Injury, 5, 291-297

Two-plate fixation in the treatment of the tibial shaft fracture and non-union Barrie Parker Department of Orthopaedic Surgery, Redhill General Hospital

Summary A series of 34 tibial shaft fractures treated by the application of 2 plates is presented. A high degree of rigidity was achieved and allowed early unsplinted weight bearing. The technique is suggested as a method for limited use in severe fractures, particularly in the elderly or multiply injured. The technique also has a useful place in the treatment of non-union, especially if previous surgery has failed.

I N T R O D U C T I O N THE purpose of this paper is to present a series of fresh and un-united fractures of the tibial shaft treated by the application of 2 plates. Breck and Basom (1944) were the first to report the use of double plating. The method has not gained any significant popularity but has a useful

place in certain situations. The possible indi- cations and limitations of the technique will be derived f rom a study of this series and a review of the literature.

THE METHOD There are 5 available plates made of E.N.58J stainless steel and supplied by Down Brothers (Figs. 1 and 2). There are plates with 6 screw holes, 7 and 8 in. long, and plates with 4 screw holes, 4, 5, and 6 in. long. The screw holes are so arranged that any two plates can be used as a pair. There is a fairly long central shank without

Fig. 1 .--The 5 available plates. Note the arrangement of the screw holes so that any 2 plates may be used together.

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Fig. 2.--Six- and 7-in. plates being used in combina- tion. The long central shanks allow moderate comminution to be accommodated. Here union is almost complete.

292 Injury: the British Journal of Accident Surgery Vol. 5/No. 4

holes to allow for moderate degrees of com- minution. Self-tapping Sherman screws were used in this series.

The tibia is approached through a straight longitudinal incision anteriorly just lateral to the tibial crest. The plates are applied extra- periosteally, as far as is possible, in dissimilar

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of Hospitals between November, 1964, and June, 1967. Review was undertaken between 4 and 6 years after operation giving an average follow-up of 5 years and 7 months.

All the patients were under the care of Mr. P. A. Ring, who devised this technique. There were 21 patients with fresh tibial fractures; 4

Table/.--Clinical material

Patients Fractures

Fresh fractures 21 24 Non-union 10 10

Fig. 3.--A patient with a hypervascular pseud- arthrosis of the tibia that had been treated by a single plate initially. Double plating achieved rigid fixation and union then occurred without bone grafting.

planes, one to the lateral and one to the sub- cutaneous surface. It is best to apply the plates synchronously, rather than in series, as it is easier in this way to hold a good reduction and obtain maximal contact between bone and metal. In non-union, contouring the plates to bone can be tedious (Fig. 3). When closing the skin the use of many closely placed sutures minimized tension. Suction drainage was used routinely. Two or 3 grammes of chloramphenicol powder was used locally in most operations. Systemic antibiotics were reserved for open fractures.

A tendency to equinus may be present in lowest third fractures and a back slab may be useful in controlling this. Active knee and ankle exercises may be started immediately. The limb was kept elevated until the wound had healed soundly and then the patient was mobilized. No specific restriction of weight bearing was en- forced, but frequently the patients used 1 or 2 sticks for support.

C L I N I C A L M A T E R I A L This report refers to 34 tibial shaft fractures treated by double plating in the Redhill Group

patients had bilateral fractures, and all but 1 of these were double plated. There were I0 patients with delayed or non-union (Table I).

Ages The ages ranged from 16 to 90 years. The average age of patients with fresh fractures (Fig. 4) was 40 years and of those with non-union 30 years (Fig. 5).

T Y P E S O F F R A C T U R E T R E A T E D

Fresh fractures These were all unstable fractures of the middle or the lowest third of the tibial shaft. If a closed reduction had been performed the position in plaster did not remain satisfactory. Twelve of the 21 patients (Table H) had significant multiple injuries in whom problems of mobilization, particularly in the elderly, were likely to occur had a conservative approach been adopted (Fig. 6).

In patients with multiple injuries, operation was performed as soon as their general condition would allow. The timing of operation is shown in Table IlL

Open fractures One-third of the fresh fractures were open. Operation was performed when wound healing was complete in 5 cases but as a primary pro- cedure in 3 cases (Table IV). It was possible to apply retrospectively the Portsmouth Classifica- tion (Hamza, Dunkerley, and Murray, 1971) to these injuries.

Delayed and non-union Ten patients with un-united tibial fractures were treated by double plating. Half of these had had previous unsuccessful operations (Table V). Four cases of delayed union with marked clinical instability were double plated between 13 and

Parker : T w o - p l a t e F i xa t i on o f T ib ia l S h a f t Fractures 2 9 3

16 weeks after injury. Six established cases of non-union were double plated between 21 and 64 weeks alter injury. In 1 patient a cancellous graft was added and in 2 patients the fibula was resected. In the other patients the application of the plates was the sole operative procedure. Three of these patients had had a fractured femur of the same limb treated by intramedullary nailing.

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11-20 21-3( 131-40141-5C ; I - 60 61-7a 71-80 81-90 1 YR';

Fig. 4.--Ages of the patients with fresh fractures.

R E S U L T S

U n i o n Two patients died within 8 weeks of injury but union occurred in all but 1 of the remaining fractures (Table VI). There was usually little external callus and it was difficult therefore to give a very exact time of union. However, all but 4 fractures were judged to be united within 6 months (Fig. 7).

C o m p l i c a t i o n s One death was due to massive pulmonary embolism and the other to the delayed effects of a severe head and chest injury. A serious complication occurred in 8 of the remaining 32 fractures (25 per cent) (Table VII).

Sepsis Three of 24 fractures (12"5 per cent) developed infection. One of these was a 58-year-old man with a Type 3 open fracture treated by immediate double plating. A below-knee amputation for infected non-union was necessary 1 year after injury.

Two patients developed chronic osteomyelitis after open fractures, but despite this their fractures united. In both of these patients the plates were removed and dead bone excised

after an early stage of union was established (Fig. 8). One of these patients still has a dis- charging sinus but declines further operative treatment.

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Fig. 5.--Ages of the patients treated for delayed or non-union.

Table/L--Twelve of 21 patients with fresh fractures had multiple injuries

Associated injuries Fractured femur same side 3 Fractures of both tibiae 4 Port's fracture same side 2 Fractured patella 1 Severe upper limb injury 5 Severe head/chest injury 1

Two of the un-united fractures developed superficial infection with no evidence of bone necrosis. One followed an operation to resect a traumatic arteriovenous fistula of the peroneal vessels. In both cases sepsis resolved following plate removal after union.

Stress fractures There were 2 instances of late stress fractures. One occurred just below the plated area 10 months after injury. The second appeared through a screw hole 3~ years after the original injury. This was in a patient who had required plate removal for shin discomfort 3 weeks previously. Radiographs before plate removal had seemed satisfactory. Both of these fractures united after 4 months in plaster.

294 Injury : the British Journal of Accident Surgery Vol. 5/No. 4

Ank le equ inus This occurred in a patient wi th a Pott's fracture- dislocation of the same leg treated by open reduction and screwing of the medial malleolus. The remaining patients had a satisfactory range of ankle joint movement.

Breck and Basom (1944), Key (1945), and Wen- ger (1946) applied 2 plates perpendicular to each other. Their techniques required special jigs to direct thescrews or boltsand this necessitated alarge exposure. Adams and Coonse (1948) warned of the danger of bone necrosis with these methods.

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Fig. 6.--An 81-year-old man with bilateral closed tibial fractures. Both were treated by immediate double plating. Note the below-knee back splints to control any tendency to equinus in the early postoperative phase. When the wounds were healed he walked free of plaster with a stick. His fractures were united within 16 weeks.

Table HL--Timing of operation in 24 fresh fractures

Within 24 hours 11 1-7 days 5 1-2 weeks 3 2-4 weeks 3 Over 4 weeks 2

DISCUSSION Nicoll (1964) showed in a series of 705 tibial fractures of mixed severity treated by a con- servative approach that union occurred in 95 per cent, and that the quality of result was generally satisfactory. This management of most tibial fractures is followed at Redhill. Despite this, many unstable fractures are seen and if i.t is felt that internal fixation has specific advantages, it is used freely. Burwell (1971) has shown that such fractures can usually be treated satisfactorily by standard plating tech- niques. There is, however, a group of severe tibial fractures in which rigid fixation offers advantages and it is in this group that double plating may be considered.

Table/V.--Open fractures

Immediate Delayed plating plating

Type 1 * 2 2 Type 2 0 3 Type 3 1 0

Total 3 5

*Type 1: Puncture wound. Type 2: Moderately open with a 2-5 to 5 cm wound. Type 3: Severe lacerated wound with considerable tissue damage and possibly skin loss.

Marshall (1958) and Berkin and Marshall (1972) describe the use of a two-plate assembly in which a slotted plate is bolted to a counter plate in such a way that a hold is obtained on all three tibial surfaces. His results in 51 fresh tibial fractures seemed very satisfactory but the technique is complex and has not gained any widespread acceptance.

McLoughlin, Gaston, Neer, and Craig (1949) and Murray, Lucas, and Inman (1964) report the

Parker: Two-plate Fixation of Tibial Shaft Fractures

use of 2 plates in dissimilar planes by a tech- nique similar to that used in this series. Most other reports on double plating refer mainly to fractures of the lower femoral shaft and to the use of slotted plates.

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studied the strength of fixation of various implants mechanically. They all found that the application of two small plates achieved a higher degree of rigidity than standard plates. Compres- sive techniques enhance rigidity but are limited

Table V.--Ten un-united fractures

Previous treatment Failed manipulation and plaster 5 Failed single plate 3 Failed bone graft 2

Table V/.--Union

Fresh fractures 21 out of 22 Non- and delayed union 10 out of 10

Table V/L--Complications

Fresh fractures Non-union

Deaths 2 0 Sepsis 3 2 Amputation 1 0 Arteriovenous fistula 0 1 Stress fracture 2 0 Ankle equinus 1 0

Fig. 7.--This illustrates primary bone union (union without external callus). It is often difficult to say when union has occurred until the fracture line is totally obliterated.

Double plating of tibial fractures by the simple method described does not involve any wider exposure, or more periosteal stripping, than in the application of an adequate single plate. Double plating is often criticized because of the risk of causing bone necrosis but it is felt that this does not apply to the technique used in this series.

Biomechanical studies Lindahl (1962, 1964, 1967), Laurence, Freeman, and Swanson (1969), and Hicks (1969) have

Fig. 8.--Chronic osteomyelitis followed double plating of this open fracture. The plates were removed after a very early stage of union was present. A sequestrectomy was necessary before a discharging sinus would heal.

in their effectiveness if there is much com- minution, if forces are applied in such a way as to open the fracture, or if resorption of bone ends occurs (Kiintscher, 1970). In this situation the degree of rigidity will depend on the strength of the plate and the strength of its fixation to bone by screws (Freeman, 1971). It requires a much more bulky single plate to produce the degree of rigidity obtained by two relatively small plates on different cortices.

Biological e f fects of internal f ixat ion Most tibial fractures will unite without internal fixation and most will also unite when non-rigid

296 Injury : the British Journal of Accident Surgery Vol. 5/No. 4

methods are employed. Hicks (1969) has pointed out that considerable movement at the fracture site can occur in a standard plated fracture without being detectable by clinical or normal radioiogical means. If this movement is abolished or very considerably reduced, then union with minimal callus, primary bone union, takes place (Danis, 1949). Abolishing movement at a ttbial fracture site probably does affect the occurrence of union. The union of an un-united fracture treated by only the application of the principle of rigid internal fixation being very strong supporting evidence.

THE PLACE OF DOUBLE PLATING Fresh fractures If early unsplinted weight-bearing is desirable, the technique of double plating may be con= sidered. This is of particular advantage in the patient with multiple limb injuries, and in the elderly, who may be unable to cope with plasters and crutches. An outstanding indication is the elderly patient with unstable bilateral tibial fractures.

The experience of 3 cases of osteomyelitis in 8 open fractures certainly suggests that double plating should await sound soft-tissue healing. In the severe open fracture of the tibial shaft-- Type 3--immediate internal fixation offers distinct advantages in allowing rapid soft-tissue healing and early joint mobilization, but in these conditions an intramedullary nail or single plate are more appropriate.

Since this series of patients was treated, the method has been used in a more selective way in unstable fractures with sound skin. Attention has been paid to obtaining complete wound healing before permitting walking. There has been no case of sepsis since adopting this policy.

The stress fracture may be regarded as a harm- ful effect of such rigid fixation. Local osteo- porosis is produced because of the protection of the plated bone from normally acting osteogenic stimulating forces. Murray and others (1964) warned of the danger of removing both plates at the same time. They suggested that the plates should be removed singly with an interval of 10 weeks between the removal of each plate. There was 1 example of such a fracture occurring in this series when both plates were removed at the same time 3½ years after the original operation. It is now becoming recognized that similar fractures may occur following the removal of compression plates when rigid fixaiion has also been achieved. Protected weight bearing for 6 weeks following plate removal is advisable.

N o n - u n i o n Key (1945) appeared to be the first to describe the use of two plates in the treatment of non-union. He illustrated its use in a tibial fracture but the number treated was not revealed. Murray and others (1964) reported the results of 51 cases of non-union treated by this method. There were 7 cases of tibial non-union in their series, all of which united.

Hicks (1963) described two types of non-union: 1. Non-union with much callus. 2. Non-union due to dead bone.

The first of these appears as the typical 'elephant 's foo t ' on radiographs. The bone around the fracture is sclerotic due to increased vascularity and Mtiller (1966) terms this a ' hyper- vascular pseudarthrosis '. This type of non-union is due to persistent movement of the fracture, and union can be anticipated if the fracture is rigidly immobilized. Double plating is a n effective method of achieving this end.

The second type of non-union invites the use of bone grafting but rigid fixation is also desirable as many of these patients have spent a consider- able time in plaster already. Once non-union is established, especially if previous surgery has failed, double plating can mean the end of what may become a time-consuming process for both patient and surgeon.

Acknowledgement I am indebted to Mr. P. A. Ring, for allowing me to report on his patients and for his constant guidance on this project.

REFERENCES ADAMS, J. D., and COONSE, G. K. (1948), ' Complete

rigid internal fixation by double plating fractures of long bones ', Proc. Inst. Med., Chicago, 17, 98.

BERKIN, C. R., and MARSHALL, D. V. (1972), ' Tl'u'ee- sided plate fixation for fractures of the tibial and femoral shafts. A follow-up note ', J. Bone Jt Surg., 54A, 1105.

BRECK, L. W., and BASOM, W. C. (1944), ' The dual plate, no cast, internal fixation of shaft fractures ', Sth. reed. J., Nashville, 37, 582.

BURWELL, H. N. (1971), ' Plate fixation of tibial shaft fractures ', J. Bone Jt Surg., 53B, 258.

DANIS, R. (1949), Thdorie et Practique de I'Osteo- synthdse. Paris: Masson.

FREEMAN, M. A. R. (1971), personal communication. HAMZA, K. N., DUNKERLEY, G. E., and MURRAY,

C. M. M. (1971), ' Fractures of the tibia ', J. Bone Jt Surg., 53B, 696.

HICKS, J. H. (1963), 'Hypothesis: non-union of fractures ', Lancet, 1, 86.

Parker : Two-plate Fixation of Tibial Shaft Fractures 297

HICKS, . l .H. (1969), ' Rigidity in fracture fixation ', Injury, 1, 69.

KEY, J. A. (1945), ' D u a l plates for internal fixation in non-union of fractures ', J. Bone Jr Surg., 27, 632.

KONTSCHER, G. (1970), Das Kallus-Problem. Stutt- gart: Verlag.

LAURENCE, i . , FREEMAN, i . A. R., and SWANSON, S. A. V. (1969), ' Engineering considerations in the internal fixation of fractures of the tibial shaft ', J. Bone J t Surg., 51B, 754.

LINDAHL, O. (1962), ' Rigidity of immobilisation of transverse fractures ' , Aeta orthop, scand., 32, 237.

- - - - (1964), ' Rigidity of immobilisation of oblique fractures ', Ibid., 35, 39.

- - - - (1967), ' The rigidity of fracture immobilisation with plates ', Ibid., 38, 101.

McLOUGHLIN, H. L., GASTON, S. R., NEER, C. S., and CRAIG, F. S. (1949), ' O p e n reduction and internal fixation of long bones ", J. Bone .It Surg., 31A, 94.

MARSHALL, D. V. (1958), 'Three-side plate fixation for fractures of the femoral and tibial shafts ', Ibid., 40A, 323.

MOLLER, M. E. (1966), ' Treatment of non-unions by compression ', Clin. Orthop., 43, 83.

MURRAY, W. R., LUCAS, D. B., and INMAN, V. D. (1964), 'Trea tment of non-union of fractures of the long bones by the two-plate method ', J. Bone .It Surg., 46A, 1027.

NICOLL, E. A. (1964), ' Fractures of the tibial shaft ', J. Bone Jt Surg., 46B, 373.

WENGER, H. L. (1946), ' A new method of bone plating ', Surgery, St. Louis, 20, 547.

Requests for repriats should be addressed to:--Barrie Parker, Esq., F.R.C.S., Senior Registrar, Orthopaedic Unit, Charing Cross Hospital (Fulham), Fulham Palace Road, London, W6 8RF.

ERRATUM

INJURY, 5, 212, Fig. 3 is inverted.