Tibial Shaft Fractures Caused by Indirect Violence

Abstract

A series of 182 fractures of the adult tibial shaft caused by indirect violence, i.e. torsion, axial compression or bending without direct impact, and located at the junction of the middle and distal thirds of the tibia is reported. Fall at ground level was the mode of injury in 59 per cent. The initial lateral displacement was marked or severe in 38 per cent. The treatment was conservative in 114 patients. Internal fixation was undertaken only if acceptable position of the fracture could not be attained and maintained by conservative means. Screw fixation was mainly used for longitudinal fractures, plate osteosynthesis for fractures with a butterfly fragment, and intramedullary nailing for short oblique fractures. Healing time, anatomical restoration and functional recovery were assessed. The following factors were associated with prolonged healing time: marked or severe initial lateral displacement (P < 0.01), butterfly fragment (P < 0.02), repeated closed reduction (P < 0.02) and high-energy trauma (P < 0.05). Delayed union occurred in 13.7 per cent. The overall infection rate was 5.5 per cent, infection being involved in 36 per cent of the cases with delayed union. Intramedullary nailing, the infra-isthmal location of the fracture in addition often necessitating a supplementary plaster cast, showed the lowest complication rate. With conservative treatment marked or severe initial lateral displacement predisposed (P < 0.01) to angular deformity and shortening. Refractures were seen in 7 per cent after conservative treatment.