Une série monocentrique de 49 fractures bifocales de jambe a été rétrospectivement analysée dans le but de préciser la place de chaque méthode d'ostéosynthèse : enclouage, fixation externe. Il s'agissait de sujets jeunes (moyenne = 40,8 ans), victimes de traumatisme à haute énergie : 30 fractures étaient ouvertes, 2 avaient un syndrome de loge immédiat, 17 patients étaient polytraumatisés et 25 polyfracturés. Les traits de fracture étaient métaphyso-métaphysaire disto-proximal 1 fois, diaphyso métaphysaires proximaux 17 fois, diaphyso-diaphysaires 27 fois et diaphyso métaphysaires distaux 4 fois. L'enclouage centromédullaire verrouillé avec alésage (GK) a été utilisé 32 fois, sans alésage 7 fois et 10 fixateurs externes ont été posés dont 3 rapidement convertis en enclouage (2 GK, 1 clou non alésé). Ont été déplorés après enclouage : 4 syndromes de loge, 1 décès par traumatisme crânien majeur, et deux amputations après échec d'un lambeau libre et d'une réparation vasculaire. Quatre patients ont été perdus de vue, 1 clou GK septique a été converti en fixateur. Les délais de consolidation ont été de 10 ± 4,8 mois pour les GK, 9,2 ± 2,9 mois pour les fixateurs externes, et 9,5 ± mois 2,5 pour les clous non alésés. Le nombre de pseudarthroses aseptiques était de 8/27 pour les GK, 2 sur 7 fixateurs externes et 2/8 clous non alésés. Toutes les pseudarthroses ont été reprises avec succès par un enclouage avec suralésage. Une attitude interventionniste est proposée en cas de retard de consolidation ou de pseudarthrose. Chaque technique a ses indications propres et irremplaçables même si l'enclouage avec alésage modéré doit être privilégié.

Segmental tibia fracture is defined by the presence of two distinct fracture lines separating the cortical and completely isolating an intermediary segment of the tibia. Little work has been published on this clinical entity. We report a retrospective analysis of 49 patients treated in one center for segmental tibia fracture in order to determine more precisely the indications for three surgical techniques: locked intramedullary nailing with or without reaming, and external fixation.

The series included 34 men and 15 women, mean age 40.8 years. All patients had traffic accident: 25 had multiple fractures, 17 had multiple organ injury, and 9 had floating knees. There were 30 open fractures; 2 patients developed compartment syndrome. The segments were: distal-proximal metaphyso-metaphyseal (n = 1), proximal diaphyso-metaphyseal (n = 17), diaphyso-diaphyseal (n = 27), and distal diaphyso-metaphyseal (n = 4). The mean length of the intermediary segment was 14.1 cm. The emergency procedure involved intramedullary nailing with reaming (Grosse-Kempf nail) in 32 patients, intramedullary nailing without reaming in 7 patients (Collin nail in 5 and UTN in 2) and external fixation with non-transfixing pins in 10 patients (Orthofix). External fixation was converted early to intramedullary nailing in three patients (Grosse-Kempf nail in 2 and Collin nail in 1).

Three patients were excluded: 2 underwent amputation after failure of vessel repair and 1 developed septic necrosis of a free latissimus dorsi flap; 1 patient died from multiple organ failure. Outcome at at least 18 months was known for 42 patients (4 patients lost to follow-up). There were 4 cases of post-nailing compartment syndrome; one case of deep infection on a Grosse-Kempf nail was treated by external fixation. Among the 27 patients with segment tibia fractures finally stabilized with a Grosse-Kempf nail, nonunion developed in 8; mean time to bone healing was 10 ± 4.8 months (with dynamization in 13 patients). For the 7 external fixations, nonunion developed in 2; mean time to bone healing was 9.2 ± 2.9 months. For the 8 nailings without reaming, nonunion developed in 2; mean time to bone healing was 9.5 ± 2.5 months. Bone healing was not simultaneous in the two foci in more than half of patients. Two patients developed clinical sequelae of their compartment syndrome with deficient knee flexion in two. The 12 cases of aseptic nonunion were successfully treated by nailing with reaming and early weight bearing.

Comparing our results with the therapeutic modalities used in published reports on segmentary tibia fractures showed that time to bone healing and the rate of nonunion were generally greater than in our series. A critical analysis of these results allows us to propose a more interventionalistic attitude before the development of late healing. We also propose a classification of segmental tibia fractures and a decisional tree for choosing between the three techniques based on the presence of soft tissue damage, the presence of compartment syndrome (nailing without reaming), and the presence of proximal or distal metaphyseal fractures (distal locked nail). Nailing with moderate reaming remains the preferred method.