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Treatment of open fracture of tibial shaft comparison of external fixation versus intramedulary nailing as the primary procedure

Pankaj Kumar, MBBS MS (ortho.)*,  Shobha S Arora**, Girish kumar Singh#

* Senior Resident, Department of Orthopedics,
   B P Koirala Institute of health science, Dharan , Nepal

**Reader, Department of orthopaedics,
   UCMS, Delhi

#Prof and HOD,Department of Orthopaedics,
  BPKIHS,,Dharan ,Nepal

Address for Correspondence

Dr. Pankaj kumar
C/o Ramnandan MandalCampus chowk-4, Janakpurdham,(Nepal)                    



Objective- The purpose of this study is to compare the result of intramedularyKuntscher’s nailing with that of external fixation in the primary management of theOpen fracture of the tibial shaft.
Design- Quasi-Experimental study.
Setting-A tertiary care hospital, Dharan, Nepal
Patients-Thirty Grade 3B tibia-fibula shaft fracture, age 30.9±12.7 years were primarily Reduced and fixed by AO type uni or biplanar external fixator (20 cases) and Kuntschers IM nail (10 cases). Intra articular fracture, open epiphysis fractures and comminuted fractures were excluded. Main outcome measure- 1.Time taken for union, 2.Malunion, 3.Number of operations, 4.ROM, 5 Deep infection, 6.Non union
Result-Time taken for union was more with IM nailing (31.33±7.66 weeks) than External Fixator (26.15±5.62), p>0.05.. Odds of non-union 0.75 times with external Fixator as compared to IM nailing but the 95% CI 0.27 – 2.06 making the association Statistically insignificant at p = 0.891. Sample size was too small for comparison of malunion and deep infection. Odds of residual deformity were similar in the two groups but greater numbers of surgeries were needed in the external fixator group.

Keywords: compound fracture tibia, 3B,External fixation, IM (K-nail) nailing

J.Orthopaedics 2004;1(3)e3


High velocity trauma is the cause of maximum number of fatality in the younger age group worldwide. The implication of losing a young active member of the population is obvious in terms of personal, social and economic losses to the family as well as the nation. In the field of trauma surgery open fractures of the leg remain the injuries with a higher complication rate. Bone and soft tissue injuries need aggressive yet careful treatment to avoid further damage that results in uncomplicated healing. Due to its location, structural anatomy and sparse anterior soft tissue coverage the tibia is particularly prone to exposure and ischaemia due to injury. The optimum treatment for open fractures of the tibia remains controversial 1. Treatment options include wound debridement, reduction and immobilization with cast (Winnette Orr), open reduction and plate fixation, external fixation and intramedullary nailing. External fixation of open fracture with severe soft tissues injury has been standardized during the 1980s 2. More recently closed undreamed nailing of open fracture of tibia has become popular. Tibia nailing has been shown to be a reasonable treatment option to external fixation in tibia 16

Shaft fractures with severe soft tissue damage 3, 4. The process of external fixation has many complications as pin tract infection, aseptic non-union, re-fracture and may need bone grafting but has been said to have the advantage of low infection rate. Intramedullary nailing specially reamed nailing in open tibia fracture is said to have a high rate of septic non-union. Kuntscher’s intramedullary nailing has been used for fixation of a variety of fracture including those of the tibia. Although this device does not have the advantage of locking, it’s place in the armamentarium of fixation of the tibia fracture is undisputed specially because its allows vertical compression and is the most economic options amongst all the intramedullary implants. The purpose of this study is to compare the result of intramedullary Kuntscher’s nailing with that of external fixation in the primary management of the fracture of the tibial shaft. 


Thirty cases of tibia-fibula shaft fracture with soft tissue injury of Grade 3B between age of 16- 62 years (30.9±12.7) treated at BPKIHS, Dharan Nepal during march 2001 to march 2002 were studied. The two modalities of primary fixation compared were AO type uni or biplanar external fixator (20 cases) and Kuntschers straight unlocked intramedullary nailing (10 cases). INCLUSION CRITERIA –Patients in whom the fracture configuration was amenable to fixation with intramedullary nailing by virtue of having intact medullary cavity of sufficient length were alternatively treated with k-nailing or external fixator. EXCLUSION CRITERIA- Fracture extending into the articular surfaces of either end of the tibia. Initial resuscitation, splint age and primary care for the wound was provided in the emergency room. Any bone fragments that were protruding out were covered with sterile dressing. The patients were then taken to the operating room and treated by pulsed lavage and debridement of the wound and fixation of the fracture according to criteria already mentioned. Every attempt was made to cover the exposed part of tibia with soft tissue, however flap coverage was not needed in any cases. The configuration of the external fixator used was an either a delta frame or unilateral uni axial frame. All patients were made to stand with support after 48 hours and toe touching was permitted as per the stability of the fixation diagnosed radio graphically. Partial weight bearing with support was started within 2 weeks of fixation. Wounds were inspected at the interval of 48-72 hours and repeat debridement was done whenever required. Split thickness grafting was performed within 3 weeks of primary surgery. Clinical and radiological feature assessed the progress of bony union at 6 weeks interval till union was sound. Radiological criteria for union were same for both the groups i.e. good evidence of bridging periosteal and endosteal callus formation as seen by the obliteration of the fracture line. The clinical assessment of the union was mainly based on complete absence of pain and tenderness at the fracture site. Satisfactory wound healing and good progress of radiological union were taken as the criteria for removal of the fixator and application of a patellar tendon-bearing cast. As soon as the wound healed in the nailing group, a patellar tendon-bearing cast was applied, gradual full weight bearing was permitted, and support discarded. The cast continued till union and was changed every 6 weeks with clinico-radiological assessment. Active physiotherapy for regaining ankle and knee mobility were instituted till the range of movement was satisfactory. Complications were treated. The following 6 criteria were used to compare the 2 method of treatment

1. Time taken for union measured from day of treatment to day full clinico-radiological Union assessed.

2. Malunion as defined as varus or valgus alignment of 5or more, posterior Angulations 10°or more. Shortening was considered as malunion if it was of >2 cm as compared with the contra lateral leg.

3. Number of operations (all procedure that necessitated general or spinal anesthesia and were directly related to treatment of the tibial fracture were counted as operations).

4.Final range of motion of the knee and ankle as compared to the opposite side.

5 Presence of deep infection (exogenous osreomyelitis)



External fixator was better on Union time, deep infection rate and non-union rate. IM nailing was better on malunion rate, chance of shortening and number of surgeries needed.( Table 1 ) Multiple surgeries including repeat debridement, split thickness skin grafting, bone grafting and bone marrow injection were required in both groups. 1 patient in the IM nailing group developed preoperative compartment syndrome due to the original injury and required fasciotomy followed by skin grafting. There was one valgus deformity at the distal 1/3rd of the leg in fixator group. One cases of IM nailing group develop septic non – union, which is treated with Ilizarov distraction osteogenesis method. The chance of non union in the group were nearly 0.75 times with external fixator as compared to IM nailing, however, since the sample size was small the association did not reach statistical significance.(Table2)


Open fractures of tibia; commonly a consequence of high velocity road traffic accident, affects young males causing considerable morbidity. Time taken for union was different in both the groups means 31.33±7.66(IM Nailing) means 26.1538±5.625(external fixator) p>0.05 Odds of non union were 0.75 times with external fixator as compared to IM nailing but the 95% CI of 0.27-2.06 making the association statistically insignificant at p=0.891(table2). Sample size did not allow comparison of complication rate like malunion and deep infection. No evidence of greater residual deformity at ankle and knee. Greater number of surgery required in the external fixator groups.  


Table –1
Comparing IM nailing with external fixator



IM Nailing (10 cases)

Ext. Fixation (20 cases)

Average time to union





10°(1 case)



2 cm 1(cases)

No. of surgery

60%-1, 25%-3

45%-1, 25%-3, 20%-2, 10%-3







Deep infection

1 case (osreomyelitis)



4 cases (40%)

6 cases (30%)



Comparing risk 0f non –union in the two group









IM nail








Relative Risk =0.75,95%CI0.27<RR<2.06,P=0.891


1 Holbrook J.L., Swontkowski M.F., Sanders R: Treatment of open fractures of the tibial shaft Enders nailing Vs external fixation. J. Bone joint surgery .vol 71-A.No 8, September 1989 90

2 Vidal J.: External fixation, yesterday, today and tomorrow: Clin. Ortho. Rel. Res; 180: 7, 1983.  

3 Henley B, Mayo;Benirschke S.: Prospective  unreamed interlocking nails and half –pin external fixator for group II or III open tibial fractures : Preliminary results: Presented at the annual meeting of the orthopaedic trauma association; Philadelphia; PA ; Oct21, 1989.

4 Kimmel R.B.: Results of treatment using the Hoffman external fixator for fractures of the Tibial Diaphysis: J. Trauma; 22: 960-965, 1982 21.

5 Schandelmaier Krettek C., Rudoff J., Tscherne H.: Outcome of tibial shaft fracture with severe soft tissue injury treated by unreamed nailing Vs external fixation. The Journal of trauma: injury, infection and critical care; Vol 39, No. 4, 1995. 3


 This is a peer reviewed paper 

Please cite as :
Pankaj Kumar: Treatment of open fracture of tibial shaft comparison of external fixation versus intramedulary nailing as the primary procedure
J.Orthopaedics 2004;1(3)e3





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