MANAGEMENT OF DIAPHYSEAL FRACTURES OF TIBIA BY USED OF CLOSED REAMED INTERLOCKING NAIL

Background: Fracture shaft of tibia is one of the common fracture encountered by the orthopaedic surgeons in their daily practice, Many patients come to Department of Orthopaedics with tibial fractures. It is one of the common injuries occurring in adult age group. Material and Methods: A total of 30 patients with closed tibial fractures underwent surgery for the fracture fixation with intramedullary interlocking nail in the Department of Orthopaedics, Patna medical college and Hospital Patna Bihar. Duration of Two years. Patients were selected irrespective of sex. Conclusion: Intramedullary interlocking nail is the reliable, versatile and effective treatment for closed tibial fractures. The advantage of rapid rehabilitation and relatively few complications serves to recommend this procedure.


Introduction
Fracture shaft of tibia is one of the common fracture encountered by the orthopaedic surgeons in their daily practice, this is because the bone is subcutaneous with less protection from the surrounding muscle. Over the years various modalities of treatment has been used. Now a days the well laid principle of biological osyteosynthesis rightly applied in long bone fracture healing and hence the selection of closed intra-meduallary interlocking nailing in this study. Both operative and non-operative treatments of tibial shaft fractures have been strongly advocated. less severe fractures gradually do well without surgery, the more severe fractures requires surgery. Closed interlocking nailing helps in faster healing of fractures,because the fracture haemotoma is not disturbed and also the periosteal callus formation is not disturbed. Interlocking intramedullary nailing of the tibia greatly improves rotational stability and can be used for axially unstable fractures located from 7cm below the knee joint to 4cm above the ankle joint¹. Intramedullary nails with interlocking capabilities were developed in an effort to provide a more stable fracture construct and to expand the spectrum of fractures that could be nailed while avoiding the complications of malunion 2

Aims and Objectives
To evaluate the functional outcome in fracture shaft of tibia treated with intramedullary interlocking nail. To maintain limb length and prevent shortening,To study fracture healing and the union rate with intermedullary interlocking nailing. To prevent angulation and deformity. To mobilize the patient as early as possible.

Review of Literature
Hippocrates also taught about fractures in detail and its management over two thousand years ago. In the treatment of fractures, he employed traction with a wind lass, supported with a bench. His work has historic worth, and is also the background of many principle of modern orthopaedic surgery. The term "Orthopaedics" comes from its origin to the Greek word and was coined by the French Physician Nicolas Andry (1741), who published a book titled "La Orthopaedica", meaning art of correcting deformities in children.
The 19th century also saw the emergence of Orthopaedics as a speciality and the first orthopaediccentre was started. Plaster cast was used in 1852, by Mathysen and he used bandages impregnated with Plaster of Paris.In the 19th Century, Othropaedics and fractures depended on braces, casts, manipulations and exercise. John Hilton (1804-1878) advocated absolute bed rest for the fractured limb. At the dawn of 20th century, there was rapid evolution of surgery in orthopaedics. The art of correcting deformities and bone injuries, was given a scientific out look.

Intramedullary Nailing
Parsian Surgeon J. Friedrich Dieffenbachin1841, used Ivory pegs to cross the fracture site. Early orthopaedic surgeons, such as Senn, Lambotte and Hey Groves investigated the use of Ivory, Bone and Metal nails. The Rush brothers, Leshi and Lewry from Mississippi, developed the Rush rod in1927. "Vase-of-flowers< analogy of Rush, was usage of straight pins in curved bone and curved pins in straight bone, which is a three point fixation. 1940, Gerhard Kuntscher, regarded as Father of Intramedullary nailing, described at the German Surgical Conference, the clover leaf nail. Before this, he has also devised the V-nail. In 1950, Kuntscher added medullary reaming to achieve a uniform diameter of medullary canal better fit, extending the indications, to fractures a little away from the isthmus.
Herzog modified Kuntscher nail with bend at the upper quarter of the nail for tibial fractures to accommodate the eccentric proximal portal of entry. This was a standard treatment for unstable fractures. Here, two transfixation pins are inserted in the proximal end and distal end of the tibia. Closed reduction is done and below knee plaster cast is applied. This method maintains the length, prevents rotation and allows the mobilization of knee. It is also used in case of open fractures and communited fractures. main aim was to weight bearing and were used after initial consolidation of fracture. A full-length weight -relieving caliper with a cylindrical shin-guard made out of molded leather of plastic has been used. External fixators: They are used in open fractures, as it allows for regular wound dressing and allows for skin grafting. It is used as both a temporary and definitive stabilization They can be (1) Ring fixators (2) Frame fixators.

Internal Fixation
Cerclage Wiring : Applicable in spiral fractures. This was first devised by Goetz in 1993. However, this technique is an inefficient form of fixation and has to be supported externally. Also, if the fracture is widely displaced, percutaneous wiring has the danger of picking tendons and even vessels, unless displacement has been accurately reduced

Materials and Methods
All confirmed cases of fracture shaft of tibia in Department of Orthopedics at Patna medical college and Hospital Patna Bihar, India. Admitted between September 2019-May 2021 was taken up for the study. 30 cases including both males & females were studied. Cases were also followed up at an interval of 6 weeks, 3 months and 6 months.

COLLECTION OF DATA
Incidence rate of fracture shaft of tibia due to RTA is 37.5% (Rockwood Greens Fractures in adults 5th edition. Vol 2) at a permissible error 35%. Size of sample works out to be 30 using statistical formula n=4pq/l2.

Inclusion criteria
Patient who has been diagnosed as fracture shaft of tibia. Age group of more than 20 years of either sex. Patient who are fit for surgery.

Exclusion criteria
Skeletally immature individual. Gustilo -Anderson classification of open fractures of shaft of tibia Type III. Neurovascular injury Pathological fracture. Nonunion, Segmental fracture, Preoperatively the length of the nail is calculated by subtracting 3 to 4cm from measurement taken from the knee joint line to tip of the medial malleolus clinically and medullary canal is measured at the isthmus on X-rays.,

Surgical technique
Patients were operated under spinal / general anesthesia. Patient was placed in supine position over a radiolucent operating table. The injured leg was positioned freely, with knee flexed 90⁰ over the edge of operating table to relax the gastro-soleus muscle and allow traction by gravity. The uninjured leg was placed in abduction, flexion and external rotation to ensure free movements of the image intensifier from AP to lateral plane Bone Awl used for opening medullary canal.
Guide wire introduced.

Nail been inserted. Nail positon confirmed in c-arm OBSERVATION AND RESULTS
30 patients with fracture shaft of tibia were treated with closed interlocking nailing.
56.67% of the patients in our study were between the age group of 20-30 years.
The results obtained were as follows: Marut Nandan Kumar et al.  (1995). we have used intramedullay nails ranging from 8 to 10 mm in diameter and from 280 to 360 mm in length.Thirty closed reamed intramedullary nailing were done in our series. All the fractures were stabilized on a calcaneal traction till surgery. All patients in our series were given spinal anesthesia. In reamed nailing, the nail size in our series was 8mm. Static locking was done for all 30 cases in our series. Fracture Union was considered when patient was full weight bearing without pain; fracture site was not tender on palpation and radiograph showed osseous union. Final assessment in our series was done at 6 months using the Johner and Wruh's criteria, taking into account of the following criteria, gait, pain, deformity, range of motion of knee, ankle and subtalar joints, shortening and Neurovascular disturbances, ability to do strenuous activities, radiological union and presence or absence of non-union.

Conclusion
Tibial diaphyseal fractures are commonly seen in physically active young male and are commonly seen as result of road traffic accidents. The interlocking nailing restores length, Alignment and controls rotation, preserves periosteal blood supply, some amount of endosteal blood supply and with biological osteosynthesis, lowers the rate of infection and malunion. The advantage of locking screws over the conventional methods reduces the rate of malunion, loss of alignment, angulation and shortening which are commonly found in a plaster cast or functional brace. The addition of locking screws extends its indications to within 5 cm of ankle and knee joint. The method of treatment employing closed intramedullary interlocking nailing to stabilize both principal fragments on the nail is an excellent one for closed fractures with communition.