Tibial Fractures - Lucy Dennell 27/11/2001

Papers by MM McQueen and CM Court-Brown from The Royal Infimary, Edinburgh

MMM + CMC are

- Pro reamed nails over unreamed for closed and open #’s

- Have established algorithms for the treatment of tibial non union and infection complicating tibial nailing over the years

- Have particular opinions on compartment syndrome in the context of tibial fractures regarding epidemiology, monitoring, indication for fasciotomy relationship of pressure to nailing

Author CM Court-Brown, JF Keating, MM McQueen

Title Infection after intramedullary nailing of the tibia Incidence and protocol for management

Reference JBJS Br 1992;74-B:770-4

Summary 459 patients all had primary reamed nailing over 5 year period. Infection rates closed or Gustilo I 1.8% Gustilo II 3.8 %, Gustilo III 9.5 %, (IIIa 5.5% IIIb 12.5 %) For closed + type I #s a worldwide incidence of 4% = to plating but slightly higher than ex fix. For II + III less easy to compare but lower than others published results.

Critique A retrospective review. A good paper to back up the use of reamed im nailing in open fractures. Dispels a myth of “panosseous tibial osteomyelitis”. Emphasises the importance of handling of soft tissues. See protocol

Author CM Court-Brown, JF Keating, J Christie, MM McQueen

Title Exchange intramedullary nailing its use in aseptic tibial non union

Reference JBJS Br 1995; 77-B: 407-11

Summary 33 patients over 6 years primarily Rx w GK nails. Diagnosis of aseptic non-union made on the absence of progression of radiological signs and persistence of pain at # site. Used exchange nailing to treat all Except Gustilo IIIb2 with significant bone loss (i.e. >2cm length + 50% circumference) for these open bone grafting recommended. Biggest problem was wound infection (initial 1.6% exchange 12.1 %)Av. time 1st –2 nd nailing was 21.7 and 20.1 weeks for closed and open respectively and thereafter to union was 16 and 15.2 weeks respectively

Critique Case series, smallish nos. did not go into technique for open bone grafting

Also see;

JF Keating , PA Blachut, PJ O’Brien, CM Court-Brown

Reamed nailing of Gustilo grade IIIB tibial fractures.

Royal Infirmary Edinburgh +Vancouver General Hospital JBJS Br2000;82 B:1113-6

Which has updated algorithms for the management of non union and infection in IIIB #s.

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