Gunshot tibia fractures treated with intramedullary nailing: A single centre retrospective review

Abstract

Background: Open tibia fractures are notoriously difficult to treat, with a high rate of union problems and infection. Gunshot wound-associated fractures of the tibia compound these issues further by causing extensive bone comminution and soft tissue damage. No universally accepted management protocol exists, but intramedullary (IM) nailing of these injuries is an attractive treatment strategy. It provides stable internal fixation and limits further insult to the soft tissue envelope. It also allows complete access for wound management and early range of movement of the adjacent joints. This study aims to review the results of patients treated with IM nailing for gunshot wound (GSW) tibia fractures to assess whether this is a viable treatment option for this injury.Methods: A retrospective folder review was performed of all adult patients who sustained a GSW tibia fracture treated with intramedullary nailing between January 2009 and December 2014. Parameters evaluated included time to theatre, time to wound closure, radiographic extent of fracture comminution, anatomical alignment, time to union and incidence of chronic osteomyelitis.Results: Twenty-two patients were eligible for inclusion; however, nine were lost to follow-up. The remaining 13 patients achieved union over an average of 26 weeks. Three cases developed osteomyelitis, all of which had radiographic zones of comminution exceeding 120 mm. No cases of malunion were reported and no other significant trends noted.Conclusion: Treatment of tibial gunshot fractures must be individualised according to both the soft tissue injury and radiographic zone of comminution in order to achieve a favourable outcome. Intramedullary nailing is an effective treatment strategy for low Gustilo-Anderson grade injuries, with minimal complications.

Treatment outcomes of civilian gunshot tibia fractures at a major trauma centre

“…IMN fixation showed outcomes comparable to a previous publication by Hilton et al who reported a 76.9% initial union rate following intermedullary nailing for gunshot tibial shaft fractures, with three patients developing osteomyelitis. 8 The union rate observed in the present study for IMN was 91%.…”

“…The first finding of this study was the demographic sample and the predominant involvement of young males (89% male with a mean age of 29.2±10.2 years), which is similar to previous published reports on orthopaedic injuries following civilian gunshots. 3,6,8 A recent study conducted in South Africa reported a higher rate of intentional and gang-related violence together with the use of alcohol and illegal drugs among young, gunshot-injured males. 5 While we did not test patients for alcohol or illegal drugs in the present study, our finding, together with the previous reports, again highlights this group of individuals to be a potential target for intervention in the future.…”

“…Gunshots involve the transfer of blast energy to the bone and soft tissue resulting in cavitary tissue damage and a large zone of injury. 8 Further, the risk of infection, compartment syndrome, nerve palsies, delayed union or non-union are increased due to the subcutaneous location of the tibia. Moreover, poor correlation between external wound size and degree of underlying tissue damage may lead to an underestimation of the injury severity.…”

“…Moreover, poor correlation between external wound size and degree of underlying tissue damage may lead to an underestimation of the injury severity. 8 Several controversies regarding the management of gunshotinduced tibia fractures persist as a result of the heterogeneity of these injuries. Management of these injuries can range from conservative management to formal debridement and skeletal stabilisation either in a single setting, or as a staged approach.…”

CORR Insights®: Low-energy Gunshot-induced Tibia Fractures: What Proportion Develop Complications?

“…An alternative classification by Long et al [5], specifically designed for gunshot-associated femur fractures, may be a more appropriate accounting for both the physical wound characteristics and the radiographic zone of injury of both the skin and soft tissue, as well as the degree of comminution. One study [2] suggested that the radiographic zone of comminution should be considered as important as the size of the soft tissue wound when determining treatment, with a trend toward an increased risk of infection when the radiographic zone of comminution exceeded 120 mm. The authors cautioned, however, that strong consideration should be given to external fixation for fractures with zones in excess of 120 mm as a way to minimize complications.…”