Primary non-reamed locked nailing in acute open: segmental tibial shaft fractures [high-risk tibial shaft fractures]

ABSTRACT

From November, 1999, to April 2004, 23 open segmental tibial shaft fractures were treated by primary non-reamed intramedullary locked nailing after appropriate wound debridement. Most patients were active labor men, the youngest was 27 years old and the oldest was 68 years, with an average of 46 years. The mechanism of injury was high energy trauma; road traffic accidents were responsible for the majority of fractures 15[65.2%]; 9[39.1%] patients had been struck by a motor vehicle as a pedestrian, 4[17.4%] were occupants of a motor vehicle that was involved in an accident; one [4.3%] as a driver, and the other 3[13.1%] as passengers - 2[8.7%] were motorbike accidents Industrial accidents due to blunt trauma represented the remaining 8[34.8%] fractures; 6[26.1%] had a fall from a considerable height, and in two patients [8.7%] the tibiae were crushed by a heavy object. Concomitant fractures of other bones had occurred in approximately half of the cases 11[47.8%], three [13%] had in addition, head injury. For all cases, prophylactic antibiotics were started on admission. Surgery was done immediately post-injury, the average time from injury-to-surgery was 4 hours. Delayed nailing after primary debridement was performed between 3-and-8 days in 5 [21.7%] fractures. No post-operative plaster was needed. Additional bone grafting operation was done in 3 [13%] cases, and pedicle muscle flap to cover the exposed bone in another 3 [13%]. Secondary procedures; plastic reconstructive surgery including delayed wound coverage, bone-marrow injection, fibular osteotomy, Illizaroy application, and nail exchange using 1-2 mm larger diameter nail were done in 9[39.1%] patients. Dynamization of the static locked nailing was needed after 3-to-6 months in 11[47.8%] cases to enhance consolidation and corticalization of the formed callus. After dynamization shortening up to 2 cm was observed in 7[30.4%] patients, 4 of the 7, in addition, developed varus and external rotation malalignment. These deformities did not show further change or progression in the course of follow-up. The patients were allowed partial weight-bearing with crutches as tolerated as soon as they were comfortable and as the other injuries had allowed Patients were evaluated clinically - and radiologically until healing of the fractures. Most of the patients 19[82.6%] achieved clinical union in 9-to- 11 weeks after nailing, however, osseous union had occurred in less than 4 months in 5[21.7%] fractures, and between 4-to-8 months in 14[60.9%]. Only 4[17.4%] fractures were not united after 8 months, that needed further surgical intervention to achieve union