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 Changing Trends In The Pattern Of Tibial Fractures In Nigeria: A Review  Of 70 Cases

Adeleke Olusegun Ifesanya* ,Temitope Oluwagbenga Alonge,Samuel Olusegun Ogunlade,Ajibade B Omololu,Timothy Eyo Nottidge,Raphael Omotayo Ayorinde

* Consultant Orthopaedic Surgeon
Department of Orthopaedics & Trauma, University of Uyo Teaching Hospital, Uyo. Nigeria.

Address for Correspondence:  
Adeleke Olusegun Ifesanya
Department of Orthopaedics & Trauma,
University College Hospital (UCH), Ibadan. Nigeria.


Background: Studies in our environment show that fractures of the tibia occur mainly following road traffic crashes. The increasing volume of motor vehicular traffic and the emergence of commercial motorcycling (popularly called ‘okada’) suggest a change in the pattern of road traffic injuries and subsequent fractures.

Study design: A retrospective review of records of patients with tibial fractures seen at the Accident and Emergency (A/E) Department of the University College Hospital (UCH), Ibadan between January and December 2002 was carried out. The aim was to re-evaluate the aetiology, severity and mechanisms of injuries responsible for tibia fractures.

Results: A total of 70 tibial fractures in 68 patients with a mean age of 35.5±18.8 years (peak 31-40 years) were reviewed. The causes of injury were motor vehicular crashes (35%), pedestrian injuries (29%), falls (16%) and motorcycle crashes (10%). The tibial shaft was the commonest site of fracture (66% of cases). Delay before presentation averaged 10.7 hours. Forty eight percent of the fractures were open, 61% of these being of the severe, high energy type. Most (87%) were managed nonoperatively. Mean time to union was 18.1 weeks and the complications included wound infection (2), delayed union (2), malunion (2), non-union (1), and chronic osteomyelitis (1).

Conclusion: There is a change in the causation of tibial fractures most being due to motor vehicular and pedestrian injuries. An issue for concern is the increasing incidence of open fractures which are often of the more severe varieties in this study. Efforts should be geared towards curtailing the menace of road crashes as well as the provision of standard but affordable health care for victims of road traffic crashes.

J.Orthopaedics 2008;5(2)e4

Tibia; fracture; road crashes; injuries; Nigeria; traffic injuries

The tibia is the commonest long bone involved in fractures and is also the commonest site of open fractures of long bones1,2. The weight-bearing function and the location of the tibia make injuries to this bone particularly important. Few epidemiological studies have been undertaken of tibial fractures in our environment. In previous reports from Nigeria, the magnitude of the energy causing the injury as evidenced by fracture comminution was not considered3,4. Moreover, these studies were conducted about two decades ago.

This study therefore aims to re-evaluate the aetiology, mechanisms of injury and modes of presentation of patients with tibial fractures. In addition, associated injuries (including soft tissue injury) and the degree of comminution were assessed.

This work was carried out at the University College Hospital (UCH), Ibadan which, together with a few other hospitals serves as a referral centre for the Southwestern zone of Nigeria.

Material and Methods :

The manual retrieval method was used to obtain the clinical records of patients with tibial fractures seen at the A/E of the University College Hospital, Ibadan between January and December 2002 from our Medical Records Department. The demographic characteristics of patients, aetiological factors, patterns of injury, treatment and its outcome are recorded.

All the patients reviewed were initially assessed, resuscitated and investigated in the A/E. Treatment was instituted after which they were either admitted or discharged to the clinic. The time to union was based on clinical as well as radiological assessments.

Table 1  Causes of tibial fractures seen at the UCH, Ibadan in year 2002

Cause of injury

No of cases (%)

Vehicular traffic crashes

24 (34.3)

Pedestrian traffic injuries

21 (30.0)


11 (15.7)

Motorcycle crashes

7 (10.0)


7 (10.0)


70 (100.0)

Table 2   Types of open fractures of the tibia seen in UCH, Ibadan in year 2002

Type of open fracture (Gustilo)

No of cases (%)

Type I

7 (22.6)

Type II

5 (16.1)

Type IIIa

9 (29.0)

Type IIIb

10 (32.3)


31 (100.0)

Results :

In this retrospective review, 68 patients with 70 tibial fractures were seen during the one-year period. This consisted 52 males and 18 females (M:F ratio of 2.9: 1) with a mean age of 35.5±18.8 years (range=1.5-75 years). Sixty seven percent of the patients were between 21-60 years of age while the peak age was 31-40 years. The left tibia was involved in 42 cases (left:right ratio of 1.5: 1). The parts of the tibia fractured are shown in figure 2.

Most of the patients (73%) presented during the rainy months of April to September. Twenty percent presented respectively in the months of April and September (figure 1).

Motor vehicular crashes were the leading cause of tibial fractures, representing 35% of cases (table 1 shows details of the causes of tibial fractures). Forty percent of the fractures occurred along dual carriageways, 34% along township roads, 17% at home, while 9% occurred at work.

Most patients were referred from private hospitals (55%) while a quarter came directly from the accident scene. The remaining 20% were from other public health institutions and traditional bonesetters.

Our patients presented between 1.2-46 hours after injury (mean: 10.7±9.3 hours). Fifty one percent were seen within 8 hours of injury; 42% between 8 and 24 hours, while 7% presented after 24 hours.

Clear description of the fracture sites were recorded in 38 (79%) of the tibial shaft fractures. They were simple or non-comminuted in 15 (40%), comminuted in 21 (55%), while 2 (5%) were segmental fractures.

Forty eight percent (31) of the fractures were open; 32% of these (14.3% of all tibial fractures) were of type IIIb Gustilo5 variety. There was no statistically significant relationship between the cause of the injury and the severity of the open fracture (p=0.55). Table 2 shows the distribution of open tibial fractures.

Thirty four patients (50%) had other associated injuries, 23 patients (68%) had other limb injuries, 7 (20%) had craniofacial injuries, while 4 (12%) had other injuries. There was associated fibular fracture in 88% of the cases. The relationship between the cause of injury and associated injury was statistically significant (p=0.05) with road crashes having an increased risk of associated injuries.

Twenty four (34%) patients were treated in the A/E and discharged on account of reasons ranging from lack of funds for treatment, lack of theatre or bed space, and patients’ decision to seek treatment elsewhere. Forty four patients with 46 fractures were admitted and managed using various techniques: plaster cast (in 35 fractures), skeletal traction (5), plate osteosynthesis (3), external fixation (2), and amputation (1).

Majority of the patients were lost to follow up and only 13 had fracture healing times documented. Nine of these occurred within 20 weeks while the remaining 4 healed within 40 weeks. Mean time to union was 18.1±10 weeks (range= 6-36 weeks). Severe open fractures were associated with prolonged healing time in this series (p=0.03).

The complications recorded included wound infection, delayed union and malunion each occurring in two patients. Nonunion and chronic osteomyelitis each occurred in one patient.

Figure 1:  Bar chart showing the monthly distribution of tibial fractures seen in the year 2002 in UCH, Ibadan

Figure 2:  Pie chart showing the frequency of involvement of different parts of the tibia  in fractures in UCH, Ibadan in the year 2002

Discussion :

In this study, males were more predisposed to tibial fractures, a situation which is similar to those independently reported by Alabi3 and Onabowale et al6, although Oguachuba4 found a ratio of 8:1. Reports from other parts of the world are also in keeping with a male predisposition7-10. Alabi3 also found a similar age incidence.

Other local reports showed a predisposition to right tibial fractures rather than the left as found in our study3,4.

We found a disproportionately high incidence of tibial fractures during the rainy season especially in the months of April and September. Ebong2 had noted a peak incidence of injuries in the month of April. This could be attributed to poor visibility on the roads which predisposes to road crashes while slippery floors after rainfall my occasion falls.

Motorcycle crashes which was once the leading cause of tibial fractures during the 80’s3,4 accounted for only a tenth of cases in our series. The drastic increase in the number of motor vehicles following the financial empowerment of Nigeria’s working class within the last decade might account for this. Motor vehicular and pedestrian crashes are certainly on the increase compared to earlier studies3,4.

A significant period of delay is still encountered before presentation of injured patients to our centre although this is an improvement on the findings of Ebong2 and Onabowale et al6. Though our figures are still far from ideal, it suggests an improvement in utilization of medical services and rescue services.

The predilection for the tibial shaft to fracture may be as a result of the subcutaneous nature of the whole length compared to the proximal and distal ends. While Court-Brown et al9 reported a similar finding, Alabi3 and Oguachuba4 in separate studies found the distal tibia as the commonest site of fractures.

Considering the incidence of comminution and fracture segmentation, it becomes obvious that most of the cases in this series were due to high energy injuries. The almost 50% incidence of open fractures which were usually of the severe type III drives home the peculiar risk of open fractures already described for this bone1,2. The implication is that complex soft tissue reconstruction will be indicated in these patients. It is evident that the incidence of open fractures has increased in our environment over the years going by the Alabi study3 for reasons earlier advanced. It is ironical that even the United Kingdom with better health facilities does not record as many open tibial fractures as we see in our under-equipped medical centres11.

The one-third who discharged before definitive management could be instituted is actually an improvement on the almost half who discharged to be treated by traditional bonesetters in Oguachuba’s series4. The impoverished state of our nation, lack of proper health education, and ignorance on the part of our community with its heavy cultural attachment have been advanced as reasons why people still seek treatment from traditional bonesetters in spite of the well known risks14.

Follow up in this study, as for many retrospective studies in this environment is very poor. It is generally believed that most of these patients do not report to the clinic unless they have complaints or complications. There have also been instances where patients have been lost to traditional bonesetters who continue treatment initiated by the orthopaedic surgeons. In spite of the high incidence of severe open fractures in this series, the incidence of deep bone infection was low; some patients may however present with late onset chronic osteomyelitis several years after the injury.


This study highlights the subtle temporal changes in the epidemiology of tibial fractures in Nigeria. It also brings to the fore the unfortunate fact that these injuries are more severe compared to what obtains in the developed world. These statistics call for determined efforts on the part of the government to curb the incidence of road traffic crashes in our society. Facilities for treatment of this and other injuries should be provided at affordable cost in our health facilities.

Reference :

  1. Nicoll EA. Fractures of the tibial shaft: a survey of 705 cases. J Bone Joint Surg 1964; 46-B: 373-387.
  2. Ebong WW. The pattern of fractures and dislocations in Western Nigeria. Injury 1978; 9: 221-224.
  3. Alabi ZO. The pattern of tibial fractures in Ilesa, Nigeria. Nig Med J 1981; 11 (1): 22-29.
  4. Oguachuba HN. The pattern of tibia/fibula fractures in Jos, Plateau State, Nigeria. Nig Med J 1986; 83-87.
  5. Gustilo RB, Merkow RL, Templeman D. The management of open fractures. J Bone Joint Surg 1990;72-A:299-304
  6. Onabowale BO, Onuminya JE, Essien IAJ, Ukegbu ND. The management of open tibial shaft fractures: the National Orthopaedic Hospital experience. Nig J Surg 1995; 2 (2): 37-42.
  7. Johner R, Wruhs O. Classification of tibial shaft fractures and correlation with results after rigid internal fixation. Clin Orthop 1983; 178: 7-25
  8. Singer BR, McLauchlan GJ, Robinson CM, Christie J. Epidemiology of fractures in 15 000 adults: the influence of age and gender. J Bone Joint Surg 1998; 80-B: 243-248.
  9. Court-Brown CM, Rimmer S, Prakash U, McQueen MM. The epidemiology of open long bone fractures. Injury 1998; 29: 529-534.
  10. Grutter R, Cordey J, Buhler M, Johner R, Regazzoni P. The epidemiology of diaphyseal fractures of the tibia. Injury 2000; 31(suppl.): 64-67.
  11. Court-Brown CM, McBirnie J. The epidemiology of tibial fractures. J Bone Joint Surg 1995; 77-B: 417-421.
  12. Ayeni JP. Pilon fractures of the tibia. A study based on 19 cases. Injury 1988;19:109-114
  13. Cullen MC, Roy DR, Crawford AH, Assenmacher J, Levy MS, Wen D. Open fracture of the tibia in children. J Bone Joint Surg 1996; 78-A: 1039-1047.
  14. Alonge TO, Dongo AE, Nottidge TE, Omololu AB, Ogunlade SO. Traditional bonesetters in south western Nigeria – friends or foes? West Afr J Med 2004;23:81-84.


This is a peer reviewed paper 

Please cite as : Adeleke Olusegun Ifesanya : Changing Trends In The Pattern Of Tibial Fractures In Nigeria: A Review  Of 70 Cases

J.Orthopaedics 2008;5(2)e4





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