Focus On Tibial fractures

Epidemiology A review of the literature suggests that tibial diaphyseal fractures are declining in incidence in the developed world. Weiss et al1 have shown that the incidence of tibial diaphyseal fractures in Sweden declined from 18.7/105/year in 1998 to 16.1/105/year in 2004. They also found that 48% of fractures were caused by a fall from a standing height, compared with 21% of fractures which occurred as a result of a road traffic accident. This decline is supported by an analysis of the fracture database in Edinburgh over the last 20 years. Between 1988 and 1990, the incidence of tibial diaphyseal fractures was 26/105/year.2 This fell to 21.5/105/year in 20003 and in 2007/8 it was 14.3/105/year. In addition, an analysis of the cases of tibial diaphyseal fractures that occurred between 1988 and 1990 showed that 37.5% were the result of a road traffic accident, 30.9% followed a sports injury and 17.8% occurred as a result of a fall from a standing height. Twenty years later, in 2007/8, 27.4% of the fractures followed sports injuries, 20.5% occurred as a result of a road traffic accident and 32.8% followed a fall from a standing height.2 It is interesting to note that the average age of patients with tibial diaphyseal fracture rose from 37 years in 1988-1990 to 40 years in 2000 and remained at 40 years in 2007/8. An analysis of the age and gender specific curves relating to tibial diaphyseal fractures shows that these fractures have a bimodal distribution but there is a unimodal peak in young males and a unimodal peak in older females.4,5 The epidemiological changes that have been highlighted suggest that orthopaedic surgeons are facing a somewhat different spectrum of tibial diaphyseal fracture compared with twenty years ago. It seems likely that the bimodal distribution will persist, but in developed countries there will be a more elderly population presenting with fractures although the increase in sports related fractures suggests that we will continue to see a number of low energy fractures in the younger population. Obviously, despite the decline in the incidence of tibial diaphyseal fractures caused by road traffic accidents, the complex open fractures caused by high-energy injury will continue to present a challenge to orthopaedic surgeons. A review of the epidemiology of proximal and distal tibial fractures in Edinburgh has shown a slight increase in proximal tibial fractures from 13.3/105/year in 2000 to 15.6/105/year in 2007/8 with an increase from 7.9/105/year to 10.2/105/year in distal tibial fractures. The average age of patients presenting with proximal tibial fractures rose from 48.9 years in 2000 to 56.0 years in 2007/8 and the average age of patients with distal tibial fractures rose from 37.1 years to 44.6 years in the same period. It therefore seems that surgeons in the future are going to have to treat an increasing number of osteopenic or osteoporotic proximal and distal tibial fractures. This needs to be taken into account when considering the optimal treatment methods for the various tibial fractures that occur. Treatment options Until 25 years ago in many countries, tibial diaphyseal fractures were traditionally treated non-operatively. Since then surgeons have used both plates and intramedullary nails to treat these fractures, although the results of unlocked tibial nailing were not particularly good and the results of plating were very variable.6-8 External fixation methods have also been used, especially in open fractures. In 2008 Busse et al9 examined the popularity of the different methods of treatment of tibial diaphyseal fractures. They surveyed 450 Canadian Orthopaedic Trauma Surgeons and found that 87% used intramedullary nailing for closed tibial diaphyseal fractures compared with 8% who used plates and a further 2% who preferred non-operative management. In open tibial fractures 83% of surgeons used nails compared with 7% who used plates and 7% who favoured external fixation. In closed tibial fractures there was a slight preference (54%) for unreamed nailing, compared with reamed nailing, whereas in open fractures, 71% of the surgeons who used intramedullary nailing, favoured unreamed nailing. Since many of the surgeons who took part in this survey would have trained in a time when non-operative management of closed tibial fractures was the accepted method of treatment for most fractures, the results of this survey indicate that intramedullary nailing has taken over quickly from non-operative management as the preferred treatment method.