OTA 1998 Posters

Treatment of Closed Tibial Shaft Fractures: A Survey from the 1997 Orthopaedic Trauma Association Meeting

Cyna Khalily, MD; Stephen Behnke; David Seligson, MD, University of Louisville, Department of Orthopaedic Surgery, Louisville, KY

Introduction: The treatment of choice for tibial shaft fractures is based on the treating surgeon's belief that a certain treatment modality is in some way best. The purpose of this study was to identify any differences in these perceptions based on practice location (US/Canadian vs. European) and level of training, and to identify any consensus of opinion regarding time to return to duty and residual impairment.

Methods: A simple one-page survey was administered at the 1997 combined meeting of the Orthopaedic Trauma Association (OTA) and the Gerhard Kuntscher Kries (GKK) in Louisville, KY, USA. It was felt that this represented a rare opportunity to canvas opinions from a cross section of physicians with a special interest in fracture management. The survey described a healthy patient with a nondisplaced midshaft closed tibia fracture and asked the surgeon to identify country of practice, level of training, treatment of choice (cast, intramedullary nail, plating, external fixation) and to answer questions regarding return to duty, time to reach maximum medical improvement (MMI), and percentage impairment.

Results: There was approximately a 1:2 ratio of physicians willing to take the time to fill out the survey versus those that refused. Of the 600+ registered participants at the OTA and the 150+ registered at the GKK (with some overlap) 205 surveys were returned. Of these, 178 were completely (or nearly completely) filled out. One hundred and four were from the US or Canada, 59 from Europe, and 15 had no country listed; there were 93 in practice, 50 in training, and 35 unknown. Thirty percent of respondents chose cast as the treatment of choice and 67% chose closed intramedullary (IM) nailing. Practicing surgeons leaned toward IM nailing (70%) while those in training were distributed between casting and nailing. Only 2% chose plate and 1% chose external fixation. The respondents that chose IM nailing treatment felt the other treatment modalities were roughly equivalent to one another with longer healing time and more impairment as compared to nailing. Those that chose cast treatment tended to think an IM nail would heal faster and was similar to cast in terms of MMI and impairment.

Of interest was the wide variation in opinion concerning return to duty, MMI, and impairment. For instance, of the total respondents who chose cast, 15% felt it would take a nailed patient less than 10 weeks to return to regular duty while another 5% felt it would take more than 26 weeks with the remainder of respondents falling in between in a bell-shaped distribution. The US/Canadian respondents also were distributed in a bell-shaped curve while the international respondents leaned more heavily toward earlier return. Similarly, of the total respondents that chose cast treatment, the majority (>50%) felt it would take less than 10 weeks to return to light duty but there were 2% who felt it would take more than 26 weeks.

Discussion: Wide variation exists in surgeons' perceptions of the treatment of simple fractures. There continues to be a lack of consensus as to optimal treatment and estimates of healing time, return to duty, and residual impairment with various treatment modalities. In this age of managed care, worker's compensation, and third party payers, the use of questions being asked of us about our patients is of dubious value.

Figure 1: Of those respondents with IM nail as treatment of choice, time for nailed closed tibia fracture to reach maximum medical improvement.

Figure 2: Of those that chose cast as treatment of choice, time for casted fracture to reach maximum medical improvement.

1 = less than 2 weeks 
2 = 3-6 weeks 
3 = 7-12 weeks 
4 = 13-18 weeks 
5 = more than 18 weeks
 

Figure 4: Of those that chose cast as treatment of choice, percent impairment for nailed fracture.

1 = less than 5%
2 = 6%-10% 
3 = 11%-20% 
4 = 21%-40% 
5 = more than 40%