Amputation in Fractures of the Tibia.

Fractures of the shaft of the tibia in adults are notoriously difficult to treat and are sometimes dangerous. Poor function, non-union, skin loss and infection are the great hazards, and an awkward dilemma is posed by the fact that the treatment least likely to give one of these bad results is often the most likely to give another. Amputation, both primary and secondary, should be included among the bad results of any series since these represent complete failures. It is not uncommon to find secondary amputation referred to as though it were usually a complication of operative treatment but facts and figures are difficult to obtain. Dehne, Deffer, Hall, Brown and Johnson (1961), in a series of over 200 cases treated conservatively, had no secondary amputations. On the other hand, Holderman (1959), in a series of forty-five cases treated mostly conservatively, had three secondary amputations (6 per cent) in addition to a late primary amputation due to a tight plaster. Scott (1962), also in a predominantly conservative series, recorded two secondary amputations in 236 cases (08 per cent). The survey of Holdsworth’s 99 per cent conservative series by Ellis ( 1956), which in other respects is comprehensive, only tabulates late primary amputations (23 per cent), but two secondary amputations (05 per cent) are mentioned in footnotes and it is by no means certain that these were all. Other authors only deal with fractures at the easy end of the range. For example, Alms (1962) includes in his series for intramedullary nailing mostly the non-comminuted and the mildest compound fractures and does not concern himself with results among the cases he rejects. Yet as Ellis (1958) pointed out the easy fractures can be expected to give good results. The bad fractures are the ones that tend to do badly. The fact that the tragedy of amputation can occur with conservative treatment-even of simple fractures-is evident not only from Holderman’s series but also from two of the cases described below. The suspicion remains, however, that operative treatment of the original