TREATMENT OF CLOSED UNSTABLE TIBIAL SHAFT FRACTURE BY A UNILATERAL UNIPLANER EXTERNAL FIXATION. IS A SECOND OPERATIVE STEP NECESSARY?

This is a prospective study was conducted in Basrah University Hospital from January 1996–January 2001. Thirty patients with thirty closed tibial shaft fractures were treated until healing with a unilateral uniplaner external fixation device that permits fracture site compression with weight bearing, after failure to maintain adequate closed reduction in plaster. There were twenty-five men and five women, age range from ten to fifty-five years with an average 29.9. Fractures were classified depending on the anatomic location, fracture configuration and extent of concomitant soft tissue injuries. Immediate bone graft was needed for two cases and delayed bone graft for two cases. All patients were permitted early partial weight bearing when their fractures showed early signs of union which took an average of eight to ten weeks and progressed to full weight bearing, with fixator dynamization in seventeen cases. Cast immobilization after removal of external fixation device was needed for all cases. Twenty-four cases showed complete healing. The time to fracture union ranged from twenty-six to thirty weeks average of twenty-eight weeks. The main complications were; four delayed union, two non-union, and twelve cases screw site infection four of which require screw changes with the other eight require antibiotic therapy and local cleaning and ten had stiffness of the ankle joint. The study highly recommends the use of external fixation as a good alternative to internal fixation for treatment of closed unstable tibial shaft fracture in a compliant, tolerant patient. It provides easy techniques to apply without the need of second surgery to remove it. Most of the complications can be managed without removing the device. Introduction ractures of the tibial diaphysis are considered to be the most common long bone injuries 1 . The standard treatment for the majority of closed tibial shaft fractures consists of closed reduction and cast immobilization, if an acceptable alignment is maintained and weight bearing is initiated early 2-6 . Most authors agreed that criteria for acceptable reduction include less than 12 mm of shortening with angulations less than 5° and rotational deformity less than 5 о 3,6,7 . However certain closed tibial shaft fractures are at great risk for non union or mal-union and merit consideration for early operative stabilization, such as fracture with excessive comminution, excessive initial displacement and F Treatment of closed unstable tibial shaft fracture Mubder A Mohammad Saeed Bas J Surg, September, 11, 2005 fractures of proximal and distal third which are difficult to immobilize 2,6,7 . Regardless of the treatment method chosen, the restoration of structural stability and maintenance of an acceptable mechanical axis for the tibial shaft are the criteria of successful treatment. Once the decision has been made to operate there are many options for treatment; Plate osteosynthesis 3 . Closed intramedullary nailing, reamed or un reamed with interlocking 8-10 , External fixation 7,11 and Ilizarov method 12,13 . Maintenance of an acceptable reduction while minimizing morbidity determines the treatment options for the patient. Maximum functional restoration is also dependent on the extent of associated soft tissue injury and the possibility of further damage from the proposed treatment which must be weighted when considering treatment options. External skeletal fixation has been applied primarily for open fractures but there are advocates for its application to closed tibial fractures 11,13,14 . External fixation is indicated in unstable closed fractures and closed fractures complicated by compartment syndrome, head injury, burns or impaired sensation 14,15 . The history of external skeletal fixation had began in the middle of the 19th century with Malgaigne 15 who developed straps on metal points and claws to stabilize displaced fractures. The external fixation was used in clinical practice to treat fractures and pseudoarthrosis as well as arthrodesis of the ankle and knee joints. The Association for the study of problems of internal fixation (AO) has also devoted itself to the problems of external skeletal fixation. The introduction of the AO tubular system had brought with it considerable improvements in external fixation device both in design stability and strength 15 . The purpose of this study is to present the results of the use of external fixation as a definite method of treatment for unstable closed tibial shaft