology and clinical features, documented in a series, 291 fractures treated

by AO/ASIF rigid internal fixation. The fractures were placed in 9 main

fracture groups, each with three sub-groups according to location in the

proximal, middle or distal segment of the shaft. A includes all simple

fractures, Group B includes fractures with butterfly fragments and Group C all

communited.

They also developed criteria for evaluation of final results as excellent,

good, fair, or poor by using non-union, pain, deformity, movements of joints,

shortening, neurovascular disturbances and gait as parameters for evaluation.

Lawrence B.Bone et al29 (1986) treated 112 cases of tibial fractures by

reaming and intramedullary nailing. They opined that it is also indicated in

the treatment of non-union and malunion in the absence of sepsis. In

segmental fractures, excellent results were noted with average time in union at

19 weeks.

Average time to full weight bearing was 4 weeks, 50% of primary

nailing and 40% of secondary nailing healed within 3 months. They

concluded that interlocking nailing is an excellent management for unstable

14

fractures and for secondary procedures in fractures not associated with

infection.

Kessler SB Hallefeldt et al30 (1986) published articles, stating that

fractures of tibia can be treated successfully with interlocking nailing.

Arne Ekeland et al31 (1988) treated 45 tibial shaft fractures, in 43

patients with Grosse-Kempf interlocking intramedullary nail between 1979 to

1982. Median age of the nailed patient was 35 years, it included 15 females

and 28 males. 23 fractures (51%) were caused by high energy trauma, 5

fractures (11%) were open. Median time of full weight bearing was 30 days.

Median time of bone union was 16 weeks with 29 excellent, 13 good and 2

fair results. 1 patient had non-union. They said that interlocking

intramedullary nailing is the ideal treatment for communited, segmental and

unstable fractures, and in patients with multiple polytrauma.

Scott L.Sledge et al32 (1989) in a study of 51 patients of non-union

tibia, treated with intramedullary reaming and nailing between 1980 to 1986

showed that 49 patients had union of the fracture site at an average time of 7

months postoperatively.

Thus, they concluded that intramedullary nailing with reaming, can

produce union as effectively as other alternatives, while enabling the patient to

function more normally without external immobilization or walking aids.

15

Court Brown et al33 (1990) treated 125 closed and type-I open tibial

fractures. The mean time of union was 16.7 weeks, and no fractures required

bone grafting. There was 1.6% infection rate, 40.8% of patients had knee pain

and 26.4% needed to have the nail removed, other complications were minor.

They used Grosse Kempf interlocking nail in 100 men and 23 women with a

mean age of 32.4 years. There were 114 closed and 11 type-I open fractures,

14 fractures involved only tibia and 111 involved both bones of leg. 6

fractures were in the proximal third of tibia, 46 in the middle third and 64 in

the distal third. 9 fractures were sports injuries and 35 occurred after fall,

while 6 patients were assaulted. Mean time in union was 16.7 weeks, two

patients (1.6%) had non-union, two deep infections (1.6%) developed, 5 mm

shortening in three patients, and unacceptable deformity or shorteining in

2.4% of patients. They suggested that closed intramedullary nailing with an

interlocking nail is an excellent method of treating closed and type-I open

tibial fractures.

Hooper et al34 (1991) reviewed fractures of tibia treated with

conservative treatment and closed intramedullary nailing. The results showed

that the intramedullary nailing gives more rapid union with less malunion and

shortening. Nailed patients had less time off work, with a more predictable

and rapid return to full function. Out of 62 tibial fractures, 33 fractures were

treated by conservative method and 29 fractures by closed nailing. Time of

union in nailed fractures was 15.7 weeks and time off work was 13.52 weeks.

Mean hospital stay was 11.6 days.

16

Habernek H et al35 (1992) showed 109 patients treated by interlocking

nailing for tibial fractures between 1985-1990 by K.H.Schwanz and the LKH

Bad Ischl, Austria. 92 cases were followed up. An increased number of

compound fractures were evaluated. Except for 14 malalignment and 2 leg

infections after new injuries, no other serious complications were detected.

Interlocking nailing can be safely recommended even for open fractures up to

second degree at any level from the second fifth to the fourth fifth of the tibia.

Wu CC, Shih CH36 (1993) have reported in the Canadian Journal of

Surgery on a retrospective study done in 11 tibial shaft fractures with static

interlocking nailing followed by dynamization, wich was carried on average of

7.8 months. The success rate was 54%. The follow up was at least 2 years.

The interval from nailing to dynamization did not correlate with the success

rate, the longest interval associated with successful healing was 20 months.

The authors found that static interlocking without dynamization can still

produce a high union rate and if there is sparse callus formation during the

healing process, due to low osteogenesis, dynamization will result in fracture

union in half of the cases. To improve the union rate cancellous bone grafting

may be necessary.

Wu CC, Shih CH37 (1993) have published an article in the journal of

Orthopaedic Trauma, on segmental tibial shaft fractures treated by

interlocking nailing on 38 patients and followed up for a period of 1 year.

There was 97% union rate and 4.5 months was the union period. The range of

17

motion in the knee and ankle was satisfactory. Significant complications

included 1 aseptic non-union, 3% of which healed after the static locked nail

was dynamized. They reported that whenever possible closed interlocking

nailing should be used to treat closed or mild open segmental tibial shaft

fractures.

Watson JT38 (1994) concluded from a review of literature that unstable

closed and type-I open fractures are preferably treated with intramedullary

nailing with or without reaming.

In grade-II and IIIA fractures, rate of union and rate of infection is

similar in reamed and unreamed intramedullary nails, but secondary surgery

may be needed in reamed nailing.

Watson JT38 (1994) concluded that the presence of a fibular fracture in

association with tibial fracture often indicates an unstable fracture as well as

high energy mechanism of injury. He says that good results have also been

reported with use of techniques with reaming. The reaming of the medullary

cavity allows the insertion of larger nail, thereby increasing the stability of

fixation, because of biomechanical limitations, there may be high rate of

failure of small diameter locking nails. If union is not achieved earlier, fatigue

failure of the nail or interlocking screws with subsequent non-union may

occur.

18

Anglen JO et al39 (1995) have reported in the journal of trauma on

comparison of reamed and unreamed nailing of the tibia. A retrospective

review was done on all tibial fractures treated by interlocking nailing at the

author’s institution, over the past five years, in order to compare reamed and

unreamed nailing. The unreamed nailing had lower average operative time

and lower average estimated blood loss. There was a statistically significant

difference in healing times, with unreamed nailing taking an average of 242

days to heal while reamed nailing took 158. 6 non-unions occurred, 1 in

reamed nailing and 5 in unreamed nailing. Malunions occurred in 4 reamed

nailing 6 unreamed nailing. Patellofemoral complication were more common

in unreamed nailings.

In 1995, Paul Gregory and Roy Sanders40 proposed that interlocked

intramedullary nailing inserted in an unreamed manner has become the

treatment of choice for the closed, unstable tibial shaft fractures in

polytraumatized patients in the authors institution. A high union rate, coupled

with a lack of compartment syndromes or peroneal palsy, makes this

procedure an attractive and alternative to reamed nailing.

In 1995, Gregory41 proposed that infection after unreamed nailing had

fewer complications and a higher success rate for infection control than

reamed nailing.

19

Court Brown et al42 (1996) in their article “Reamed or unreamed

nailing for closed tibial fractures said that reamed nailing showed better results

of union and unreamed nailing showed prolonged union rates.

The average union time is less and the incidence of non-union and

malunion is low in reamed nailing.

Fang Yao Chin et al43 (1996) treated unstable closed tibial shaft

fractures. Randomly 60 tibiae were fixed with interlocking nails and 56 tibiae

were fixed with ender nails. The follow up period was 24 months. They

concluded that in treating more communited tibial shaft fractures, the

interlocking nail is recommended because of its higher success rate.

Blachut PA et al44 (1997) in 152 closed fractures of tibia managed

between 1989 to 1994, with or without reaming, concluded that there are no

major advantages to nailing without reaming as compared to nailing with

reaming for the treatment of the closed fractures of the shaft of the tibia.

There was a higher prevalence of delayed union and breakage of

screws after nailing without reaming. The study included 70 fractures treated

with nailing with remaining and 56 that were treated with nailing without

reaming. Both united without the need for an additional surgery.

Schemitsch et al45 (1998) noted that there was no difference in bone

formation between reamed and unreamed nailing in sheep bone and noted that,

initially blood flow (overall tibial blood flow) decreased as the amount of

20

reaming increased, but 11 weeks after surgery the tibial perfusion had

increased to the same levels in both reamed and unreamed groups. They noted

that no long-term benefit was seen in limited reaming. They found no

evidence that the degree of reaming significantly affected.

Daudel A, Gascia et al46 (1998) concluded that non-reamed flexible

locking nailing provides effective control of axial and rotational stability.

Krettek C et al47 (1999) in a study of 20 patients showed that Poller

screws gave good supplement to stability after fixation with statically locked

intramedullary nails of small diameter in nailing of metaphyseal fractures with

a short proximal or distal fragment where an increase in malalignment can

occur in the coronal plane. Healing was evident in radiographs at 5.4±2.1

months. Mean varus-valgus alignment of –1.0 degree and mean

antecurvatum-recurvatum alignment of 1.6 degrees was noted.

Mohit Bhandari et al48 (1999) conducted a retrospective chart review

of 200 tibial fractures. They showed that plate fixation was associated with a

greater incidence of complications when compared with intramedullary nail

fixation. Complication rates were significantly greater in the delayed surgical

group. Surgical delay results in longer post-operative hospital stays, greater

complication rates, and increased total cost to the health care system.

Hernigou P et al49 (2000) in a report on proximal entry for

intramedullary nailing of the tibia, concluded that it is important to enter the

21

medullary canal at the right point, so that the nail is introduced in line with the

axis of the tibia in both the coronal and sagittal planes. If the entry point is

low, posterior tibia is endangered, if high, then, unrecognized articular

penetration can occur injuring the menisci and ligamentum transversum.

The unrecognized articular penetration was seen commonly and this

caused anterior knee pain. The safe zone is anterior to the ligamentum

transversum and anterior to the anterior horn of each meniscus. In some bones

the safe zone is smaller than the size of the standard reamers and the proximal

part of some nails.

Jarmo AK, Toivanen et al50 (2002) in a prospective randomized study

of intramedullary nailing of fractures of the tibial shaft, compared the results

of anterior knee pain in two different nail insertion techniques. The incidence

of chronic anterior knee pain was seen in up to 56% of patients. They noted

that irrespective of incision used, whether transtendinous, or paratendinous

incision (by a medial longitudinal incision without violating the patellar or its

sheath), the prevalence of anterior knee pain is the same.

They concluded by saying that intramedullary nailing is the treatment

of choice for displaced tibial shaft fractures and any change in approach in nail

insertion does not change the incidence of anterior knee pain.

Andrew Schmidt et al51 (2003) in the instructional course on treatment

of closed tibial fractures, summarized that intramedullary nailing is more

22

convenient, and it may provide superior results, but prospective randomized

studies need to be done to confirm this. Operative treatment is recommended

for open or closed unstable fractures and for fractures that cannot be held in

adequate alignment. Intramedullary nail fixation is the treatment of choice for

majority of tibial fractures that require stabilization.

Joshi et al52 (2004) proposed that the current trend of management of

Gustillo Tpe-I, II and IIIA open fractures of tibia present to emergency

department within 6-8 hours is to perform unreamed intramedullary nailing.

Unreamed nailing in experimental studies has been found to cause less

reduction in cortical circulation as compared to reaming of medullary canal.

Reaming of open fractures had been found to spread the contamination from

open wound along the medullary cavity. Reaming has also been reported to

slow the revascularization and delay osseous union.

Vineet Jain et al53 (2005) concluded that 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.

Lascombes et al54 (2006) in their article “use and abuse of flexible

intramedullary nailing in children and adolescents” stated that elastic stable

intramedullary nailing (ESIN) is awell accepted method of osteosynthesis of

diaphyseal fractures in children and adolescents for many reasons including

23

the following: No need for postoperative cast, primary bone union with

avoidance of growth plate injury and minimum invasive surgery.

Thonse et al55 (2007) in their article “antibiotic cement coated

interlocking nail for the treatment of infected non-unions and segmental bone

defects” stated that control of infection and stabilizing to promote union has

traditionally been provided by two separate procedures, methods that have

proved to be efficacious in the past. However, both these goals can be

achieved in half the patients with the use of antibiotic cement coated

intramedullary nail.

Kyung-Cheon Kim et al56 (2008) in their article “Percutaneous

reduction during intramedullary nailing in comminuted tibial shaft fractures”

stated that communited tibial shaft fractures are often associated with severe

soft tissue injury and periosteal stripping and result in major impairment of

blood supply to the communited bony fragment. Consequently the use of

unreamed intramedullary nailing in comminuted tibial shafts has gained favor

because they better preserve the endosteal blood supply and minimally disturb

the soft tissue envelop. Percutaneous reduction with conventional reduction

forceps and unreamed intramedullary nailing is thought to facilitate fracture

reduction and decrease complications, such as non-union, malalignment,

instability and fixation failure.

Vaisto O et al57 (2008) in their article “Anterior knee pain after

intramedullary nailing of fractures of tibial shaft: an eight year follow-up of a

24

prospective, randomized study comparing the different nail-insertion

techniques” stated that anterior knee pain is the most common complication

after intramedullary nailing of the tibia. Dissection of patellar tendon and its

sheath during transtendinous nailing is thought to be a contributing cause of

anterior knee pain compared with a transpatellar tendon approach, a

paratendinous approach for nail insertion does not reduce the prevalence of

chronic anterior knee pain or functional outcome after intramedullary nailing

of tibial shaft fracture. In long term anterior knee pain seems to disappear

from many patients.

25

SURGICAL ANATOMY

Surgical Anatomy of Leg

The leg is divided into 3-compartments:

1. Anterior compartment

2. Lateral compartment

3. Posterior compartment – This is divided into

a) Superficial posterior compartment

b) Deep posterior compartment, by the deep transverse fascia

Figure-1: Muscles of Leg – Anterior View

26

Anterior Compartment:

• The anterior compartment of the leg contains tibialis anterior, extensor

digitorum longus, extensor hallucis longus and peroneus tertius

muscles.

• This compartment is primarily responsible for dorsiflexion of foot and

ankle, along with inversion of foot by tibialis anterior, extension of

hallux by extensor hallucis longus and extension of toes by extensor

digitorum longus.

• Neurological damage or loss of functional integrity of motor tendon

unit itself, may lead to loss of dorsiflexion.

• All anterior crural muscles are supplied by deep peroneal nerve.

Tibialis anterior by L4 and L5 and other by L5 and S1.

• Anterior tibial artery and deep peroneal nerve run deep, andthey are

present anterior to the interosseous membrane.

• They pass in interval between the tibialis anterior and extensor hallucis

longus.

• The muscles in the anterior compartment are enclosed in a relatively

unyielding fascial compartment, which makes the anterior

compartment more at risk for compartment syndrome.

• Near the ankle, tendons of Tibialis anterior, extensor hallucis longus

and extensor digitorum longus are close to the tibia. They may be

injured in fractures near the ankle. They may also be incorporated by

the callus formed during fracture healing.

27

Lateral Compartment

• Lateral crural muscles are the peroneus brevis and longus.

• They evert the foot. The peroneus longus everts and plantar flexes the

foot.

• They are supplied by the superficial peroneal nerve L5, S1 and S2.

• Superficial peroneal nerve runs in septum between peronei and

extensor digitorum longus.

• This nerve is injured with fractures of fibular neck and in traction

injuries of lower extremity. They are also injured in fractures at

junction of middle and distal thirds of the leg, where superficial

sensory branches pass between peroneus brevis and extensor digitorum

longus muscles. Improper positioning of the knee, in flexion without

padding on the fracture table can cause compression of common

peroneal nerve proximally at the fibula.

• Padding and avoiding pressure over proximal fibula will help prevent

the development of the peroneal nerve palsy.

• Compartment syndromes are much less common in lateral

compartment than in the anterior compartment.

28

Figure-2: Muscles of Leg – Posterior View Figure-2: Muscles of Leg – Posterior View

29

29

Superficial Posterior Compartment

• Superficial posterior compartment contains gastrocnemius, soleus and

plantaris muscles.

• The gastrocnemius and plantaris act on knee and ankle, soleus acts

only on the ankle.

• They are supplied by the tibial nerve S1 and S2.

• Sural nerve, short and long saphenous veins are also within this

compartment, but there are no arterial structures.

• Gastrocnemius, crossing both knee and ankle is a primary flexor of the

knee and ankle joints.

• Soleus tendon joins gastrocnemius tendon in distal third of the leg to

form triceps surae or Achilles tendon.

• Gastrocnemius propels in walking, running and leaping, while soleus is

said to study the leg on the foot in standing.

• Plantaris has no anatomical significance, but may serve as a source of

tendon graft.

Deep Posterior Compartment

• Contains tibialis posterior, popliteus, flexor digitorum longus and

flexor hallucis longus.

• The flexor hallucis longus and flexor digitorum longus are supplied by

tibial nerve S2 and S3. The popliteus by tibital nerve L4 and L5 and

S1. Tibialis posterior by tibial nerve L4 and L5.

30

• These muscles are involved in plantar flexion of the foot and toes and

inversion of foot through tibialis posterior muscle function.

• Popliteus acts as a leg flexor, internal rotator of tibia and initiation of

knee flexion.

• The peroneal artery and posterior tibial arteries are present in this

compartment.

• Posterior tibial artery, because of its protected nature, frequently, is a

major source of arterial supply after significant open fracture and is a

potential source for anastomosis with free flaps for soft tissue

reconstruction of the leg.

Figure-3: Bones of the Leg – Tibia and Fibula

31

Surgical Anatomy of Tibia

Tibia is the medial and larger bone of the leg. It is stronger than the

fibula and its shaft is prismoid in section with the ends expanded. It is

homologous with the radius of upper limb. It lies vertically in the body. It has

a proximal end, shaft and distal end. It lies subcutaneously in the anterior part.

Proximal End

It is markedly expanded transversely. It is a bearing surface for body

weight transmitted through the femur. It has:

1. Medial and lateral condyle.

2. Intercondylar area – this is present between the condylar articular

surfaces.

3. Tuberosity of tibia – This is present at the proximal end of the

anterior border.

Shaft

It is triangular in section, is thinnest at the junction of middle and distal

third, and slightly expands at both ends. It is prism in shape and has 3-borders

and 3-surfaces. The borders are:

1. Anterior border – it forms shin of the tibia.

2. Medial border.

3. Interosseous border, it provides attachment to interosseous

membrane. The surfaces are medial, lateral and posterior surfaces.

32

Distal End

It is slightly expanded and has five surfaces, which are the anterior,

medial, posterior, lateral and distal surfaces. It projects infero-medially as the

medial malleolus.

Tibia is commonly fractured at the junction of upper 2/3rd and lower

1/3rd of its shaft, where it is most slender. The delayed or non-unions, which

may follow is said to be due to poor blood supply of this part of bone or

tearing of the nutrient artery.

Ossification

It is by three centers, in the shaft and both epiphysis. One primary

center begins in mid shaft by 7th week of intrauterine life. Two secondary

centers are:

1. Proximal epiphyseal center, which is present before birth and fuses

at 16 to 18 years.

2. Distal epiphyseal center appears during 1st year after birth, forms

medial malleolus by 7th year and fuses with shaft by 15 to 17 years.

Vascular supply to the Tibia

• Blood supply to the tibial shaft is derived from nutrient artery and

periosteal vessels.

• Nutrient artery enters middle 1/3rd and may be damaged in a segmental

fracture.

33

• This makes bone dependent on soft tissue envelope for blood spply,

and stripping of soft tissues may render the bone avascular.

• Nutrient artery arises from the post tibial artery and enters

posterolateral cortex of the tibia at the origin of the soleus muscle.

• Artery may traverse a distance of 5.5 cm before entering its oblique

nutrient canal.

• Artery divided into three ascending branches and a single descending

branch, which gives off smaller branches to the endosteal surface.

Nutrient Artery

• Nutrient artery enters into the diaphysis of long bones through an

oblique canal.

• Direction of canal is determined by relative amount of growth that has

occurred at proximal and distal ends of the bone.

• Nutrient canals slope away from the knee in femur, tibia and fibula and

towards elbow in radius, ulna and humerus.

• Nutrient artery divides after reaching the medullary cavity, sending

arterial branches in proximal and distal directions and join with

metaphyseal arteries.

• Some of these branches enter the cortex to supply Haversian canals of

inner two-third of the cortex.

34

Figure-4: Anterior tibial and dorsalis pedis arteries

35

• Other branches of the nutrient artery continue in more or less parallel

alignment to metaphysis.

• In the child, these vessels end on metaphyseal side of epiphyseal plate,

where they participate in enchondral ossification.

Disruption of Nutrient Artery

• In growing bone, can result in necrosis of large portion of the marrow

and of inner two-thirds of the cortex.

• This cortical death does not occur in adult bone, because combined

epiphyseal – metaphyseal collateral circulation has developed enough

to maintain these areas.

• Loss of circulation in terminal vessels of nutrient artery of growing

bone will interface with enchondral ossification.

Epiphyseo-metaphyseal Blood Supply

Formed by medial genicular artery, inferior genicular artery and tibial

recurrent artery.

• Metaphyseal portion of long bone contains numerous small channels.

• Through these channels pass vessels that enter marrow cavity to

anastomose with vessels derived from nutrient artery.

Majority of these metaphyseal channels, however contain veins that

permit egress of blood from the marrow cavity.

36

Anterior Tibial Artery

• May be vulnerable to injury after its division from popliteal artery,

where it passes through hiatus in upper interosseous membrane.

• Periosteum has abundant blood supply from anterior tibial artery,

which branches out as it courses down the interosseous membrane.

Figure-5: Posterior Tibial and Peroneal Arteries

37

Posterior Tibial Artery

• Posterior tibial artery enters the posterior compartment of the leg along

with, lying posterior to tibialis posterior and enters plantar aspects of

the foot after passing behind medial malleolus.

• Largest branch is peroneal artery arising high in leg and coursing

downward in the posterior compartment, lying just medial to fibula.

• Gives off branches to adjacent muscles, sends branches through

interosseous membrane to anterior compartment and gives nutrient

artery to the fibula.

• Lateral compartment of the leg has no artery proper to it.

• Tibial nutrient is a large branch of the posterior tibial artery.

• Under flexor retinaculum, the posterior tibial artery divided into the

lateral and medial plantar arteries.

Medial Plantar Artery

• Travels with medial plantar nerve, supplies medial portion of the

plantar aspect of the foot.

• Three medial metatarsal arteries usually receive branches from the

medial plantar artery.

Lateral Plantar Artery

• Travels with lateral plantar nerve and passes across the foot to form

plantar arch, which joins with deep plantar artery from the dorsalis

pedis artery.

38

Classification of Tibial Shaft Fractures

Classification

Numerous classification system, have been proposed for tibial

fractures from the simple stable versus unstable to more detailed alphanumeric

systems as proposed by AO/ ASIF/ OTA classification.

Any classification of injury is useful only if it alerts the physician to

potential dangers or helps to determine appropriate treatment. The most

important morphological variable are:

• Anatomical location

• Pattern or patterns of fracture lines

• Associated injuries of fibula

• Position and number of fragments.

• Extent of soft tissue damages.

Ellis classified tibial fractures into three groups of severity:

• Minor: Non-displaced with minor communition or small open wound.

• Moderate: Total displacement or angulation with small degree of

communition or minor open wound.

• Severe: Complete displacement of fracture fragments with major

communition or major soft tissue damage.

Weissmann and Associates

Also classified tibial fractures. This classification is based on the

initial displacement of fracture. But this is often difficult to ascertain because

39

the fractures may have been reduced from their initial displacement before X-

rays. It depends on:

• Degree of initial displacement.

• Communition

• Soft tissue wounds.

He arbitrarily assigned one of 3-grades from each factor. Nil or slight,

moderate and severe.

OTA (Orthopaedic Trauma Association)/ AO Classification

This was initially described by the AO Group. This is a morphologic

classification based on the initial anteroposterior and lateral radiographs. It

consists of three types subdivided into three groups, each of which are further

sub-divided into three sub-groups.

Type-A fractures or Unifocal Fractures

Their division into sub-groups is based on orientation of the tibial

fracture and the presence or absence of a fibular fractures.

A1 – spiral fractures

A2 – oblique fractures

A3 – transverse fractures.

If there is no fibular fracture, suffix, 1 is used, with 2 being used for

fibular fracture distant from tibial fracture and 3 for fractures where tibial and

fibular fractures are at the same level.

40

Type-B fractures are wedged fractures

BB1 – spiral wedge fractures

B2 – bending wedge fractures

B3 – fragmented wedge fractures

Type-C are classified on severity of tibial fracture, and not on position of

fibular fracture

C1 – complex spiral fractures

C1.1 – two intermediate fragments

C1.2 – three intermediate fragments

C1.3 – more than three intermediate fragments

C2 – segmental fractures

C2.1 – one segmental fragment

C2.2 – segmental fragment and additional wedge fragment

C2.3 Two segmental fragments.

C3 –All communited fractures

C3.1 – two or three intermediate fragments

C3.2 – limited communition (<4 cm)

C3.3 – Extensive communition (>4 cm).

41

ORTHOPAEDIC TRAUMA ASSOCIATION (OTA) AO

CLASSIFICATION OF TIBIAL DIAPHYSEAL FRACTURES

Type-A: Unifocal Fractures

Group A1 Spiral fractures

Sub-groups A1.1 Intactfibula

A1.2 Tibia and fibula fractures at different level

A1.3 Tibia and fibula fractures at same level

Group A2 Oblique fractures (fracture line >30º

Sub-groups A2.1 Intact fibula

A2.2 Tibia and fibula fractures at different level

A2.3 Tibia and fibula fractures at same level

Group A3 Transverse fractures (fracture line <30º)

Sub-groups A3.1 Intact fibula

A3.2 Tibia and fibula fractures at different level

A3.3 Tibia and fibula fractures at same level

Type-B: Wedge fractures

Group B1 Intact spiral wedge fractures

Sub-groups B1.1 Intact fibula

B1.2 Tibia and fibula fractures at different level

B1.3 Tibia and fibula fractures at same level

Group B2 Intact bending wedge fractures

Sub-groups B2.1 Intact fibula

B2.2 Tibia and fibula fractures at different level

B2.3 Tibia and fibula fractures at same level

Group B3 Communited wedge fractures

Sub-groups B3.1 Intact fibula

B3.2 Tibia and fibula fractures at different level

B3.3 Tibia and fibula fractures at same level

42

Type-C: Complex fractures (multifragmentary, segmental or comminuted fractures)

Group C1 Spiral wedge fractures

Sub-groups C1.1 Two intermediate fragments

C1.2 Three intermediate fragments

C1.3 More than three intermediate fragments

Group C2 Segmental fractures

Sub-groups C2.1 One segmental fragment

C2.2 Segmental fragment and additional wedgement

C2.3 Two segmental fragments

Group C3 Communited fractures

Sub-groups C3.1 Two or three intermediate fragments

C3.2 Limited comminution (<4 cm)

C3.3 Extensive comminution (>4 cm)

43

Fracture Mechanics

Bone is an anisotropic material. It exhibits different stress-strain

relationships depending on the site and direction in which stress is applied.

Cortical bone fracture in vitro, when strain exceeds 2% of the original length.

Numerous classification systems have been proposed for tibial

fractures. Unfortunately none of them have been validated for reproducibility

or sensitivity.

The following classification was followed in the study:

Closed fractures:

1. Transverse

2. Oblique – short/ long

3. Spiral

4. Segmental.

The comminution at the fracture site was graded according to Winquist

et al classification.

Grade I Number of comminution <25% of the circumference

II Comminution <50% of the circumference

III >50% of the circumference

IV Total comminution.

44

Open Fractures

They were classified according to modified Gustilo and Anderson’s

Classification58

Type Wound Level of Contamination Soft tissue injury Bone injury

I <1 cm long

Clean Minimal Simple, minimal comminution

II >1 cm long

Moderate Moderate, some muscle damage

Moderate comminution

III* A Usually >

10 cm long

High Severe with crushing Usually comminuted soft tissue coverage of bone possible

B Usually >10 cm long

High Very severe loss of coverage

Bone coverage poor usually requires soft tissue reconstructive surgery

C Usually >10 cm long

High Very severe loss of coverage plus vascular injury requiring repair

Bone coverage poor usually requires soft tissue reconstructive tissue

* Segmental fractures, farm yard injuries, fractures occurring in a highly contaminated environment, shotgun wounds, or high-velocity gunshot wounds automatically result in classification as a type-III open fracture. The mode of injury predicts the soft tissue injury and stability of the

fracture. Nicoll stated that the important factors in prognosis are:

1. Amount of initial displacement.

2. Degree of comminution

3. Presence/ absence of infection.

4. Severity of soft tissue injury.

Hoagland and States suggested that:

a) Torsional fractures with/ without comminution are low energy fracture

and have good prognosis.

45

b) Comminuted, transverse and short oblique fractures are high energy

fractures and have bad prognosis.

Long bone fracture biomechanics

Fracture pattern Mechanism of injury

Location of soft tissue hinge

Energy

Transverse Bending Concavity Moderate

Short oblique Compression + bending

Concavity or butterfly side

Moderate

Long oblique Compression + bending + torsion

Concavity (often destroyed)

Moderate to high

Spiral Torsion Vertical segment Low

Comminuted Variable Destroyed High

In analyzing fracture patterns, the mode of loading offers insight into

the mechanism of injury, the energy involved in disruption of the bone and the

prognosis.

46

Biomechanics of Intramedullary Locked Nail

All intramedullary nails, regardless of their types, act as flexible

internal splints, providing stability for the fracture fragments from within,

transferring load across the fracture site and maintaining anatomic alignment

to induce bony union.

This concept of intramedullary fixation was first introduced by Hey

Groves in 1918 and later popularized by Kuntscher in 1940.

The mechanical behavior of intramedullary nails depends on both

material and geometry of the design.

Material

If a structure is placed in a test frame and loaded to failure, the

resulting load-deflection curve would describe the mechanical behavior of that

device59. The shape of the curve can be divided into an elastic region initial

linear portion of the curve and a plastic region the non-linear portion. The

slope of the elastic portion is the stiffness of the structure, the higher the

number, more rigid the structure. Loaded within the elastic range, a structure

will return to its original shape following load removal. This is the working

area of the medullary implant. If the implant is loaded beyond the

proportional limit, a plastic deformation takes place and the shape of the

object changes. This creates a potential for complications from malunion to

non-union in fracture healing. Hence, the implant should not be loaded

beyond the proportional limits.

47

The bending rigidity59 depends on the moment of inertia of the design

which is proportional to the fourth power of the radius and the quantity of the

material, that is to say that the bending stiffness increases as the diameter and

thickness of the nail increases. A 25% increase in diameter of the nail will

double its bending strength.

The rotation stiffness depends on the configuration of the cross section

of the nail. Abolishing the open slot in the cross section increases the

rotational stiffness approximately 50 times, when compared to the same nail

with an open slot.

Clinically, bending strength and stiffness can be increased by using

unslotted thick nail with large diameter.

Stress-strain Curve59

Material properties are defined geometrically in the stress-strain curve.

Stress is defined as load per unit area and strain as the change in length

divided by the original length. The slope of the curve is termed the modulus

of elasticity (E) or Young’s modulus. It defines the elastic behavior of that

material. By multiplying the modulus of elasticity and the moment of inertia,

the structural stiffness of a cross section can be computed.

The yield strength is one at which the implant undergoes plastic

deformation. Fatigue strength is the repeated cyclical stress at which the

implant fails. For metals, the fatigue limit is approximately one-half the yield

48

stress and hence a load bearing or a load sharing implant should be designed

with the fatigue limit as the failure criteria.

Structural characteristics and mechanical factors important in the

design and evaluation of IM nails are strength, stiffness and rigidity of the

device. The working length of a nail is defined as that length which spans the

fracture site between adjacent areas of contact in the proximal and distal

fragments. This dimension also affects the stiffness of a nail. The working

length should be as short as possible to increase the stiffness in both bending

and torsion. However, the total nail contact should be distributed over a

longer section of the bone, proximally and distally to increase the gripping

strength of the nail and thus provide rotation stability. Interlocking IM nails

designed for static maintenance of length, also provide the greatest degree of

rotational stability, by rigidly locking the nail to bone through the use of

screws. Interlocking nails have a longer working length, hence, can be used in

proximal and distal tibial fractures also.

Interlocking can be of the following types:

1. Dynamic locking – placing cross-screws at one end only.

2. Static locking – cross screws are placed at both the ends.

Dynamic fixation controls bending and rotational deformities, but

allows nearly full axial load transfer by bone e.g., instable fractures.

49

Static locking controls rotation, bending and axial loading, and makes

the implant bear the load with potential for fatigue failure e.g., comminuted

and segmental fractures.

Dynamization is conversion of statically locked nail into a dynamic

mode by removal of less critical transverse screw. It is done in case of

delayed union, usually at 6 weeks. It increases fatigue life of the nail.

Clinical study of interlocking nailing did not show much difference in

healing, between dynamic and static nailing. This may be due to inherent

elasticity of the system and gradual loosening of the interlocking screws due to

bone remodeling which gives the effect of mild dynamization.

The controversies lies in the degree of mechanical instability one

should provide with fixation, in order to stimulate bone growth and case the

surgical procedure.

We have to balance between fracture stability, biological effects and

clinical practicability.

50

Biology of Fracture and Fracture Healing with Intramedullary Locked

Nail

Fractures are accompanied by perfusion disturbances of varying

degree. Simple fractures without major soft tissue damage may not lead to

any significant circulatory deficits or may be confined to a limited area of

about 1 mm. In intermediate fractures, perfusion from the intramedullary

vessels is Interrupted. Bone is perfused in the outer one-third by the periosteal

vessels only. Because fractures close to the metaphysis are located largely in

the cancellous bone, they are less likely to suffer circulatory deficiency.

Measurable vascular damage is caused only by major trauma or extensive soft

tissue detachment.

During the repair of a fracture, adjacent intraosseous and extraosseous

arterial circulations proliferate greatly. The greatest proliferation at a simple

fracture is of medulla derived arteries and arterioles. The earliest external

callus is supplied by new extraosseous arterioles derived from torn soft tissue

in the vicinity, but this new supply is only transitory. Detached bone

fragments require maintenance of the new extraosseous supply until they

become incorporated, when the medullary circulation again takes over.

Mechanical Aspects of Nailing

Mechanically, a medullary nail represents a gliding splint. Motion at

the fracture site is restricted, but not eliminated.

51

The fixation rests mainly on elastic three point contact in longitudinal

direction. Rotational stability using conventional nailing is limited.

The interlocking nail allows for insertion of screws through the bone

and the nail, both proximally and distally, preventing shortening, tilting and

torsional displacement. It allows a certain amount of fracture mobility, but the

critical amount of strain for healing is not exceeded.

Effects of Intramedullary Fixation by a Loose Fitting Nail – Unreamed

Nailing

Implantation of a medullary nail without previous reaming causes

relatively minor damage to the already compromised circulation in the

fractured tibia60. The medullary canal is revascularized more quickly

following non-reamed nail systems. Small vessels grow into existing gaps

between the bone and the nail in a short period of time, from where they

penetrate into the neighboring malperfused cortical bone. At the relatively

few sites of close contact between bone and medullary nail, bone lamellae will

be removed by osteoelastic activity, so that vessels can sprout into the newly

formed gap.

Effects of Reaming61

The reaming process results in the destruction of all vessels in the

medullary canal resulting in the necrosis of inner 50%-70% of the cortex. Due

to the anatomy of the medullary blood supply, the first reaming causes the

essential damage. Subsequent reaming has little effect on cortical vascularity

52

or viability. Hence, reaming is performed only to such an extent as to ensure

sufficient fracture stabilization.

Reaming particles possess bone inductive potential and hence is of

great importance in fracture healing, if surrounded by vital tissue. On the

other hand, the reaming dust represents a large amount of necrotic particles or

microsequestrae, if they are deposited in devitalized zones of the medullary

canal, especially in view of the possible bacterial contamination in open

intramedullary nailing or nailing in open fractures.

The medullary canal is irregular in size in the long axis as well as in

cross-section. Stable intramedullary fixation requires a firm fit for a variable

distance. In reaming the medullary canal, a cylindrical channel of uniform

diameter is prepared for the nail, which improves the stabilizing effect of the

implant. Furthermore, the bending stiffness increases with progressively

larger diameter nails. Therefore, it is necessary to ream to a certain extent.

Various processes contribute to revascularization of disrupted bone.

The medullary circulation regenerate slowly, by means of formation of

longitudinally directed intracortical arterioles, derived from the transected

nutrient artery and arterioles within a new endosteal membrane that come to

surround the nail after osteoclastic removal of nercrotic cortex.

The best configuration for an intramedullary nail is one with open

sources or flutes extending longitudinally between flanges. The flanges will

give firm support to all sectors of the endosteal cortex, and the flutes will

permit regeneration of the essential medullary circulation as rapidly as

possible.

53

Advantages, Disadvantages and Complications of Intramedullary Nailing

Advantages of the Intramedullary Interlocking Nailing

• It is a load sharing mechanism.

• Healing occurs biologically

• Fracture haematoma is preserved

• Periosteal vascular damage is minimal.

• Proved method of treatment in delayed and non-union.

• Effective in open fracture type-I and II with clean wound.

• Even in severe compound fractures Grade-III, IIIA and IIIB (it can be

initially treated with external fixators and later secondary interlocking

can be done).

• Additional bone grafting is not needed.

• Stability and length is well maintained.

• Rotational instability checked by locked screws.

• Joint motion preserved.

• Early mobilization and early weight bearing can be started.

• There is no skin necrosis.

Disadvantages of Intramedullary Interlocking Intermedullary Nailing

• Long leaning curve is present, it is technically demanding and

therefore a larger period of exposure and training is required.

• Exposure irradiation occurs by using the C-arm.

• It is not suitable in fixation of proximal and distal 1/5th of tibia.

54

Complications of Intramedullary Nailing

1. Anterior Knee Pain

This is the commonest complication.

• Keating et al reported a 57% incidence of anterior knee pain.

• Court Brown et al reported 56.2% incidence of anterior knee pain.

• Causes of anterior knee pain may be prominent nail or heterotopic

ossification of patellar tendon.

• It may be due to interarticular damage to menisci or associated

ligaments.

2. Neurologic Abnormalities

• 2% incidence of sural and saphenous nerve damage can occur due to

distal cross screw insertion as noted by Court Brown et al.

• Common peroneal nerve lesions have encountered in 19% of cases and

resolved in 80% of them, due to incorrect positioning of the knee on

the nailing table.

3. Vascular Damage

• It is seen as a result of drill damage to popliteal artery in the area of

arterial trifurcation.

• Damage to medial inferior genicular artery has also been noted.

4. Hardware Breakage

• Screw breakage is common in unreamed nails, which use smaller

screws.

55

• Titanium has lower screw breakage rates.

• Broken nails are associated with untreated non-unions.

• Breaking of drill bits are common and they remain in the bone or soft

tissues.

5. Thermal Necrosis

• Is unusual

• It is caused by excessive use of force and blunt reamers.

• Tourniquet should not be used as it eliminates heat convective transfer

by shutting down global blood flow to whole limb.

6. Bone Damage

• Incorrect starting point or failure to aim the nail may damage bone and

splinter the proximal entry point.

7. Intramedullary nailing may precipitate adult respiratory distress

syndrome in patients with blunt thoracic trauma due to bone marrow

emboli and reaming of the bone may precipitate emboli formation.

56

APPROACHES

1. Medial parapatellar approach62

• A longitudinal incision along the medial margin of the patellar tendon.

• The patellar tendon is retracted laterally exposing the point of entry.

• Anterior knee pain is one of the commonest complication.

2. Midline Patellar Splitting Approach63

• A longitudinal incision in the midline anteriorly.

• The portal of entry is approached by splitting the patellar tendon

vertically.

• Anterior knee pain and extensor lag are common complications.

3. Lateral Approach

• Inverted “J’ shaped incision along the lateral border of the patellar

tendon.

• The portal of entry is approached by retracting the patellar tendon

medially.

Guidelines

a) Patellar tendon should be retracted gently.

b) To avoid stress on the medial and posterior cortex, the nail should be

oriented along the long axis of the medullary canal.

57

Point of Entry

The point of entry is proximal to the tibial tuberosity at the level

corresponding to the proximal tip of the fibular head centered on the

medullary canal in the midline62.

Insertion Angle

The insertion angle should be in line with the medullary canal in the

antero-posterior view to prevent valgus/ varus deformity and parallel to the

anterior cortex of the proximal fragment in the lateral view to prevent apex

anterior angulation.

58

MATERIALS AND METHODS

Patients of both sexes belonging to adult age group presenting with

fracture tibia to Orthopaedic Department of Basaveshwar Teaching & General

Hospital, attached to M.R.Medical College, Gulbarga are admitted from

October 2006 to March 2008 and evaluated. Those satisfying our inclusion

criteria and are surgically fit are included in the study. This includes a

prospective study of 20 cases.

Inclusion ad Exclusion Criteria:

Inclusion Criteria

• Transverse and short oblique fractures

• Segmental fractures of shaft of the tibia

• Grade-I (Gustillo Anderson) compound fractures

• Polytrauma cases where early mobilization of patient is indicated.

Exclusion Criteria

• Fractures in children

• Grade-II and III (Gustillo Anderson) compound fractures

• Fractures with intra-articular extension

• Burns/ wounds over the entry portal.

59

1. The name of the patient, age of the patient and sex of the patient

was recorded routinely.

2. The occupation of the patient was noted, and this is considered as

important deciding factor in the early rehabilitation of the patient to

his work.

3. The address of the patient is taken routinely and would be

beneficial in following up the patient.

4. An initial detailed history of the patient, which included mode and

nature of injury, conscious level, any treatment history, signs of

shock and any emergency treatment taken were recorded.

5. A complete clinical examination of the patient was done and the

patient admitted to the ward.

6. A proforma was prepared, which gave complete details of the

patient.

In the history, symptoms of pain, swelling, abnormal mobility,

deformity, loss of function were recorded.

Pain perception may vary according to the fracture, whether fresh or

old fracture, with pain severity being more in fresh fractures.

Swelling is associated with a fracture and is mentioned. Abnormal

mobility is noted. Deformity is also noted in the presenting complaint. The

patient with fracture shaft of the tibia having loss of function is indicated.

60

The mode or nature of injury is noted

• Sports related injuries are low-velocity injuries.

• Direct blow/ assaults are injuries associated with high and significant

soft tissue damage.

• Motor vehicle accidents are high-velocity injuries.

• Gunshot injuries are both low and high-velocity injuries.

• Pathological fractures may be as a result of trivial trauma.

• The injuries is classified in the proforma enclosed.

• Sports injuries are usually closed injuries and simple injuries.

• In cases of fall, sports injuries and direct blow to tibia, a simple

fracture configuration is present.

• Falls from a height and motor vehicle accidents have a more complex

fracture pattern with open wounds.

• The duration of injury is noted.

• Systemic illness is enquired, which includes diabetes, hypertension,

ischemic heart disease and epilepsy and it is recorded in the proforma.

• Personal history is enquired like smoking, alcohol intake, which may

have a bearing on fracture healing.

General Physical Examination

• The assessment is done routinely, to evaluate the fitness of the patient

to undergo surgery and the bearing it would have in the successful

outcome on the surgery.

61

• The patient’s build, nourishment and pallor is evaluated along with his

vital functions.

Systemic Examination

• This is done to assess the cardiovascular, respiratory, central nervous

system and includes an abdominal examination.

• This is a pre-operative assessment, to evaluate fitness of patient from

the proposed surgery and to treat the abnormalities, if any.

Local Examination includes Inspection and Palpation

1. Gait: is assessed to whether the patient is able/ unable to walk.

2. Skin: Is examined with the associated wound if present. Simple falls,

sports injuries have a closed injury pattern with skin being normal.

3. Swelling: is assessed, and according to the severity is graded as present

or absent.

4. Attitude and deformity is assessed, whether there is varus, valgus or

rotational deformity. It is mentioned as present or absent.

5. Tenderness is palpated and may be mild, moderate or severe, at the site

of fracture. It is mentioned as present or absent.

6. Movement of the knee and ankle is mentioned as restricted or normal

and if abnormal mobility is present at fracture site it is assessed and is

noted with associated Crepitus.

7. Shortening is measured in the leg segment and is mentioned as the

amount of shortening in cms.

62

8. Associated injuries were noted in same or contralateral side. Bony

injuries and associated neurovascular injuries like dorsalis pedis,

posterior tibial, common peroneal, and tibial nerve injury is mentioned

as it is.

9. Abnormal mobility is mentioned as present or absent. Complications

like fat embolism, shock and compartment syndrome should be ruled

out and treated if present.

Provisional Diagnosis

• Is made on the basis of history, clinical signs and symptoms.

• Once a provisional diagnosis is made an emergency radiograph is

taken, at the same time giving the patient some analgesics and tetanus

toxoid, and immobilization is done with a splint temporarily.

• If there is low blood pressure, feeble pulse and tachycardia, the

protocol of shock management is initiated.

Investigations

1. Routine

Blood

• Hb%

• PCV

• TC

• DC

• ESR

63

• FBS, if the patient is diabetic

• PPBS, if the patient is diabetic

• RBS

• BT

• CT

• Blood grouping and typing

• Blood urea

• Creatinine

• HIV – After obtaining the patient’s consent.

• HbsAg – After obtaining the patient’s consent.

• VDRL

Urine

• Routine – albumin/ sugar/ microscopy.

Stool

• Ova

• Cyst

• Microscopy

2. ECG – in all chest leads

3. Chest X-ray PA view.

4. X-ray of the leg both antero-posterior and lateral view.

64

A diagnosis of the type of fracture is done, whether it is unifocal

fracture (spiral, oblique and transverse), wedge fracture, or a complex fracture.

The assessment of the level of fracture is also done.

The Tscherne type is assessed radiologically.

Fibular fracture is noted as present or absent.

Preoperatively

1. Once the routine investigation along with the required ECG, CRX-PA

view is done, physician’s advice regarding fitness for surgery is

obtained in the form.

2. In case of anemia adequate transfusions of whole blood, packed cells

and autotransfusions to improve the general condition is carried out.

3. Static quadriceps exercises are taught to the patient and he is educated

regarding surgery and outcome.

4. Active hip, knee and ankle movements are initiated.

5. The limb is immobilized during the pre-operative stage by above knee

POP slab.

6. Pre-anesthetic check-up is done with a bottle of blood as standby.

7. Preparation of part to be operated is done.

8. Preoperative nail selection is done on the basis of preoperative X-ray

to assess the width of nail by measuring the canal diameter at the

narrowest portion in X-rays in the antero-posterior view.

65

9. Length of the nail is assessed by measuring the normal leg from tibial

tuberosity to medial malleolus and subtracting 2 cm from it. The nail

is selected according to the economy of the patient. Bend in tibial nail

takes into account the anatomic angle of 11 degrees formed by axis of

access canal and the medullary canal.

The section in the sagittal plane shows the 11º angle between the insertion (ic)

and the axis (a) of the tibial cavity.

10. The instrumentation required is selected appropriate for the make of

the nail.

66

Operative Procedure

Positioning of the Patient

Patient is operated on a ordinary fracture table with his leg hanging by

the side/ edge of the table.

A pad is used to support the distal femur at a sufficient distance from

the popliteal artery and vein, if it is not properly positioned, circulation is

inhibited by the force used to insert the nail and damages the vascular wall.

• The injured leg is scrubbed, painted with betadine, spirit and draped.

• Longitudinal incision over the patellar ligament at the level of joint, 5

to 6 cm long is used, splitting the tendon longitudinally.

• Entry portal is made 2 cm proximal in the midline or slightly medial

and behind the tibial tuberosity.

• A curved awl is used to open the medullary canal and is pushed as far

as possible into the medullary canal, while the handle should be in line

with the axis of the shaft.

• 3.2 mm guide wire with ball tip is pushed into the canal, past the

fracture site into the malleolar region (0.5 to 1 cm proximal to ankle

joint) assisted by reduction manually.

• If need arises, a small incision is made over fracture site to align the

bones.

• In case of atropic non-union, the fracture site is opened and excision of

the sclerosed ends is done before nailing.

67

• Determination of the length of nail is done by subtracting the exposed

length of guide wire from its overall length using another guide wire of

same size or another nail of same size, which is used with C-arm

assistance.

• The nail with the proximal insertion handle and jig is passed over the

guide wire and is inserted as far as possible, measured hammering is

done to drive the tip of nail to the distal metaphysis and proximal end

should be flush with the surface of cortex at the point of insertion.

• The nail should be centralized as far as possible.

• The guide wire is removed.

• For distal locking by C-arm and free hand technique, the C-arm is

placed to show the locking holes of nail as perfect circles on the

monitor.

• The position is marked with a scalpel and an incision is done on the

skin over the marked locking holes. Steinmann pin is centered on

locking hole under C-arm and a mark is made on the bone with gentle

tap of a mallet.

• Drill bit is inserted through the skin incision down to the bone near the

locking holes and drilled under C-arm with axis of drill centered on the

locking hole with a 4.0 mm drill bit. Drilling hole is done through both

cortices, across locking holes.

• The length is determined with a depth gauge and confirmed with the C-

arm.

68

• The distal locking is done.

• Proximal locking is done with proximal jig and insertion handle.

• Stab-incision is done over appropriate locking hole.

• A 8 mm protection sleeve is inserted and trocar through it, till the

cortex is contacted.

• Trocar is removed and 4.5mm diameter drill sleeve is inserted and

drilled with 4 mm drill bit.

• The drill sleeve is removed, depth of hole is measured with a depth

gauge and a screw/ bolt is inserted which is confirmed with the C-arm.

• The C-arm is used to confirm the locking and nail position and fracture

alignment.

• The wound is closed and dressing is done, compression crepe bandage

is applied to control postoperative swelling.

• Postoperatively the limb is elevated on a pillow.

Post-operative Period

Postoperatively, the limb is elevated on a pillow. Immediate

postoperative complications like fat embolism and compartment syndrome,

neurological damage and vascular injury is looked for. Wound infection is

watched for in the postoperative period.

Parenteral antibiotics are given for 5 days, and continued in the form of

oral antibiotics till suture removal, which is done on 14th day.

69

Active quadriceps exercises are restarted on the first postoperative day

with active ankle and toe movement with knee mobilization, as far as the

patient is comfortable and free of pain.

Radiograph of the leg is taken to assess the fracture alignment, nail

placement and locking screws.

The patient is made to ambulate from the third postoperative day

without bearing weight on the operated leg with crutches or walker. Suture

removal is done after the 14th day if the wound has healed.

Follow Up

It was done using Johner and Wruh’s criteria. Patients were followed

up periodically on an outpatient basis at 4th, 6th, 10th, 12th, 16th, 20th weeks and

6th month and in between if required. The complaints were noted and the

clinical and radiological assessment of the patients were done, for pain,

deformity, shortening, range of motion of knee, ankle and subtalar joints and

radiological union.

Pain was noted as none, occasional, moderate and severe. Deformity was noted as none, anteversion-recurvatum, varus-valgus

and rotation deformity in degrees.

Shortening was noted in the form of measurement and was noted in

cms or was noted as nil if absent.

70

Range of motion of knee, ankle and subtalar joints was noted in

percentage. 100% being normal. More than 80% for knee, more than 75% for

ankle and more than 50% for subtalar joint was considered good.

Radiological assessment is done on the basis of whether there is callus,

or union or if fracture is consolidated.

Radiological union is noted as consolidated for excellent and good

results. Union for fair results and not consolidated for poor results at 6

months.

Angular alignment (varus-valgus, anterior and posterior angulation)

was assessed radiologically. Varus-valgus was determined by measuring the

angle between the line drawn perpendicular to bisecting the tibial plateau and

proximal medullary canal with the line bisecting the distal medullary canal

and tibial plafond.

Anteroposterior alignment was determined by measuring the angle

between the lines parallel to the proximal fragment and distal fragment on

lateral radiographs. Rotations were assessed clinically.

Malunion was considered when varus-valgus angulation was more than

5º, anterior-posterior was more than 10º, internal and external rotations of

more than 10º and shortening of more than 10 mm.

71

Weight bearing was done, initially partial weight bearing at the 4th

week depending on type of fracture and rigidity of fixation.

Full weight bearing is allowed after bridging callus is seen and there is

solid union, usually at 10-12th week.

Late delayed complications like screw breakage, nail bending, mal-

union, non-union, limp, anterior knee pain and infection is noted and any

secondary procedure done is noted in the proforma.

Dynamization if needed is done, if there is a delay in callus formation

and is done of screws further away from fracture site. It is noted whether

dynamization of proximal/ distal screws was done.

Gait was assessed whether normal or associated with a limp.

In this study fracture union was considered when patient was weight

bearing without pain, fracture site was not tender on palpation, radiograph

showed osseous union in antero-posterior and lateral views.

Gait and ability to do strenuous activities was also assessed.

They were graded as excellent, good, fair or poor using Johner &

Wruh’s criteria.

72

Johner & Wruh’s Criteria for Evaluation of Final Results

Sl. No.

Criteria Excellent (Left=Right)

Good Fair Poor

1. Non-unions, ostetitis, amputation

None Non None Yes

2. Neurovascular disturbances

None Minimal Moderate Severe

3. Deformity

Varus/ Valgus None 2-5º 6-10º >10º

Anteversion/ Recurvation

0-5º 6-10º 11-20º >20º

Rotation 0-5º 6-10º 11-20º >20º

4. Shortening 0-5mm 6-10mm 11-20mm >20 mm

5. Mobility

Knee Normal >80% >75% <75%

Ankle Normal >75% >50% <50%

Subtalar >75% >50% <50% --

6. Pain None Occasional Moderate Severe

7. Gait Normal Normal Insignificant limp

Significant limp

8. Strenuous activities Possible Limited Severely limited

Impossible

9. Radiological union Consolidated Consolidated Union Not consolidated

Keeping all these criteria in mind the final function outcome was assessed.

73

Figure-6: Instrumentation Set for Tibia Intramedullary Locking Nail BASIC STANDARD SET

• CURVED BONE AWL • I.L.GUIDE WIRE - 2.5 MM * 750 MM • SOCKET WRENCH - 10 MM • HEAD FOR INTRODUCER • CURVED JIG • CONICAL BOLT WITH LOCKING NUT, CHECK NUT & TOMY BAR - 8 -

9MM (SP) • CONICAL BOLT WITH LOCKING NUT, CHECK NUT & TOMY BAR - 10 - 13

MM (SP) • S . S . DRILL BIT - 3.2 MM - 200 MM (SP) • S . S . DRILL BIT - 4.0 MM - 200MM (SP) • I . L . DRILL SLEEVE - 3 . 2 MM • I . L . DRILL SLEEVE - 4 . 0MM • PROTECTION SLEEVE - 8 . 0MM • I. . L . DEPTH GUAGE - 4 . 5 MM • POINTER • EXTRACTOR ROD • HANDLE FOR EXTRACTOR • ROUND HAMMER • ALUMINIUM BOX WITH THREE TRAY - 18"

74

75

76

OBSERVATION AND RESULTS

This study was done in the Basaveshwar Teaching & General Hospital,

Gulbarga, 20 patients with fracture shaft of tibia were treated with closed

interlocking nailing. The results are observed here.

Table-1: Age Incidence

Age group (years) No. of Patients Percentage 11 – 20 1 5.00 21 – 30 7 35.00 31 – 40 8 40.00 41 – 50 3 15.00 51 – 60 1 5.00 61 – 70 -- -- 71 – 80 -- -- Total 20 100.00

Figure-8: Showing Age Incidence

0

1

2

3

4

5

6

7

8

No.

of

Cas

es

11 –

20

21 –

30

31 –

40

41 –

50

51 –

60

61 –

70

71 –

80

Age group (years)

77

In this study the minimum age of the patient was 18 years and the

maximum age was 60 years. Average age of the patient in the study was

34.75 years. The tibial shaft fractures were common in the age group of 31-40

years in the present study.

Table-2: Sex Incidence

Sex No. of Patients Percentage

Male 17 85.00

Female 3 15.00

Total 20 100.00

In our study, males predominate the female sex. The present study has

85% males and 15% females.

Figure-9: Sex Incidence

Male 85%

Female15%

78

Table-3: Involved Limb

Involved Limb No. of Patients Percentage

Right 15 75.00

Left 5 25.00

Both -- --

Total 20 100.00

In this study, the right tibia was affected in 75% of all patients and the

left tibia in 25% of all patients.

Figure-10: Showing Involved Limb

0

2

4

6

8

10

12

14

16

No.

of

Cas

es

Righ

t

Left

Both

Involved Limb

79

Table-4: Mode of Injury

Mode of Injury No. of Patients Percentage

Road traffic accident 17 85.00

Fall from a height 2 10.00

Assault 1 5.00

Total 20 100.00

Figure-11: Mode of Injury

0

2

4

6

8

10

12

14

16

18

No.

of

Cas

es

Road

tra

ffic

acci

dent

Fall

from

ahe

ight

Assa

ult

Mode of Injury

In this study, road traffic accidents were the most common mode of

injury causing tibial shaft fractures in 17 of all patients. They accounted for

85% of tibial fractures.

80

Table-5: Anatomical Location of the Fracture

Anatomical location of the fracture No. of Patients Percentage

Upper third 2 10.00 Upper third and middle third junction 1 5.00 Middle third 10 50.00 Middle third and lower third junction 1 5.00 Lower third 5 25.00 Upper third and middle third junction and middle and lower third junction (segmental)

1 5.00

Total 20 100.00 The commonest anatomical location of fracture was at the middle-third

of the tibia. This constituted 50% of tibial shaft fractures.

Figure-12: Anatomical location of the fracture

0

1

2

3

4

5

6

7

8

9

10

No.

of

Cas

es

Upper third Upper third andmiddle third

junct ion

M iddle third M iddle third andlower third

junct ion

Lower third Upper & middle3rd and middleand lower 3rd

junct ions

Anatomical Location of Fracture

81

Table-6: Type of Injury

Type of injury No. of Patients Percentage

Simple 15 75.00

Compound (Grade-I) 5 5.00

Total 20 100.00

In this study 15 fracture were simple (75%) and 5 fractures were

Gustillo Grade-I compound fractures (25%).

Figure-13: Type of Injury

Simple

75%

Compound (Grade-I)

25%

82

Table-7: Type of Fracture

Type of Fracture No. of Patients Percentage

Transverse 4 20.00 Oblique 7 35.00 Wedge (butterfly) 2 10.00 Spiral 1 5.00 Segmental 1 5.00 Communited 5 25.00

Total 20 100.00

In this study, oblique fractures were seen in 35% of patients, followed

by communited fractures in 25% of patients, followed by transverse in 20% of

patients. Wedge fractures were seen in 10% of patients.

Figure-14: Type of fracture

0

1

2

3

4

5

6

7

No.

of

Cas

es

Tran

sver

se

Obl

ique

Wed

ge(b

utte

rfly

)

Spira

l

Segm

enta

l

Com

mun

ited

Type of Fracture

83

Incidence of Intact Fibula

In our study, 15 cases (75%) had ipsilateral fibular fractures, 5 cases

(25%) had an intact fibula.

Associated Injuries

In our study 15 patients had fracture fibula without any neurological

deficit, which were treated conservatively.

One patient had fracture-V metatarsal (right) which was fixed with a

K-wire.

One patient had fracture distal end of radius (right) who was managed

by percutaneous K-wire fixation.

84

Table-8: Weight-bearing

Weeks Partial weight bearing No. of Patients

Full weight bearing No. of patients

0 – 4 10 0

5 – 6 5 0

7 – 12 5 15

13 – 18 0 5

19 – 24 0 0

>25 0 0

Figure-15: Weight bearing

0

2

4

6

8

10

12

14

16

0 – 4 5 – 6 7 – 12 13 – 18 19 – 24 >25

Partial Full

In our study, partial weight bearing was started at 4th week in 11

patients (55%), at 6th week in 4 patients (20%) and at 8th week in 5 patients

(25%).

85

Full weight bearing was started at 10th week in 10 patients (45%), at

12th week in 6 patients (30%) and at 14th week in 4 patients (20%).

Table-9: Fracture Union

Time taken in weeks No. of Patients Percentage

12 – 16 4 20.00

17 – 20 12 60.00

21 – 24 4 20.00

Total 20 100 In our study, majority of fractures united within 20 weeks. This is

comparable with other series. The average healing time was 19.1 weeks.

Figure-16: Fracture Union

12 – 16

20%

17 – 20

60%

21 – 24

20%

86

Table-10: Complications

Complications No. of Patients Percentage

Superficial infection 2 10.00

Proximal screw breakage 0 0.00

Distal screw breakage 0 0.00

Non-union and nail breakage 0 0.00

Anterior knee pain 2 10.00

Malunion 0 0.00

Shortening 2 10.00

Figure-17: Complications

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

No.

of

Cas

es

Superf icialinfect ion

Proximal screwbreakage

Distal screwbreakage

Non-union andnail breakage

Anterior kneepain

M alunion Shortening

Complications

87

Complications

• The infection rate was around 10% in our study, which included 2

superficial infections.

• Superficial infections healed by dressing and antibiotics.

• Anterior knee pain was seen in two patients. In one patient, nail was

abutting the patellar tendon and tibial tuberosity and this can be

relieved after removal of the nail.

• Shortening was seen in two patients. One patient had a shortening of 1

cm and the other of 1.5 cms. These were managed by heel raise of the

footwear.

88

Table-11: Functional Outcome

Functional Outcome No. of Patients Percentage

Excellent 12 60.00

Good 6 30.00

Fair 2 10.00

Poor 0 0.00

Total 20 100.00 In our study 60% patients had excellent or good functional results and

30 percent had good functional outcome, while only 10 percent had fair

functional outcome.

Figure-18: Functional Outcome

0

2

4

6

8

10

12

No.

of

Cas

es

Exce

llent

Goo

d

Fair

Poor

Type of Fracture

89

90

Figure-20

91

Figure-21

92

Figure-22

93

Figure-23

94

Figure-24

95

Figure-25

96

Figure-26

97

DISCUSSION

This study includes 20 patients who were admitted to the Orthopedics

Wards of Basaveshwar Teaching & General Hospital, Gulbarga.

This series includes various patterns of fractures, closed as well as

open injuries treated by closed method.

Age Incidence

In our study, the majority of the patients were in the age group of 3140

years. There were 8 patients in this age group in our study series. The

average of the patient in our study was 34.75 years. Tibial shaft diaphyseal

fractures were seen in the younger age group as they are the persons who are

physically active, were engaged in increased various outdoor activities and as

a result most of the injuries sustained were high-velocity injuries.

Arne Ekeland et al31 (1988) in a study series of 45 patients noted the

average age of patients to be around 35 years.

Court Brown et al33 (1990) noted the average age to be 32.4 years.

Average age was seen to be around 37 years in a study by Court Brown et al64

in 1995 in a study titled “The Epidemiology of Tibial Fractures”.

Our series with an average age of 34.75 years is comparable to the

other worker’s series, with respect to the average age of the patient in fractures

of the tibial diaphysis.

98

Sex Incidence

In our series, males predominated the females. There were 17 male

patients (85%) and 3 female patients (15%). The incidence of males is higher

because of their more outdoor activities, while women confined themselves to

the domestic activities.

Court Brown et al33 (1990) in their series noted the male incidence to

be around 81.3%, while the female incidence to be around 18.7%.

Hooper et al34 (1991) noted male incidence at 82% and female

incidence at 18%.

Our series of 85% males, the incidence is higher when compared to

above workers series, whereas 15% females in our study is lower when

compared to workers series.

Mode of Injury

In our series, we have found that majority of the tibial diaphyseal

fractures occurred due to road traffic accidents (17 patients). In the majority

of cases, they involved the patients who were the motorists, while the

remaining patients tended to be pedestrians or motor vehicle occupants.

The incidence of fracture shaft of tibia due to road traffic accidents

(85%) seemed to be higher in our series compared to Court Brown et al9

(1995) in whose series, the incidence was around 37.5%. But in this series,

99

also the commonest mode of injury was road traffic accidents followed by

sport injuries. This can be attributed to the poor road traffic sense and poor

quality of roads, leading to a higher incidence of road traffic accidents in our

country.

Lawrence B Bone et al29 (1986) reported in an earlier series a 90%

incidence of Road Traffic Accidents in tibial shaft fractures.

Hooper et al34 (1991) reported a 59% incidence in his series.

Anatomical Location of the Fracture

In our series, the anatomical location of the fracture was in the middle-

third of the shaft of tibia in 10 (50%) patients, followed by the lower third in

25% of the cases.

This is comparable to Lawrence B Bone et al29 (1986) series, where

53.5% were middle-third fractures, Hooper et al34 (1991), where 48% were

middle-third fractures and Court Brown et al64 (1995), where 44% were

middle-third fractures.

The middle-third fractures are common because of anatomical features

of more rigidity of the bone and is subcutaneous nature make it more

vulnerable to the injuring force.

100

Type of Fracture

Our series had an higher incidence of oblique fractures in 35% of

cases, transverse fractures made up 20% cases. Oblique and transverse

fractures made 55% fractures (11 patients).

This is comparable to Sankarsan Patro et al25 (1998) in whose series,

there were 59% of these fractures.

Court Brown et al64 (1995) reported 37.2% and Arne Ekeland31 (1988)

reported 42% of transverse and oblique fractures.

The fibula was fractured along with the shaft of tibia in our series in

55% of cases, this is comparable to the series of Court Brown et al64 (1995),

where the fibula was also fractured in 77.7% of the cases. The associated

fracture of the fibula, in most of the cases reflects on the high-velocity injury

pattern in our series, as most of the injuries are due to road traffic accidents.

Preoperative, Operative and Nailing Procedure

In our series, we have used intramedullary nails ranging from 8 to 10

mm in diameter and from 300 to 360 mm in length.

Unreamed closed intramedullary nailing were done in all the cases in

our series. Static locking was done in all the cases.

Schemitsh et al45 (1998) noted no difference in bone formation

between reamed and unreamed nailing.

101

Postoperatively, in our series, no complications like fat embolism,

compartment syndrome, neurological or vascular injury occurred. Superficial

infections occurred in two patients at the site of surgical incision over knee

and both the superficial infections healed by dressings and antibiotics.

In majority of our patients, active hip, knee, ankle movements and

quadriceps exercises were started on the first postoperative day in all the 20

patients. Majority of the patients were mobilized with the walker from the

third postoperative day, without bearing weight on the operated leg. Suture

removal was done in all patients on 14th day. Complete relief of pain was seen

in majority of patients in two weeks.

Follow up was done at 4th, 6th, 10th, 12th, 16th, 20th week and 6th month.

At follow-ups, clinical and radiological assessment was done regularly with

suitable follow-up advice.

Depending upon the type of fracture and stable fixation of fracture,

partial weight bearing was started. In our series, partial weight bearing was

started in the majority of patients (11) by the 4th week.

Full Weight Bearing

Full weight bearing in our series was started at 10th week in 10 patients

(50%) at 12th week in 6 patients (30%) and at 14 week in 4 patients (20%).

The appearance of bridging callus was used to assess and allow the patient full

weight bearing. The average time of full weight bearing was 9 weeks. Full

102

weight bearing has been delayed in 5 patients as there were communited

fractures.

This is comparable to Lawrence B.Bone et al29 (1986), wherein his

study weight bearing has been delayed in unstable fractures.

Eighteen patients (10%) in our series recovered and got normal knee,

ankle and subtalar joint movements.

In two patients, there was restricted mobility of knee, ankle and

subtalar joints.

Fracture Union

Fracture union was considered when patient was full weight bearing

without pain, fracture site was not tender on palpation and radiograph showed

osseous union.

In our series, majority of fractures united within 20 weeks (16 patiens).

The average time of union 19.1 weeks. This is comparable to the study done

by Lawrence B.Bone et al29 (1986) who reported average union time at 19

weeks. Court Brown et al33 (1990) reported average union time at 16.7 weeks.

Arne Ekeland et al31 (1988) reported average union time at 16 weeks.

In our series, average time of union was 19.1 weeks.

Complications

Lawrence B.Bone et al29 (1986) noted an infection rate of 6.25%.

103

Arne Ekeland et al31 (1988) noted infection rate of 4.4%.

Blachut PA et al44 (1997) noted an infection rate of 1%.

In our series, which is comparable to the above workers study series,

superficial infection rate was 10% and it healed with dressings and antibiotics.

Anterior knee pain was seen in two patients 10%. In these patients the

nail was abutting the patellar tendon and tibial tuberosity, causing anterior

knee pain and this can be relieved after removal of the nail.

Anterior knee pain can be compared to Hernigou P et al49 (2000), who

noted improper entry of nail into medullary canal, may cause anterior knee

pain.

Jarmo AK Toivannen et al50 (2002) noted anterior knee pain to be

common in tibial intramedullary nailing.

Functional Outcome

Final assessment in our series was done at 6 months using the Johner

and Wruh’s criteria28, taking into account the following objective and

subjective symptoms of gait, pain, deformity, range of motion of knee, ankle

and subtalar joints, shortening, neurovascular disturbances, ability to do

strenuous activities, radiological union and presence or absence of non-union.

Functional outcome was graded into excellent, good, fair and poor.

104

In our series, 60% (12 patients) have got excellent, 30% (6 patients)

have good, 10% (2 patients) have fair functional outcome.

Arne Ekeland et al31 (1988) reported 64.4% excellent, 28.8% good and

4.4% as fair.

105

SUMMARY

From October 2006 to March 2008, 20 patients with fractures of the

shaft of tibia were treated by closed intramedullary interlocking nailing at

Basaveshwar Teaching & General Hospital, Gulbarga.

• Majority of the patients were in the age group of 31 to 40 years.

• Average age of the patient in our series is 34.75 years.

• Males predominated the females in the ratio of 85:15.

• Right tibia was affected in 75% of the cases.

• Road traffic accidents were the main mode of injury in 85% of cases.

• 75% of the fractures were closed and 25% were open (Gustillo-I).

• Majority of fractures were located in the middle-third (50%) in 10

patients and in lower-third in 5 patients (25%).

• Transverse and oblique fractures (55%) were common.

• Fibula was fractured in 75% of cases.

• Unreamed closed intramedullary interlocking nailing were done in all

the 20 cases.

• Static locking was done in all (20) cases in our series.

• In our study, partial weight bearing was started at 4th week in 11

patients (55%), at 6th week in 4 patients (20%) and at 8th week in 5

patients (25%).

106

• Full weight bearing was started at 10th week in 10 patients (50%), at

12th week in 6 patients (30%) and at 14th week in 4 patients (20%).

• Final assessment was done after 6 months taking into account gait,

pain, deformity, movement of knee, ankle and subtalar joints, ability to

do strenuous activity, shortening and radiological union, taking into

account neurovascular disturbances.

• The average healing time was 19.1 weeks.

• There were two superficial infections and two patients with anterior

knee pain.

• Two patients had slight shortening.

• In our study 12 patients (60%) had excellent, 6 patients (30%) had

good, 2 patients (10%) had fair functional outcome.

107

CONCLUSION

• Tibial diaphyseal fractures are commonly seen in physically active

young people and are commonly seen as a result of road traffic

accidents.

• The interlocking nailing combines control of length, alignment and

rotation, preserves periosteal blood supply, some amount of endosteal

blood supply and with biological osteosynthesis, lowers the infection

and malunion.

The advantage of locking screws over the conventional methods

reduces the rate of malunion, loss of alignment, angulation and shortening

which are commonly found in a plaster cast or functional brace. The addition

of locking screws extends its indications to within 5 cm of ankle and knee

joint.

• The method of treatment employing closed intramedullary interlocking

nailing to stabilize both principal fragments on the nail, is an excellent

one for closed fractures with communition and open fractures of

Gustillo Grade-I variety.

• Patients operated with this technique can be ambulated early without

external immobilization in majority of cases, patients are allowed to

resume work early as tolerated and this procedure also reduces the

hospital stay and boosts up the morale of the patient.

108

• The method of intramedullary interlocking nailing is ideal because of

excellent (60%) and good results (30%), which is comparable to other

workers series.

• The method has a long learning curve but with the excellent results, the

advantage of rapid rehabilitation and relatively few complications

serve to recommend it for wider use.

109

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117

ANNEXURES

PROFORMA

Case No.

Name of Patient Age: Sex: IP No.:

Occupation Date of Injury:

Address Date of Admission:

Date of Surgery:

Date of Discharge:

1. Presenting complaints

Pain/ Swelling/ Deformity/ Abnormal mobility/ Loss of function

Nature of injury

• Road traffic accident

• Fall

• Industrial injury

• Farming injury

• Assault

• Fall of an object

• Sports injury

2. General examination

Nourishment Pallor

Pulse Blood pressure Temperature

Respiratory rate

118

3. Systemic examination

• CVS

• RS

• PA

• CNS and neurological status

4. Local Examination

1. Gait

2. Involved limb Present/ Absent

3. Deformity Present/ Absent

4. Swelling Present/ Absent

5. Type of fracture Closed

6. Tenderness Present/ Absent

7. Crepitus Present/ Absent

8. Abnormal mobility Present/ Absent

9. Shortening _________ cms

10. Complications Shock/ Fat

Embolism/ compartment

Syndrome

a) Associated injuries

b) Associated diseases

c) Personal habits

d) Treatment given in the casualty

* Injection – Tetanus toxoid

119

* Splinting/ Skeletal traction

5. Radiological examination: AP/ Lateral view

a) Level of the fracture and site

1. Upper 1/3rd

2. Upper and middle 1/3rd junction

3. Middle 1/3rd junction

4. Middle and lower 1/3rd

5. Lower 1/3rd

b) Type of fracture

* Unifocal (spiral/ oblique/ transverse fracture)

* Wedge (spiral wedge/ bending wedge/ communited wedge)

* Complex (spiral wedge/ segmental/ communited)

* Tscherne type – C0/ C1 / C2 / C3

* Fibular fracture – Present / Absent

6. Investigations

Hb% RBS Urine

PCV Blood urea * Albumin

TC Serum creatinine * Sugar

DC ECG in all chest levels * Microscopy

ESR Chest X-ray in PA view Stool

HIV Blood grouping & typing * Ova

HbsAg * Cyst

VDRL * Microscopy

120

7. Preoperative Planning for Surgery

1. Type of nail and size:

2. Preparation of the patient:

3. Low molecular weight heparin: Administered/ not administered

4. Education of the patient regarding surgery and outcome:

5. Consent for surgery:

8. Surgical Treatment

* Date of operation:

* Type of anesthesia:

* Approach: Vertical patellar splitting

* Nailing: Reamed/ Unreamed

* Locking of nail: Static/ Dynamic

i) Proximal i) Done (1 screw/ 2 screws) ii) Not done

ii) Distal i) Done (1 screw/ 2 screws) ii) Not done

9. Intraoperative complications

Splintering of bone/ breakage of drill bit

a) Intermediate postoperative complications:

Fat embolism/ neurological damage/ compartment syndrome/

hypotension/ vascular injury.

b) Wound infection: Superficial/ Deep

c) Suture removal done: _______ day (between 1 to 2 weeks).

d) Weight bearing: Non-weight bearing – Till 4th week.

* Partial: At 4th week/ 6th week/ 8th week/ 12th week/ 16th week

121

* Full weight bearing: 10th week/ 12th week/ 14th week/ 16th week/

20th week with/ without walking aids

10. Follow up

4th week

6th week

10th week

12th week

16th week

20th week

6 months & above

1. Pain

2. Deformity

3. Range of motion

* Knee

* Ankle

* Subtalar

4. Shortening

5. Radiological union

11. Late of Delayed Complications

• Screw breakage

• Nail bending/ breakage

• Anterior knee pain

• Infection – superficial / deep

• Malunion

• Shortening

• Non-union.

a) Secondary procedures

Dynamization

• Proximal

122

• Distal

b) Procedure done in nail bending/ screw breakage

c) Gait: Normal/ Limping (significant/ insignificant limp)

d) Functional outcome

• Excellent

• Good

• Fair

• Poor

123

KEY TO MASTER CHART

DOA................Date of admission

DOD................Date of discharge

DOHS..............Duration of hospital stay

DOI .................Date of injury

DOS................. Date of surgery

FWB................ Full weight bearing

PWB................ Partial weight bearing

RTA................. Road traffic accident

Knee AnkleSub-talar

1 Santosh 23 M 230854 Business 12.12.2006 13.12.2006 22.12.2006 31.12.2006 18 Left RTA Closed Communited Middle third Fibula segment 340 x 9 8 w 12 w 20 w -- Nil -- -- Nil -- >80% >75% >50% -- Nil -- N Consolidated -- Nil -- Good

2 Devindrappa 38 M 231608 Farmer 6 month back

23.12.2007 05.01.2007 08.02.2007 47 Right Assault Open Gr-I Oblique Middle third Fibula (united) 320 x 8 4 w 12 w 22 w -- Nil -- -- Nil -- >75% >50% <50% 1 cm Insignificant limp

Consolidated -- Nil -- Fair

3 Yellappa 60 M 231804 Retired 25.12.2006 26.12.2006 12.01.2007 25.01.2007 30 Right RTA Open Gr-I Wedge (Butterfly) Lower third --- 320 x 8 6 w 12 w 20 w -- Nil -- -- Nil -- N N N -- Nil -- N Consolidated -- Nil -- Excellent

4 Ravi 40 M 232605 Farmer 06.01.2007 06.01.2007 12.01.2007 01.02.2007 26 Right Fall from height Closed Oblique Upper third, Middle third junction

Fibula upper third and middle third junction

320 x 8 4 w 10 w 16 w -- Nil -- -- Nil -- N N N -- Nil -- N Consolidated -- Nil -- Excellent

5 Sharanbasayya 32 M 233100 Self employed

12.01.2007 13.01.2007 22.01.2007 08.02.2007 26 Right RTA Open Gr-I Communited Middle third Right 4 meta-torsal fibula, middle third

340 x 9 8 w 14 w 20 w -- Nil -- -- Nil -- N N N -- Nil -- N Consolidated Superficial infection

Good

6 Parvati 40 F 237729 House-wife 18.03.2007 18.03.2007 02.04.2007 17.04.2007 30 Right RTA Closed Segmental Upper third-Middle third and middle third-lower third junctions

Fibula middle third 300 x 9 6 w 12 w 22 w -- Nil -- -- Nil -- N N N -- Nil -- N Consolidated -- Nil -- Excellent

7 Mallikarjun 48 M 241881 Manual labour

1½ yr back 20.05.2007 24.05.2007 25.06.2007 36 Left RTA Closed Oblique Middle third Fibula segmental 320 x 9 4 w 10 w 20 w -- Nil -- -- Nil -- >75% >50% <50% 1.5 cm Insignificnt limp

Consolidated -- Nil -- Fair

8 Uma Devi 28 F 243551 House-wife 09.06.2007 10.06.2007 12.06.2007 23.06.2007 13 Right RTA Closed Transverse Middle third --- 320 x 8 4 w 10 w 20 w -- Nil -- -- Nil -- N N N -- Nil -- N Consolidated -- Nil -- Excellent

9 Mallayya 30 M 244995 Private Service

25.06.2007 25.06.2007 30.06.2007 02.07.2007 7 Right RTA Closed Transverse Middle third --- 320 x 9 4 w 10 w 16 w Anterior knee pain

-- Nil -- N N N -- Nil -- N Consolidated Anterior knee pain

Good

10 Krishna 18 M 248212 STD Shop 03.08.2007 03.08.2007 09.08.2007 24.08.2007 21 Right RTA Closed Oblique Middle third --- 340 x 9 4 w 10 w 16 w -- Nil -- -- Nil -- N N N -- Nil -- N Consolidated -- Nil -- Excellent

11 Siddappa 50 M 24910 Agriculture 01.08.07 17.08.07 16.08.07 29.08.07 13 Right Fall from height Closed Wedge (Butterfly) Middle third Fibula mid third 360 x 9 6 w 12 w 20 w -- Nil -- -- Nil -- N N N -- Nil -- N Consolidated -- Nil -- Excellent

12 Veerbhadrayya 45 M 249582 Bank Employee

2 months back

27.08.07 21.08.07 09.09.07 19 Right RTA Closed Segmental Upper third, Middle third junction

Fibula upper third and middle third junction

340x 9 6 w 12 w 22 w Anterior knee pain

-- Nil -- N N N -- Nil -- N Consolidated Occasional knee pain

Good

13 Baburao 38 M 250178 Govt Service 29.08.07 31.08.07 29.08.07 25.09.07 27 Left RTA Closed Communited Middle third and lower third junction

Fibula middle third 300 x 9 8 w 14 w 20 w -- Nil -- -- Nil -- N N N -- Nil -- N Consolidated -- Nil -- Excellent

14 Sunanda 40 F 250682 House-wife 04.09.07 07.09.07 05.09.07 22.09.07 17 Right RTA Closed Oblique Middle third Fracture distal end of radius

320 x 8 4 w 10 w 20 w -- Nil -- -- Nil -- N N N -- Nil -- N Consolidated -- Nil -- Excellent

15 Ningappa 35 M 250557 Self employed

2 months back

08.09.07 04.09.07 21.09.07 17 Right RTA Open Gr-I Transverse Upper third Fibula upper third 320 x 8 4 w 10 w 20 w -- Nil -- -- Nil -- N N N -- Nil -- N Consolidated -- Nil -- Excellent

16 Sangamesh 22 M 250479 STD Shop 02.09.07 10.09.07 02.09.07 26.09.07 24 Left RTA Closed Transverse Middle third Fibula upper third 320 x 9 4 w 10 w 16 w -- Nil -- -- Nil -- N N N -- Nil -- N Consolidated -- Nil -- Excellent

17 Mallikarjun 38 M 251260 General Secretary

14.09.07 27.09.07 14.09.07 12.10.07 28 Right RTA Closed Communited Lower third Fibula middle third 340 x 8 8 w 14 w 20 w -- Nil -- -- Nil -- >80% >75% >50% -- Nil -- N Consolidated -- Nil -- Good

18 Karthik 24 M 254767 Private Service

02.11.07 07.11.07 02.11.07 22.11.07 20 Left RTA Closed Oblique Lower third Fibula upper third 340 x 9 4 w 10 w 20 w -- Nil -- -- Nil -- N N N -- Nil -- N Consolidated -- Nil -- Excellent

19 Afsar 22 M 257384 Unemployed 09.12.07 05.01.08 09.12.07 23.02.08 76 Right RTA Open Gr-I Communited Lower third Fibula middle third 340 x 9 8 w 14 w 22 w -- Nil -- -- Nil -- N N N -- Nil -- N Consolidated Superficial infection

Good

20 Chandra 24 M 263402 Self employed

03.03.08 08.03.08 03.03.08 14.03.08 11 Right RTA Closed Oblique Lower third Fibula middle third 360 x 9 4 w 10 w 20 w -- Nil -- -- Nil -- N N N -- Nil -- N Consolidated -- Nil -- Excellent

MASTER CHART

Sl. No.

Name

Age

(Y

ears

)

Sex IP No.Occupatio

nDOI DOA DOS DOD

DO

HS

(Day

s)

Invo

lved

lim

b

Mode of InjuryType of Injury

Type of #Anatomical

Location of #Associated

injury

Nai

l Siz

e (i

n

mm

)

PW

B

FWB

Un

ion Compli-

cationsFunctional outcome

Follow up at 6 months

PainDeform

ity

Range of motionShort-ening

GaitRadiolog-ical Union