OTA 1998 Posters

Gun Shot Fractures of the Tibia: A Severe Injury

Richard G. Levine, MD; Neal Hochwald, MD; William Urban Jr., MD; Paul Tornetta III, MD, Kings County Hospital, Brooklyn, NY

Purpose: The purpose of this paper was to evaluate a subset of patients admitted to our institution with a gun shot fracture of the tibia.

Methods: A review of the inpatient and follow-up records of patients admitted to our institution over a five year period was conducted. This study included only those (57 patients, 60 fractures) who required inpatient management. The indications for admission were treatment of associated injuries, grade II and III open fractures, and fracture patterns necessitating operative intervention. The duration of admission, type and grade of fracture, duration of antibiotics, associated injuries, treatment, and complications were reviewed. Shaft fractures were classified by Winquist type, location, and fracture pattern. Open fracture grade was determined by the Gustilo classification. Union was defined as bridging callus in two planes, a nontender fracture site, and ambulation without assistive devices. Malunion was considered to be greater than 5 degrees of varus/valgus or 10 degrees of anterior/posterior angulation.

Results: The average patient was 25 years old. The duration of initial hospitalization averaged 12 days. There were 37 fractures of the tibial shaft (OTA 42), 7 of the tibial plateau (OTA 41C), 9 of the tibial plafond (OTA 43), and 7 of the proximal metaphysis (OTA 41A) with 17 associated fibula fractures. There were 8 grade II, 3 grade IIIC, and 1 grade IIIB fractures. The remainder were considered grade I. Associate injuries included arterial injuries (7), compartment syndromes (8), neurologic injury (2), pulmonary embolus (1), and associated fractures (15). Patients were treated nonoperatively by closed reduction and casting in the majority of cases. Operative intervention included I & D with external fixation (12), ORIF (4), and IM nailing (6). All patients received IV antibiotics. Those that received greater than three days of antibiotics did so for nonorthopedic injuries. All fractures healed, although one required bone grafting. The average time to union was 42 weeks. There were 4 varus/valgus malunions and 6 anterior/posterior malunions. Two malunions were operatively corrected. There were 4 infections resulting in chronic osteomyelitis. All were treated with surgical debridement and IV antibiotics.

Discussion: Tibia fractures caused by gunshot wounds (GSW) are common injuries in our inner cities. We studied a subset of patients with GSW tibia fractures that were admitted to the hospital for treatment. The patients reviewed in this series represent the more serious injuries in the spectrum of GSW fractures. They had high-grade open fractures, impending or present compartment syndromes, vascular injuries, or other injuries requiring admission. This is reflected by the length of antibiotic course and length of stay. All patients healed their fractures. The infection rate of 7% is high. However, of the four infections, two had arterial injuries (one shaft and one pilon). The other two patients developed coverage problems during their treatment (one pilon and one plateau).

Conclusion: Treatment of severe gun shot fractures of the tibia carries with it a high complication rate. Seventeen percent (10/60) of the fractures resulted in malunions using strict criteria and 7% developed deep infections. Casting yielded a higher percentage of malunions. This may be partly due to the poor reliability of our patient population in returning for their follow-up visits. IM nailing may be a better choice for these patients, but prospective study will be necessary to further evaluate this possibility.