Epidemiology of tibial shaft fractures

Estudo epidemiológico das fraturas diafisárias de tíbia

Epidemiology of tibial shaft fractures

Estudo epidemiológico das fraturas diafisárias de tíbia

Marco Aurélio Sertório Grecco^I; Idyllio do Prado Junior^II; Murilo Antonio Rocha^III; José Wagner de Barros^IV

^IDoctor

^IIChairman (in memorian)

^IIIAdjunct PhD Professor

^IVDepartment Head and Chairman

^{Address for correspondence}

SUMMARY

In this work an epidemiological analysis on tibial shaft fractures was performed. During four years, our service treated 179 fractures, 132 in male, 47 in female, aged 14 to 83 years. The 21 to 30-year-old patiens were the more injured. Of these, 120 were open and 59 close fractures of which prevailing cause was road traffic accident. The study based on patients promptuaries analyses and radiographs. The fractures occurred 97 times in the middle third (54.18%); 102 times (56.98%) presented simple fragments, and 57 (31.38%) oblique lines. We treated close and open fractures, respectively, 48 and 38 cases with plaster cast immobilization; 3 and 67 with external fixation after plaster cast immobilization; 5 and 12 with osteosynthesis by means of plate and screws, and 2 and 3 with external fixation only. In both close and open fractures, respectively, 7 and 20 cases of pseudarthrosis and 1 and 11 of infections have occurred. With the data obtained we verified an actual validity of the epidemiological studies as a contribution for better identifying lesions features and their treatment and complications. This allows proceedings and apprenticeship refinement.

Key words: Tibial fracture; an epidemiological study on tibial fracture; tibial shaft fracture.

RESUMO

Foram avaliados prontuários e radiografias de 179 pacientes com fratura de tíbia, sendo 120 expostas e 59 fechadas atendidos durante 4 anos em nosso Serviço. Dos pacientes, 132 eram do sexo masculino e 47 do sexo feminino, com idade entre 14 e 83 anos. Em 97 (54,18%) pacientes, as fraturas ocorreram no terço médio. Cento e dois (56,8%) pacientes apresentavam fragmento simples e 57 (31,38%) tinham traços oblíquos. O tratamento com imobilização gessada foi realizado em 48 casos com fraturas fechadas e 38 com exposta, usando-se fixador externo seqüencial durante dias e em seguida imobilização gessada 3 e 67, com osteossíntese através de placa e parafuso 5 e 12 e, exclusivamente, com fixador externo 2 e 3, respectivamente. Nas fraturas fechadas e expostas ocorreram 7 e 20 pseudartrose e 1 e 11 infecções.

Constatamos com os dados obtidos, a validade dos estudos epidemiológicos, como contribuição para identificar melhor as características das lesões, tratamento e complicações e possibilitar o aprimoramento de condutas e aprendizado.

Descritores: Fratura de tíbia; estudo epidemiológico da fratura de tíbia; fratura da diáfise da tíbia.

INTRODUCTION

Epidemiological studies highly contribute for clarifying features of certain traumato-orthopedic pathologies, leading to a better knowledge, basically helping in prevention and treatment.

Specifically, in fractures of leg bones, the authors made an epidemiological analysis of tibial shaft fractures in inpatient⁽⁴⁾, tibial shaft fractures without displacement, that underwent non surgical treatment⁽¹⁰⁾, tibial shaft fractures⁽²⁾ using A.O. recommended ratings⁽⁹⁾ in regard to morphology(6) and, skin status and bone exposition⁽⁷⁾.

Aiming the same objective we performed in the city of Uberaba (Minas Gerais, Brazil) an epidemiological study of such tibial shaft fractures, evaluating them in order to specify these injuries among us.

MATERIAL AND METHODS

In order to evaluate tibial shaft fractures we analyzed files and respective radiographs from 179 patients admitted to our service from June/94 to June/98. From these, 132 were male and 47 female, and the ages ranged from 14 to 83 year old (average 32 years), being 98 of the fractures at the right side and 81 at the left side (Figures 1, 2, 3).

Were evaluated shaft extra-articular fractures located 5 cm below the knee and above the ankle joints⁽⁹⁾.

Regarding location, were identified those from the upper, medium and lower thirds and in regard of the direction of fracture lines as transverse, oblique, spiral, in "butterfly's wing" (wedges) and multiple.

Regarding the number of fragments, fractures were rated as simple, double, segmental and comminuted⁽⁸⁾.

In morphologic terms were divided according to A.O.'s⁽⁹⁾ method in A1 (spiral), A2 (oblique), A3 (transverse), B1 (spiral wedge), B2 (flexion wedge), B3 (fragmented wedge), C1 (spiral comminuted), C2 (segmental) and C3 (compressed).

In regard of etiology, we identified those caused by car accident, fall from high, motorcycle accident, overrun, bicycle accident, and others (horse fall, aggression, sportive trauma, animal kick, gun explosion).

For open fractures we used the GUSTILO's^(6,7) method: Grade I with a minimal injury of soft tissues (less than 1 cm); Grade II, mild injury of soft tissues (injury between 1 and 10 cm); Grade IIIA, severe injury of soft tissues (injury larger than 10 cm); Grade IIIB, severe injury of soft tissues with skin loss (injury larger than 10 cm) and Grade IIIC, with large skin loss plus vascular and/or nervous injury.

Treatment performed was evaluated according to the fractures being open or closed with : 1) plaster cast immobilization; 2) osteosynthesis with plate and screws plus plaster cast immobilization; 3) external fixation sequenced days after plaster cast immobilization; 4) just external fixation.

Regarding evolution, were evaluated time for bone healing, treatments performed and their relationship to occurring complications.

RESULTS

Different aspects of the 179 tibial shaft fractures as location, extension, fragments, line and morphology according to A.O. method can be found in (Tables 1, 2, 3, 4 and 5).

The most frequent causes of these fractures were motorcycle accidents (35.75%), overrun (28.50%), car accident (17.32%), bicycle accidents (4.47%), fall from high (2.23%) and others (11.13%) (Table 6).

Open fractures (Grade I) happened in 67.03%. Details of other grades are in (Table 7).

Regarding treatment of closed fractures, plaster cast immobilization was performed in 48 fractures; osteosynthesis with plate and screws in 5; external fixation sequenced days after plaster cast immobilization in 4 and, exclusively external fixation in 2 (Table 8).

Regarding open fractures, 38 underwent plaster cast immobilization, 67 external fixation sequenced days after plaster cast immobilization, 12 osteosynthesis with plate and screws and plaster cast immobilization and 3 external fixation (Table 9).

Time to bone healing for different treatments for closed and open fractures are displayed in (Tables 10 and 11).

In (Table 12) are found complications (infection and pseudarthrosis) for closed or open fractures.

Infections were observed in 12 cases, 7 from open fractures, one from closed fracture treated with osteosynthesis, and the other 4 (open fractures) treated with external fixation sequenced in days after with plaster cast immobilization and were 5.97% of those who were treated (Table 13).

Were observed 27 (15.09%) pseudarthrosis, in 7 cases of closed fractures treated with reduction and plaster cast immobilization, open reduction and plaster cast immobilization in 2 cases; with external fixation sequenced in days, after with plaster cast immobilization, in 17 (open) and with external fixation in one, open (Table 14).

DISCUSSION

Tibial shaft fractures were epidemiologically evaluated in patients admitted to our service in a period of four years. Several aspects were evaluated aiming characterize these injuries among us.

Were evaluated data related to the several kinds of treatment we used and the most common complications related to them. These information are useful to identify some failures that may be taking place. We studied 179 tibial shaft fractures in 132 men and 47 women, being the predominance of males similar to the findings of Xavier⁽¹¹⁾ in 27 tibial shaft fractures evaluated in Ribeirão Preto - SP, with no difference among the sides when evaluating men and women. People from 21 to 30 years old were the most affected in our sample, and the range was from 14 to 83 years old. The same author⁽¹¹⁾ reports that 50% of his cases were among 5 and 25 years old; however Nicoll⁽¹⁰⁾ had a larger incidence among 18 and 44 years old, similarly to our findings, when incidence by decade is evaluated.

Works epidemiologically analyzing tibial shaft fractures with larger samples^(2,3,4,10) did not detail the above aspects.

In regard of criteria used in choosing analyzed patients, we had some difficulties in comparing our patients to literature. Our study and those from other authors^(2,4) were performed only in inpatients. Others did it generically⁽¹¹⁾ and in outpatients⁽¹⁰⁾ with non displaced and non surgical fractures. There were discrepancies in regard to fractures classification, the criteria we used and the used by other authors^(2,6,7,8,9) as we adopted more recent classifications⁽⁹⁾.

Our results show that in 77% the most frequent causes of tibial shaft fractures were accidents linked to traffic (motorcycle, automobile, bicycle and overrun). Court-Brown et alli⁽²⁾ found as well a higher incidence (37.5%) of those causes, however in at inferior rates than ours.

This difference is related to the patients evaluated. We analyzed inpatients, that is, those of higher severity, as the above paper analyzed also outpatients. Probably, behavior of patients from our country in relation to traffic is different from the other one⁽²⁾. We believe that the social, economic and cultural profile of the different groups of patients as well influenced the causes. Perhaps for this, we had a large incidence (67%) of open fractures while Court-Brown et alli⁽²⁾ only 23.5%. We noticed that fractures of high energy (open) were more common among us due to a higher incidence of overruns in our country.

The treatments we performed, such as plaster cast immobilization, external fixation sequenced days after by plaster cast immobilization, osteosynthesis with plate and screws and external fixation alone were partially different from those in foreigner literature. Nicoll(10) treated his fractures with and without traction. Ellis⁽⁴⁾ with immobilization, continuous traction in heel, and osteosynthesis with screws, and Edward⁽³⁾ with plaster cast immobilization, closed reduction plus internal fixation (with plate, with or without binding, interlock nailing, the last plus binding, and others), open reduction plus internal fixation and open reduction without internal fixation. In regard to those procedures we distinguish for the use of external fixation, that is the most recent option, and by the absence of continuous traction.

Still in regard to treatment, in regard of complications the incompleteness of the data made difficult to compare. Nevertheless, we observed that in regard of infections occurring in open fractures there was little discrepancy (10%) between our cases and those 11.86% found by Edward⁽³⁾ even being our treatment based on external fixation (54.17%) and his in osteosynthesis (57.62%). Hospital conditions and preparedness of rescue teams only recently implanted among us by the time of the study performed by the author⁽³⁾, in 1965, did not allow a better comparison.

Regarding time for fracture healing, data vary according to the different treatments and to if the fracture was open or closed. The reasons for this difference are in the files, which occasionally had missing data. This avoids us to perform comparisons, since they could be incorrect. Regarding pseudarthrosis we hadn't this difficulty and could clearly identify their occurrence. We had 7 (11.86%) cases in closed and 20 (16.67%) in open fractures. However controversy was found in our own service when 40 patients with closed shaft fracture of the tibia had healing in 39 patients with 20 weeks follow-up in conservative classical treatment⁽⁵⁾. This result was probably obtained due to it was a prospective study with outpatient follow-up by the same doctor in patients initially seen as inpatient or outpatient. This way in our study 56.99% of the closed fractures were type A while in the other study⁽⁵⁾ 77.5% of the fractures were type A, that is, a group of patients with a less complex injury, showing a discrepancy when we compare our studies to those⁽⁵⁾ where it was found 2.5% of pseudarthrosis.

Nicoll⁽¹⁰⁾ reported a time for healing of 110.6 days and 5% of pseudarthrosis, and used treatments with and without traction, what lead to a lesser trend to this complication, unless by mistake when performing traction. On the other hand, Ellis⁽⁴⁾ doesn't mention his mean time to healing, and reports 13.3% of pseudarthrosis. If he did not exclude from his analysis, from the 112 cases treated with heel traction the 18 cases that had diastases and the nine with osteosynthesis, this incidence would be probably higher.

With these reported exclusions, and for not having correlations between them and the performed treatments, the series become different and not comparable. Additionally, he does not separate closed from open fractures. Court-Brown et alli⁽²⁾ and Edward⁽³⁾ give no information in this regard.

From this, we conclude that tibial shaft fractures had a higher incidence in males in the age range of 21 to 30 years; the most frequent causes were traffic accidents (motorcycle - 35.75%, overruns - 28.50%, automobile - 17.32% and bicycle - 4.47%); regarding location they occurred more frequently at the medium third (54.18%), were smaller than one third of the shaft (83.24%), simple (56.98%) and, according to their line were similar to the oblique (A2), transverse and multiple; open fractures prevailed in 120 cases (67.03%), with predominance of Grade I (38.34%).

From these data we could confirm the validity of epidemiological studies in contributing to better identifying characteristics of the injuries and their respective treatments and complications. This allowed us to improve our treatments and apprenticeship.

Trabalho recebido em 02/05/2002. Aprovado em 28/06/2002

Work performed at Departamento de Ortopedia e Traumatologia from Hospital Escola

da Faculdade de Medicina do Triângulo Mineiro - Uberaba - MG

References

• 1. Bengnér, U., Ekbom, T., Johnello, O. & Nilsson Bo E. Incidence of femoral and tibial shaft fractures. Acta Orthop. Scand. 61(3):251-254, 1990.
• 2. CourtBrown, C.M. & McBirnie J. The epidemiology of tibial fractures. J. Bone Joint Surg. (Br)77:417-421, 1995.
• 3. Edwards, P. Fracture of the shaft of the tibia: 492 consecutive cases in adults. Acta Orthop. Scand. suppl. 76, 1965.
• 4. Ellis, M. The speed of healing after fracture of tibial shaft. J. Bone Joint Surg. (Br)40:42-46, 1958.
• 5. Fernandes, C., Oliveira D., Barros, JW. Tratamento conservador das fraturas fechadas diafisárias da tíbia. Revista Brasileira de Ortopedia, São Paulo, v.32, p.401-404, 1997.
• 6. Gustilo, R.B. & Anderson J.T. Prevention of infection in the treatment of one thousand and twenty five open fractures of long bones: retrospective and prospective analyses. J. Bone Joint Surg. (Am)58:453-458, 1976.
• 7. Gustilo, R.B., Mendoza R.M. & Willians D.N. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J. Trauma 24:742-746, 1984.
• 8. Hebert, S., Xavier R. et al. Ortopedia e traumatologia: princípios e práticas. 1 ed. Porto Alegre: Artes Médicas, 360 pp., 1995.
• 9. Müller, M.E., Nazarian S., Koch P. & Schatzker J. The comprehensive classification of fractures of long bones. Berlin: SpringerVerlag, 1990.
• 10. Nicoll, E. A. Fractures of the tibial shaft. A survey of 705 cases. J. Bone Joint Surg. (Br) 46:373-387, 1964.
• 11. Xavier, C.A.M. Estudo da incidência de fraturas no município de Ribeirão Preto. Ribeirão Preto: Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, 1970.108 pp. (Dissertação, concurso à Livre Docência do Departamento de Ortopedia).

Address for correspondence

R. Getúlio Guaritá S/N

^o, Bairro Abadia

CEP 38025-440 Uberaba, MG

Publication Dates

• Publication in this collection
  25 Feb 2003
• Date of issue
  Dec 2002

History

• Accepted
  28 June 2002
• Received
  02 May 2002