A completely shattered tibia
A 32-year-old man, a manual labourer in a granite quarry, presented after heavy equipment had fallen on his left leg while working. He was in a state of shock and the skin of the entire left leg had multiple sieve-like punctured wounds through which small spikes of bones were visible. There was minimal contamination of the wounds. The leg sagged even when supported distally, but, surprisingly, active toe movements were present and the posterior tibial pulse was palpable. The dorsalis pedis pulse was not palpable and it was only feebly heard with a handheld Doppler.
The sensation on the sole of the foot was normal. However, there was mild sensory blunting over the dorsum of the foot. The knee did not have an effusion and the femur, hip and opposite limb were clinically normal.
Following resuscitation with fluids and blood, radiographs showed a completely shattered tibia and fibula from the proximal metaphyseodiaphyseal junction to the ankle. The medial malleolus was also fractured. The leg was truly a ‘bag of bones’.
Intravenous broad-spectrum antibiotics were started after tetanus immunisation. The limb was splinted after the wounds had been thoroughly washed with saline.
As plantar feeling was intact and the distal vascularity good we decided to aim for limb salvage rather than perform a primary amputation. The Mangled Extremity Severity Score (MESS)2 was 5, which was in favour of limb salvage. Most patients in India opt for retaining a mangled extremity, if given a choice. The severity of the injury does not matter and they are willing to undergo protracted periods of treatment with external fixators and many operations in order to retain their limb, regardless of how stiff it may be. The social stigma associated with an amputation is so degrading that many say they would rather die than have an amputation, despite the merits of early amputation and prosthetic fitting.
Our patient was adamant that all efforts should be made to save his limb. The length of tibia for an adequate below-knee stump was not available as the fracture extended to the proximal metaphyseodiaphyseal junction. If an amputation had been undertaken, it would have been either through- or above-knee.
External fixation was excluded as there were no major cortical fragments which could provide purchase for Schanz pins or tensioned Kirschner wires. Calcaneal traction would not have provided adequate reduction without additional immobilisation with a posterior splint.
This left us with the option of a locked intramedullary device. Even if the nail did not pass through the medullary canal of the shattered bone, it would help to realign the limb, restore length and provide support until the comminuted fragments were bridged by callus and consolidation occurred. The results of Grosse,3 who successfully treated a case of bilateral shattered femora with a Grosse-Kempf intramedullary nail encouraged us to proceed.
On 5 September 1998, a 9 mm x 360 mm Grosse-Kempf intramedullary nail (Stryker Trauma GmbH, Schonkirchen, Germany) was passed through the comminuted fragments of the tibia and statically-locked proximally and distally (Fig. 2⇓). The patient was placed on a radiolucent table with the knee hyperflexed using a wooden block to support the distal thigh while an assistant applied traction to the leg. An entry point was made with an awl and the proximal metaphysis reamed to 10 mm. A guide wire was passed through the comminuted fragments to the centre of the distal epiphysis. The selected nail was then passed over the guide wire and locked. Good stability was achieved. A split skin graft was used to cover a small area at the junction of the upper and middle thirds of the tibia while the other wounds were sutured. An above-knee plaster cast was applied after removal of the sutures on the 12th post-operative day.
On review eight months later, radiographs showed union in the lower two-thirds of the tibia with nonunion at the junction of the upper and middle thirds and 1 cm of shortening. In May 1999, a 4.5-mm dynamic compression plate was applied with four screws bypassing the nail and autogenous ipsilateral iliac bone graft was placed around the nonunion. Further plaster immobilisation and partial weight-bearing with crutches was advised.
One year and five months after the injury, there was persistent abnormal mobility at the junction of the upper and middle thirds with 2.5 cm of shortening. The dynamic compression plate was removed and contralateral autogenous fibular and iliac crest grafts were packed around the non-union. Electrical stimulation was added to improve healing.
Radiographs taken nearly two years after the injury showed a persistent nonunion. The nail was removed and an Ilizarov external fixator applied. The fixator was dynamised two months later and was removed two years and four months after the injury, at the request of the patient. A patellar tendon-bearing cast was applied and the patient was advised to partially weight-bear. On 4 April 2001, the cast was removed. He was subsequently fitted with a weight-relieving caliper. However, three years and three months after the injury the fracture was still visible on x-ray and there was a sequestrum.
The sequestrum was excised and bone substitute (G-Bone modified hydroxyapatite blocks; G-SurgiWear Ltd, Shahjohanpur, India) added. A local flap helped achieve bone cover. When the flap had healed, full weight-bearing with the caliper was allowed.
At this stage nearly all available techniques had been exhausted and there remained a resistant nonunion. We began to regret the decision not to undertake a primary amputation. The patient had lost his job, although his son was granted one in his place. His generous employers, who had paid for his medical expenses, were now reluctant to continue payments. He was now upset that an amputation, which would have enabled him to secure good compensation, had not been performed.
We lost the patient to follow-up after the last operation in December 2001 but were pleasantly surprised when he returned in May 2004, walking without a caliper or an aid. He was free of pain and had a new job as an autorick-shaw driver. He walked comfortably, with a short-limbed gait. Clinical examination did not show any tenderness or mobility at the site of the previous nonunion. There were two small sinuses at the junction of the middle and upper thirds of the tibia but there was no active discharge and the patient was afebrile. Full weight-bearing could be demonstrated with a single-leg stance on the affected limb. There was good alignment of the limb with a full, active range of knee movement and plantar flexion of 15° at the ankle joint. The ankle could not be dorsi-flexed beyond neutral. There was 4 cm of shortening. Radiographs revealed sound union at the junction of the upper- and middle-thirds with consolidation of the comminuted fragments and acceptable overall alignment.