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Abstract:
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
Keywords:
Tibia; fracture; road crashes; injuries; Nigeria; traffic
injuries
Introduction:
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) |
|
Falls |
11 (15.7) |
|
Motorcycle
crashes |
7 (10.0) |
|
Others |
7 (10.0) |
|
Total |
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) |
|
Total |
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.
Conclusion:
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.
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