Early versus delayed operative management of closed tibial fractures

Fractures of the tibial shaft are the most common long bone fractures. Operative treatment of isolated closed tibial shaft fractures frequently is delayed in favor of treatment of life threatening injuries. A retrospective chart review of 200 tibial fractures was performed. These injuries were managed by two surgeons at a Level 1 trauma center between 1989 and 1996. Strict inclusion criteria identified 54 patients with an isolated closed tibial fracture. Postoperative hospital stay and complication rates were recorded. At a mean followup of 3.6 years, a quality of life questionnaire was administered via telephone calls to these patients. Two patient groups were identified: Group 1, 21 patients (< 12-hour surgical delay); and Group 2, 33 patients (> 12-hour surgical delay). Both groups were similar for baseline characteristics. Group 2 patients remained an extra 4.6 days in the hospital. A Kaplan-Meier analysis revealed that by the eighth postoperative day, all Group 1 patients were discharged from the hospital, whereas 47.8% of Group 2 patients remained in the hospital. Plate fixation was associated with a greater incidence of complications when compared with intramedullary nail internal fixation. Complication rates were significantly greater in the delayed surgical group. A multiple regression analysis revealed that surgical delay and postoperative complications accounted for 35% of the total variance in postoperative hospital stay. Time to surgical treatment was not prognostic of long term quality of life. Surgical delay results in longer postoperative hospital stays, greater complication rates, and increased total cost to the health care system.