Review Question - QID 4024

The best definitive surgical fixation option for an open fracture of the tibia would be either a reamed or unreamed intrameduallary nail.

Treatment of open tibia fractures require immediate antibiotics and early irrigation and debridement. Surgical fixation options are vast, but largely based on the severity of injuries both locally or systemically. External fixation devices are mainly used for provisional fixation in polytrauma patients or definitively in proximal or distal metaphyseal fractures. Plating may be used in a staged fashion after a period of external fixation. The most common fixation method is intramedullary nailing. The use of a reamed or unreamed nail technique does not affect union rates, infection rates, or need for additional surgeries in open tibia fractures.

Bhandari et al conducted a multicenter, blinded randomized trial of 1319 adults in whom a tibial shaft fracture was treated with either reamed or unreamed intramedullary nailing. When comparing outcomes in open and closed injuries at twelve months, they found a benefit for reamed intramedullary nailing in patients with closed fractures, but found no difference between approaches in patients with open fractures.

Finkenmeier et al conducted a randomized controlled study of reamed vs. unreamed nails in open and closed tibia fractures (excluding Grades IIIB and IIIC). They found that the use of reamed insertion of IM nails for the treatment of closed tibia fractures lead to an earlier time to union without increased complications. The authors reported no differences in infection rate, compartment syndrome rate, or percent needing additional surgeries to obtain union. More secondary procedures were needed with unreamed nails in closed fractures only.

Figure A shows a mid-shaft tibia fracture.

Incorrect Answers:
Answers 1, 2, 3, 4: All prospective studies show no difference in the rates of non-union, malunion, or infection when using a reamed or unreamed nails to treat open tibia fractures.