Functional treatment of closed segmental fractures of the tibia.

Investigation conducted at the University of Miami and University of Southern California, USA.
Acta chirurgiae orthopaedicae et traumatologiae Cechoslovaca (Impact Factor: 0.42). 02/2008; 75(5):325-31.
Source: PubMed

ABSTRACT PURPOSE OF THE STUDY Segmental tibial fractures are commonly believed to be more difficult to manage, requiring surgical treatment. Our experience with forty-eight segmental tibial fractures suggests that these fractures, if closed and with shortening of an acceptable initial degree and a corrected deformity, may be successfully treated with functional braces. MATERIAL AND METHODS Forty-eight closed segmental fractures of the tibia that had initial shortening .12 mm and angular deformity manually corrected to .7 degrees were stabilized in an above-the-knee cast for a median time of 33 days and a mode of 15 days. They were subsequently stabilized in a functional brace that allowed unencumbered motion of all joints. All other segmental fractures outside the established parameters were managed by other methods. RESULTS All fractures healed at a median time of 15.3 weeks. The final shortening was 4.7 millimeters with a mode of 12 millimeters. The maximum shortening was 14 millimeters. Fractures healed with a medial-lateral (M.L) angular deformities ranging zero to 19 degrees, a median of 5.9 degrees and a mode of 3.4 degrees. CONCLUSION The relatively early introduction of weight bearing and the freedom of motion of all joints that the brace permits seem to result in motion at the fracture site, which in turn enhances osteogenesis. As we have previously documented, the initial shortening that closed tibial fractures experience does not increase with the physiological use of the extremity. The final shortening and angulation observed in most of the fractures should not be considered complications, simply inconsequential deviations from the normal. The same should apply to closed segmental fractures.

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    ABSTRACT: BACKGROUND: Segmental tibial fractures are considered to be a special injury type associated with high complication rates. However, it is unclear whether healing of these fractures truly differs from that of nonsegmental fractures. QUESTIONS/PURPOSES: We therefore asked (1) does the time to union in segmental tibial fractures differ from that of nonsegmental fractures; and (2) does the complication rate of segmental fractures differ from that of nonsegmental fractures? METHODS: We retrospectively studied 30 patients with segmental tibial fractures treated at a Level I trauma center from January 2000 to December 2008 and compared healing and complications with a matched control group of 30 nonsegmental tibial fractures. In followup we determined time to union, delayed and nonunion, and overall complication rates. Patients were followed at least until union was attained. The minimum followup was 5 months (median, 15 months; range, 5-54 months). RESULTS: Median time to union was 34 weeks (range, 12-122 weeks). Segmental fractures took longer to heal than nonsegmental fractures (median, 34 weeks; range, 12-122 weeks and median, 24 weeks; range, 11-39 weeks, respectively). The overall rate of complications was higher in segmental fractures as was the necessity for reoperation to attain healing. CONCLUSIONS: Healing of segmental tibial fractures is characterized by substantially more complications and longer healing times than nonsegmental fractures and should be considered as a special type of injury. We believe these should be treated in specialized trauma centers. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
    Clinical Orthopaedics and Related Research 12/2012; 471(9). DOI:10.1007/s11999-012-2739-z · 2.88 Impact Factor
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    ABSTRACT: Segmental fractures represent the interruption of bone integrity at two or more levels. In these fractures, a wide zone of injury (damage of all structures of the lower leg) creates very unsuitable biological conditions for healing of the fracture. Because of the damage of both intramedullary and periostal vascularization, segmental fractures are predisposed to slow healing and development of pseudoarthrosis. The aim of the paper was to present the results of treatment of patients with clo-sed segmental tibial fractures treated by external fixation. Within the period between January 1, 1998 and June 31, 2012 in the Clinical Cen-ter Niš, 26 patients with closed segmental fractures of the tibia were treated. The asse-ssment of outcomes of treatment of closed segmental tibial fractures by external fixa-tion was performed on a series of 24 patients. The mean age was 43.57 years. All the patients were treated by Mitković unilateral external fixator produced by "Trafix" firm. Fracture healing occurred in 20 (83.33%) patients; four (16.67%) patients repor-ted significant complications in the course of treatment that required further surgical treatment. By applying the method of external fixation in the treatment of closed segmental tibial fractures, reposition of fragments is achieved through a small incision, with pins of exteranal fixator placed outside the fracture zone to prevent further damage of intra-medullary and periosteal bone vascularisation, which is very important for fracture hea-ling.
    Acta Facultatis Medicae Naissensis 01/2013; 30(1):37-44. DOI:10.2478/v10283-012-0034-2
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    ABSTRACT: We report on the use of the Ilizarov method to treat 40 consecutive fractures of the tibial shaft (35 AO 42C fractures and five AO 42B3 fractures) in adults. There were 28 men and 12 women with a mean age of 43 years (19 to 81). The series included 19 open fractures (six Gustilo grade 3A and 13 grade 3B) and 21 closed injuries. The mean time from injury to application of definitive Ilizarov frame was eight days (0 to 35) with 36 fractures successfully uniting without the need for any bone-stimulating procedure. The four remaining patients with nonunion healed with a second frame. There were no amputations and no deep infections. None required intervention for malunion. The total time to healing was calculated from date of injury to removal of the frame, with a median of 166 days (mean 187, (87 to 370)). Minor complications included snapped wires in two patients and minor pin-site infections treated with oral antibiotics in nine patients (23%). Clinical scores were available for 32 of the 40 patients at a median of 55 months (mean 62, (26 to 99)) post-injury, with 'good' Olerud and Molander ankle scores (median 80, mean 75, (10 to 100)), 'excellent' Lysholm knee scores (median 97, mean 88, (29 to 100)), a median Tegner activity score of 4 (mean 4, (0 to 9)) (comparable to 'moderately heavy labour / cycling and jogging') and Short Form-12 scores that exceeded the mean of the population as a whole (median physical component score 55 (mean 51, (20 to 64)), median mental component score 57 (mean 53, (21 to 62)). In conclusion, the Ilizarov method is a safe and reliable way of treating complex tibial shaft fractures with a high rate of primary union.
    The Bone & Joint Journal 12/2012; 94(12):1678-83. DOI:10.1302/0301-620X.94B12.29266 · 2.80 Impact Factor

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