Rajiv Gandhi University of Health Sciences



RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA

SYNOPSIS FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

A CLINICAL STUDY ON SURGICAL MANAGEMENT OF DIAPHYSEAL FRACTURES OF TIBIA BY INTRAMEDULLARY INTERLOCKING NAIL

Dr. SYED AZHER HUSSAIN

P.G. M.S. IN ORTHOPAEDICS

AL – AMEEN MEDICAL COLLEGE

BIJAPUR

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

|1 |Name of the Candidate |Dr. SYED AZHER HUSSAIN |

| |And |PG IN ORTHOPAEDICS |

| |Address |DEPARTMENT OF ORTHOPAEDICS, |

| |(In block letters) |AL-AMEEN MEDICAL COLLEGE |

| | |BIJAPUR |

|2 |Name of the Institution |AL-AMEEN MEDICAL COLLEGE |

| | |BIJAPUR, KARNATAKA |

|3 |Course of study and subject |M.S. ORTHOPAEDICS |

|4 |Date of admission to course |28th MAY 2012 |

|5 |Title of the Topic |A CLINICAL STUDY ON SURGICAL MANAGEMENT OF DIAPHYSEAL FRACTURES |

| | |OF TIBIA BY INTRAMEDULLARY INTERLOCKING NAIL |

|6 |Brief resume of the intended work : | |

| |6.1 Need for the study | |

| |6.2 Review of literature |ANNEXURE – I |

| |6.3 Objectives of the study |ANNEXURE – II |

| | |ANNEXURE – III |

|7 |Material and Methods | |

| |7.1 Source of data |ANNEXURE IV |

| |7.2 Methods of collection of data{Including |ANNEXURE IV |

| |sampling procedure, if any} | |

|8 |Does the study require any investigations and | |

| |interventions to be conducted on patients, | |

| |humans or animals? If so please describe |ANNEXURE – V |

| |briefly. | |

|9 |List of References (about 8 - 10) |ANNEXURE – VI |

|10 |Has ethical clearance has been obtained from |Yes |

| |your Institutions in case of 8 |(Certificate has been enclosed herewith ) |

| | |ANNEXURE – VII |

| | | |

| | | |

|12 |Remarks of the Guide |This study will help in better understanding of the surgical |

| | |management of diaphyseal fractures of tibia by intramedullary |

| | |interlocking nail. |

| | | |

|13 |13.1 Name & Designation of the Guide (in block |Dr. VISHWAS V. MUNDEWADI |

| |letters) |M.S.(Ortho),D.(Ortho) |

| | |PROFESSOR |

| | |DEPARTMENT OF ORTHOPAEDICS |

| | |AL-AMEEN MEDICAL COLLEGE, BIJAPUR |

| | | |

| | | |

| | | |

| |13.2 Signature | |

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| | | |

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| | | |

| |13.3 Co-Guide | |

| | | |

| |13.4 Signature | |

| | | |

| | |Dr. A.H.SASNUR |

| |13.5 Head of the Department |M.S.(ORTHO) |

| | |PROFESSOR & HEAD OF THE DEPARTMENT OF ORTHOPAEDICS, |

| | |AL-AMEEN MEDICAL COLLEGE, |

| | |BIJAPUR |

| | | |

| | | |

| | | |

| |13.6 Signature | |

| |14.1 Remarks of the Chairman & Principal |DR. B. S. PATIL |

| | | |

|14 | |We will provide the necessary facilities for this study. |

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| |14.2 Signature | |

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| | | |

| | | |

ANNEXURE – I

6.1 NEED FOR STUDY

With the increasing number of vehicles on roads in India, Complex trauma cases caused by Road Traffic Accidents have increased progressively being subcutaneous in location, the tibia is the commonest bone to be fractured and seen commonly in orthopaedic practice. Due to its frequency, topography and mode of injury it has become a major source of temporary disability and morbidity.

The major goal in the treatment of fracture tibia is achieving functionally useful and stable extremity. Yet, the spectrum of injuries to tibia is so great that no single method of treatment is applicable to all the fractures.

Now-a-days the well laid principle of biological osteosynthesis is rightly applied in long bone fracture healing and hence the selection of closed intramedullary interlocking nailing in this study.

ANNEXURE – II

6.2 REVIEW OF LITERATURE

Intramedullary fixation of fractures of long bone was one of the modes of treatment

since a very long time.

G Gerhard Kuntscher developed his V-shaped a cover leaf nails in 1930. Herzog

modified the straight Kuntscher’s nail to accommodate the eccentric proximal

portal. Some authors proposed reaming of medullary canal to improve the fit of the

nail and increase its rotational control and strength. In 1950 Lottes developed a rigid

nail that could be inserted without reaming using an open or closed technique1.

In 1958, Kuntscher opined that intramedullary nailing represents the ideal treatment

of fractures and requires no external fixation or special post operative care2.

Kessler SB Hallefeldt et al (1986) published articles, stating that fractures of tibia

can be treated successfully with inter locking nailing.3

Watson JT (1994) concluded from a review of literature that unstable closed

and type-I open Fractures are preferably treated with intramedullary nailing with or

without reaming.

In grade-II and IIIA fractures, rate of union and rate of infection is similar in

reamed and unreamed intramedullary nails, but secondary surgery may be needed in

reamed nailing4.

In 1995, Paul Gregory and Roy Sanders proposed that interlocked intramedullary

nailing inserted in unreamed manner has become the treatment of choice for the

closed, unstable Tibial shaft fractures in polytraumatised patients in the author’s

institution. A high union rate, coupled with a lack of compartment syndromes or

peroneal palsy, makes this procedure an attractive and alternative to reamed nailing5.

In 1995, Gregory proposed that infection after unreamed nailing had fewer

complications and a higher success rate of infection controlled than reamed nailing6.

In 1998, A Daudel-Gascia et al, concluded that non -reamed flexible locking nailing

provides effective control of axial and rotational stability7.

Hernigou P et al (2000) in a report on proximal entry for intramedullary nailing of

tibia, concluded that it is important to enter the medullary canal at the right point, so

that nail is introduced in line with the axis of the tibia in both the coronal and

sagittal planes. If the entry Point is low, posterior tibia is endangered, if high, then,

unrecognized articular penetration can occur injuring the menisci and ligamentum

transversum.

The unrecognized articular penetration was seen commonly and this caused

anterior knee pain. The safe zone is anterior to the ligamentum transversum and

anterior to the anterior horn of each meniscus. In some bones the safe zone is

smaller than the size of the standard reamers and the proximal part of some nails8.

In December 2004, Joshi et al proposed that the current trend of management of gustillo type I, II and III A open fractures of tibia present to emergency department within six to eight hours is to perform unreamed intramedullary nailing. Unreamed nailing in experimental studies has to be found to cause less reduction in cortical circulation as compared to reaming of medullary canal. Reaming of open fractures has been found to spread the contamination from open wound along the medullary cavity. Reaming has also been reported to slow the Re-vascularization and delay osseous union9.

Vineet Jain et al (2005) concluded that primary unreamed intramedullary nailing

offers advantage of rigid fixation, low incidence of infection, non-union, good

functional results and early return to work. An adequate soft tissue management is

mandatory in treatment of these fractures10.

ANNEXURE – III

6.3 OBJECTIVES

➢ To assess and study diaphyseal fractures of tibia with special reference to fracture anatomy, pattern and status of stability.

➢ To study fracture healing and the union rates with intramedullary interlocking nail.

➢ To study the functional outcome with regard to knee, ankle and subtalar joint movements.

➢ To prevent angulation, deformity to maintain limb length equality.

➢ To mobilize the patients as early as possible.

ANNEXURE- IV

7. MATERIALS AND METHODS

7.1 SOURCE OF DATA

Patients of both the sexes belonging to the adult age group i.e. after fusion of epiphysis presenting with diaphyseal fractures of tibia to orthopaedic department in Al-Ameen Medical College & Hospital, Bijapur from July 2012 to June 2014

7.2 METHODS OF COLLECTION OF DATA [INCLUDING SAMPLING PROCEDURE IF ANY]

All cases of both the sexes belonging to adult age group presenting with fracture tibia to orthopedic department of Al-Ameen medical college and hospital, Bijapur satisfying the inclusion criteria and are surgically fit.

THE INCLUSION CRITERIA

1. Transverse and short oblique fractures.

2. Segmental fractures of shaft of the tibia.

3. Communited fractures of the shaft of the tibia.

4. Grade I [Gustillo Anderson] compound fractures.

5. Polytrauma cases where early mobilization of patient is indicated.

THE EXCLUSION CRITERIA

1. Fractures in children.

2. Grade II and III [Gustillo Anderson] compound fractures.

3. Fractures with intraarticular extensions.

4. Burns/Wounds over the entry portal.

5. Patients not fit and not willing for surgery.

This study will be conducted on a minimum of twenty patients. If need be, the number of cases will be increased depending on patient input during the course of the study.

Period of study: Two years i.e.; July 2012 –June 2014.

Period of follow-up: 6 to 12 months

Method of treatment: After stabilization and subsequent investigations, under spinal/General anesthesia we will adopt a technique of closed reduction and internal fixation with intramedullary interlocking nail. If need arises, a small incision will be made over fracture site to align bones.

ANNEXURE – V

8.0 Does the study require any investigations or interventions to be conducted on the patients, humans or animals?

“YES” this study requires surgical intervention to be conducted on humans.

a) X-ray standard antero-posterior and lateral views of tibia.

b) Other investigations as deemed necessary.

ANNEXURE – VI

9. REFERENCES

1. S.Terry Canale, Campbells operative orthopaedics, 10th edition, Philadelphia, Pennsylvania, Mosby 2003; 3; 2757.

2. Gerhard. B.G. Kuntscher., The Kuntscher method of intramedullary fixation. Journal of Bone and Joint surgery, 1958; 40A:17-26.

3. Kessler SB Hallefeldt, Perren Schwiberer. The effects of reaming and intramedullary nailing on fracture healing. Clinical orthopaedics. 1986:212

4. Watson JT. Current concepts review, treatment of unstable fractures of the shaft of tibia. Journal of Bone and Joint Surgery. 1994; 76 A:1575-1583

5. Paul Gregory, Roy Sanders. “The treatment of closed, unstable tibial shaft fractures with unreamed interlocking nails”. Clinical orthopaedics, 1995 June; 315; 48-55.

6. Gregory A Zych, and James J.Hutson Jr; Diagnosis and management of infection after tibial intramedullary nailing. Clinical orthopaedics, 1995 June; 315: 153 - 162.

7. A Daudel. Gascia, A Dardker Prats, and F Gomar sancho. “Non-reamed flexible locked intra-medullary nailing in tibial open fractures”. Clinical Orthopaedics, 1998 May; 350: 97-104.

8. Hernigou P et al. Proximal entry for intramedullary nailing of tibia. Journal of Bone and Joint Surgery. 2000; 82B: 33-41.

9. Joshi. D, Ahmed A ,Krishna C, and Lal Y. Unreamed interlocking nailing is open fractures of tibia. Journal of orthopedic surgery [Hong Kong], December 2004; 12(2): 216-21

10. Jain V, Aggarwal A, Mehtani A, Jain P, Garg V, Dhaon BK. Primary unreamed intramedullary locked nailing in open fractures of tibia. Indian J Orthop 2005; 39:30-2.

ANNEXURE VII

ETHICAL COMMITTEE

AL-AMEEN MEDICAL COLLEGE, BIJAPUR

The following study entitled “A CLINICAL STUDY ON SURGICAL MANAGEMENT OF DIAPHYSEAL FRACTURES OF TIBIA BY INTRAMEDULLARY INTERLOCKING NAIL” by Dr. Syed Azher Hussain P.G. student in department of orthopaedics belonging to 2012 batch has been cleared from ethical committee of this institution for the purpose of dissertation work

Date: Chairman,

Ethical Committee,

Place: Al Ameen Medical College,Bijapur

PROFORMA

CASE NO:

NAME : IP NO:

AGE: DATE OF ADMISSION:

SEX: DATE OF SURGERY:

OCCUPATION: DATE OF DISCHARGE:

ADDRESS: DATE OF INJURY:

1. Presenting complaints

Pain/swelling/deformity/abnormal mobility/loss of function

Nature of Injury

❖ Road traffic accident

❖ Fall from height

❖ Industrial injury

❖ Farming injury

❖ Assault

❖ Fall of an object

❖ Sports related injury

❖ Others

2. GENERAL EXAMINATION:

Nourishment Pallor

Pulse Blood pressure

Temperature Respiratory rate

3. SYSTEMIC EXAMINATION:

a. Respiratory system

b. Cardio Vascular system

c. Per Abdomen

d. Central nervous system and neurological status

4. Local examination

1. Gait

2. Involved Limb Present/absent

3. Deformity Present/absent

4. Swelling Present/absent

5. Type of fracture Closed

6. Tenderness Present/absent

7. Crepitus Present/absent

8. Abnormal mobility Present/absent

9. Shortening _________ cms

10. Complications Shock/Fat embolism/

Compartment syndrome

a. Associated Injuries

b. Associated diseases

c. Personal habits

d. Treatment given in casualty

i. Injection-Tetanus toxoid

ii. Splinting/skeletal traction

6. Radiological examination :AP/Lateral view

1. Level of the fracture and site

1) Upper 1/3rd

2) Upper and middle 1/3rd junction

3) Middle 1/3rd junction

4) Middle and lower 1/3rd junction

5) Lower 1/3rd

2. Type of fracture

➢ Unifocal(Spiral/oblique/transverse fracture)

➢ Wedge(Spiral wedge/Bending wedge/Communited wedge)

➢ Complex( Spiral wedge/segmental/communited)

➢ Tscherne type-c0/c1/c2/c3

➢ Fibular fracture-Present/Absent

6. Investigations

➢ Hb% RBS Urine

➢ PCV Blood urea Albumin

➢ TC Serum creatinine Sugar

➢ DC ECG in all chest levels Microscopy

➢ ESR Chest x-ray PA view Stool

➢ HIV Blood grouping Ova

➢ HbsAg and Rh typing Cyst

➢ VDRL Microscopy

7. Preoperative planning for surgery

1) Type of nail and size:

2) Preparation of the patient:

3) Low Molecular weight heparin: Administered/not administered

4) Education of the patient regarding surgery and outcome:

5) Consent of surgery:

8. Surgical treatment

➢ Date of Operation:

➢ Type of anesthesia:

➢ Approach: Vertical patellar splitting

➢ Nailing: Reamed/Unreamed

➢ Locking of nail: Static/Dynamic

i. Proximal i) Done(1 screw/2 screws) ii)Not done

ii. Distal i) Done(1 screw/2 screws) ii)Not done

9. Intraoperative complications

Splintering of bone/breakage of drill bit

a) Intermediate postoperative complications:

Fat Embolism/ Neurological damage/Compartment syndrome/ hypotension/ vascular

Injury.

b) Wound infection: Superficial/deep

c) Suture removal done ______ day(between 1-2 weeks)

d) Weight bearing: Non weight bearing- till 4th week:

• Partial: At 4th week/6th week/8th week/12th week/16th week

• Full weight bearing: 10th week/12th week/14th week/16th week/20th week

• with/without walking aids

10. Follow uP

| | |4th |6th |10th |12,th |16th |20th |6 months & |

| | |week |week |Week |week |week |Week |above |

|1. |Pain | | | | | | | |

|2. |Deformity | | | | | | | |

|3. |Range of motion | | | | | | | |

| |* Knee | | | | | | | |

| |*Ankle | | | | | | | |

| |* Subtalar | | | | | | | |

|4. |Shortening | | | |- | | | |

|5. |Radiological union | | | | | | | |

11. “Late of Delayed Complications”

• Screw breakage

• Nail bending^ breakage

• Anterior knee-pain

• Infection - superficial / deep

• Malunion

• Shortening

• Non-union.

a) Secondary procedures

Dynamization

➢ Proximal

➢ Distal

b) Procedure done in nail bending/ screw breakage

c) Gait: Normal/ Limping (significant/ insignificant limp)

d) Functional outcome

➢ Excellent

➢ Good

➢ Fair

➢ Poor

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