REVIEW ARTICLE

ANZJSurg.com

Comparison of three fixation methods in treatment of tibial fracture in

adolescents
Lixiang Lin, Yang Liu, Chuanlu Lin, Yifei Zhou, Yongzeng Feng, Xiaolong Shui, Kehe Yu, Xiaolang Lu,
Jianjun Hong and Yang Yu
Department of Orthopaedics, Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China

Key words Abstract

adolescents, comparison, fixations, tibial fracture.
Correspondence
Dr Yang Yu, Department of Orthopaedics, Second
Affiliated Hospital of Wenzhou Medical University,
109 Xueyuan Road, Wenzhou, Zhejiang 325027,
China. Email: yangyu993@yeah.net
L. Lin; Y. Liu; C. Lin; Y. Zhou MD; Y. Feng MD;
X. Shui MD; K. Yu MD; X. Lu MD; J. Hong MD;
Y. Yu MD.
Accepted for publication 5 September 2017.
doi: 10.1111/ans.14258
Background: Tibial fractures are the most common musculoskeletal injury in adolescents.
The optimal management of tibial fractures in adolescents is controversial. In this study, we
compared the outcomes including complications of three fixation methods in tibial fractures
of adolescents and explored the factors associated with the complications.
Methods: A retrospective cohort study about 83 diaphyseal tibial fractures in 79 children
and adolescents, who were treated with plate fixation (PF), elastic stable intramedullary nail
fixation (ESINF), or external fixation (EF), was conducted. After adjustment for age,
weight, energy of the injury, polytrauma, fracture level and pattern, and extent of comminu-
tion, treatment outcomes were compared in accordance with the length of the hospital stay,
time to union, and complication rates including many factors.
Results: The mean age of the patients was 13.4 years, and their mean weight was 44.2 kg.
There was a loss of reduction in two of 33 fractures treated with ESINF and four of 13 trea-
ted with EF (P < 0.001). At the time of final follow-up, three patients (two treated with EF
and one treated with ESINF) had ≥2.0 cm of shortening. Four of the 32 patients (33 frac-
tures) treated with ESINF underwent a reoperation (two due to loss of reduction and one
each because of delayed union and nonunion). Six patients treated with EF required a reo-
peration (four due to loss of reduction, one for malunion and one for replacement of a pin
complicated by infection). Two fracture treated with PF required refixation attributing to
nonunion and malunion. A multivariate analysis with adjustment for baseline differences
showed that EF was associated with a 7.56-times (95% confidence interval 3.74–29.87)
greater risk of loss of reduction and/or malunion than ESINF.
Conclusions: All three treatments had satisfactory outcomes, and EF was correlated with
the highest rate of complications in our series of adolescents treated with a tibial fracture.
However, we cannot currently recommend that all fractures might be suitable for ESINF.
The choice of fixation will remain influenced by surgeon preference in term of expertise and
experience, patient and fracture characteristics, and patients and family preferences.

mobilization, preserve or optimize fracture biology, minimize scar-

Introduction
Tibial fractures are the most common musculoskeletal injury in
adolescents. That in younger children are generally thought to heal
satisfactorily irrespective of treatment form, but the management of
tibial fractures in adolescents presents specific challenges. As the
body weight and the size of skeletally immature adolescents
approach those of adults, there are greater demands on the stability
afforded by implants used to treat these fractures. The ideal treat-
ment method should provide adequate stability to permit early
ring, avoid serious complications and achieve these above goals in
a cost-effective manner. Currently, there are several surgical
options, including elastic stable intramedullary nail fixation
(ESINF), or external fixation (EF), and compression or bridge plate
fixation (PF). Consequently, the optimal method of treatment is
unclear. The purpose of this study was to compare the treatment
outcomes and complications of three different methods of fixation
of tibial fractures in adolescents and to determine the factors related
to these complications.

© 2017 Royal Australasian College of Surgeons ANZ J Surg (2017)

2 Lin et al.

Table 1 Age, sex and body weight

Total (n = 83 fractures, Elastic nail (n = 33 External fixation (n = 13 Plate (n = 37 fractures, P

79 patients) fractures, 32 patients) fractures, 13 patients) 34 patients) value

Age (SD) (year) 13.4 (3.8) 13.4 (5.2) 12.4 (4.6) 13.6 (3.7) 0.068
Sex
Male 55 22 (69%) 9 (69%) 24 (70%) 0.095
Female 24 10 (31%) 4 (31%) 10 (30%) 0.074
Body weight (SD) (kg) 44.2 (5.9) 43.4 (7.9) 42.1 (6.3) 49.3 (7.1) 0.001

Methods 79 fractures were associated with multiple injuries, including other

We conducted a retrospective cohort study of traumatic diaphyseal
tibial fractures in children (age: 11–17.6 years) who had been treated
at the Wenzhou Medical University of the second affiliated hospital,
a Department of Orthopaedics trauma centre between 2007 and 2013,
and pathological fractures were excluded. Patients have been fol-
lowed at least until radiographic or clinical union of the fracture
and/or until they had regained their usual physical function. A total of
83 diaphyseal tibial fractures were identified during this period. The
patients were characterized according to age, sex, weight, mechanism
and energy of injury, whether they had sustained multiple injuries or
an isolated injury, fracture level and pattern, percentage comminution
(according to a modification of the classification system of Winquist
and Hansen1) and method of fixation. Three fracture fixation methods
were ESINF (33 fractures; 32 patients), compression or bridge PF
(37 fractures; 34 patients) and EF (13 fractures; 13 patients).
Age, sex and body weight (Table 1)
There were 55 boys and 24 girls with an average age of 13.9 years
(range from 11 to 17.6 years). Both age and the sex distribution
were similar across all three groups (P > 0.05).
The patients had a mean weight of 47.2 kg (range from 24 to
68 kg), with a wide distribution of body weights across all three
groups. The patients in the plate group were, on the average, signif-
icantly heavier (49.3 kg) than those in the ESINF group (43.4 kg),
and those in the EF group (42.1 kg) (P = 0.001).
Mechanism of injury and associated trauma
(Table 2)
Various injury mechanisms were responsible for these fractures
across all treatment groups. Twenty-four percent (19) of the
fractures, visceral injuries and head injuries. The proportion of frac-
tures associated with polytrauma did not differ significantly among
the three treatment groups (P = 0.24). Twenty-eight (33%) of the
fractures were caused by high-energy trauma, which was character-
ized on the basis of injury mechanism (a pedestrian or bicyclist
struck by a motor vehicle or a motor vehicle accident) and/or the
presence of other injuries. The rates of high-energy trauma were
comparable across the three treatment groups.
Fracture level, pattern, and percent
comminution (Table 3)
There were 48 fractures (58%) involved the midpart of the femoral
diaphysis, 23 (28%) involved the proximal third of the diaphysis
and 12 (14%) involved the distal third. The distribution of fracture
levels did not differ significantly among the treatment groups.
Thirty-seven (45%) of the fractures were transverse, 29 (35%)
were oblique and 17 (20%) were spiral. The distribution of fracture
patterns varied among the three treatment groups. There was a sig-
nificantly higher proportion of spiral fractures and fewer transverse
and oblique fractures in the EF group than in the other treatment
groups (P = 0.001).
The magnitude of comminution was graded according to the per-
centage of the shaft width that was fragmented, a method adapted
from the classification system described by Winquist and Hansen.
There was no fragmentation (grade 0) at the fracture site in 23 tib-
ial (28%), whereas there was some degree of comminution in
60 (72%). Grade I fragmentation (<25% of the shaft width) was
noted in 31 tibial (37%); grade II (25–<50%), in 16 (19%); grade
III (50–<75%), in seven (7%) and grade IV (75–100% or segmen-
tal), in six (9%). The distribution of fracture comminution varied
significantly among three treatment groups. The EF group had a

Table 2 Mechanism of injury and associated trauma

Total (n = 83 Elastic nail (n = 33 External fixation (n = 13 Plate (n = 37 P

fractures) fractures) fractures) fractures) value

Mechanism of injury
Low energy (walk, glide, sports) 55 22 9 24 0.55
High energy (a pedestrian or bicyclist 28 11 4 13 0.79
struck by a motor vehicle or a motor
vehicle accident)
Associated trauma 19 8 5 6 0.24
Other fractures 9 4 2 2
Visceral injuries 4 2 1 1
Head injuries 6 2 2 3

© 2017 Royal Australasian College of Surgeons

Fixation in adolescent tibial fracture 3

Table 3 Fracture level, pattern and percent comminution

Total (n = 83 Elastic nail (n = 33 External fixation (n = 13 Plate (n = 37 P

fractures) fractures) fractures) fractures) value

Fracture level
Proximal 23 8 3 12
Middle 48 23 7 18
Distal 12 2 3 7
Pattern
Oblique 29 9 4 16 <0.001
Spiral 17 4 7 6 <0.001
Transverse 37 20 2 15 <0.001
Percent comminution
Grade 0 23 18 2 3
Grade I 31 11 2 18
Grade II 16 4 1 11 <0.001
Grade III 7 0 4 3
Grade IV 6 0 4 2
Open fracture 8 1 5 2 <0.001

significantly higher proportion of more comminuted fractures than
the ESINF group or plate group (P < 0.001).
There were eight open fractures which were categorized based
on the Gustilo–Anderson classification, and a significantly higher
rate of open fractures in the EF group (five) than in the ESINF
group (one), or plate group (two) (P < 0.001).
Outcomes
The length of the hospital stay, time to union and complications
associated with each method are presented in Tables 1 and 2. The
time to union was defined as the number of weeks until there was
radiographic and clinical evidence of union. Radiographic evidence
of union was defined as remodelling (mature) callus bridging at
least three of the four cortices seen on two orthogonal views of the
tibia. Clinical union was inferred from the absence of tenderness at
the fracture site along with full weight-bearing without pain. Com-
plications of interest included loss of reduction, malunion, non-
union, refracture, infection and the need for a reoperation.
Malunion was defined as one or more of the following: ≥10 of
angulation in the coronal plane (varus or valgus), ≥20 of angula-
tion in the sagittal plane (apex-anterior or apex-posterior angula-
tion), clinically obvious malrotation (an asymmetric foot
progression angle with corresponding asymmetry of internal or
external rotation of the knee), or a limb-length discrepancy of
≥2.0 cm. A clinically relevant loss of reduction was defined as any
change in the post-operative alignment that prompted operative
intervention or resulted in malunion as defined by the criteria
described above. A reoperation was defined as any fracture-related
procedure, other than routine hardware removal, performed after
the initial fixation.
Statistical methods
Interval data are exhibited as M  SD. The baseline characteristics
in the three groups were compared using variance analysis for con-
tinuous data and Pearson chi-square statistics for proportions. Vari-
ance analysis was used to compare the mean lengths of the hospital
stay and the time to union. When a significant difference was
found, pairwise comparisons of the three groups were performed
with significance levels adjusted by Bonferroni correction to
account for multiple comparisons. Medians are reported for skewed
data. Complications are showed as rates. We hypothesized that mal-
union and/or loss of reduction requiring a reoperation would be
associated with age, sex, body weight, high-energy trauma, poly-
trauma, increased comminution, fracture level and pattern, an open
fracture and fixation method. Univariate analyses were performed
with Pearson chi-square statistics. Multiple logistic regression was
utilized to test jointly the explanatory variables that were significant
up to the 0.1 level in the univariate analyses. The adjusted odds
ratios are presented with their respective 95% confidence intervals.
Significance was set at a two-tailed level of 0.05.
Results
The mean follow-up time was 15.8 months.
Length of hospital stay (Table 4)
The median hospital stay all treatment groups was 6 days. The
median hospital stay, which did not vary significantly among the
treatment groups, was 6 days in the ESINF group, 7 days in the EF
group and 6 days in the plate group.
Time to union (Table 4)
All fractures united, in a mean of 12 weeks. An increased time to
union was significantly associated with the fixation type
(P = 0.004), high-energy fracture (P = 0.007), polytrauma
(P < 0.001) and open fracture (P = 0.006). The mean time to union
(and SD) was 10.8  6.4 weeks in the ESINF group, 18.3  7.9
weeks in the EF group, and 12.1  5.1 weeks in the plate group.
The pairwise comparison of the time to union between the groups
(adjusted for multiple comparisons) showed that the EF group had
a significantly longer time to union than the ESINF group
(P = 0.005) and the rigid nail group (P = 0.005). In the

© 2017 Royal Australasian College of Surgeons

4 Lin et al.

Table 4 Result

Total (n = 83 Elastic nail (n = 33 External fixation (n = 13 Plate (n = 37

fractures, 79 patients) fractures, 32 patients) fractures, 13 patients) fractures, 34 patients) P value

Length of hospital 0.073

stay (days)
Median 6 6 8 7
Mean (SD) 12.2 (9.3) 8.9 (7.2) 9 (5.7) 11.3 (9.6)
Mean time to 13.4 (7.4) 10.8 (6.4) 18.3 (7.9) 12.1 (5.1) 0.004 (0.017)
union
(SD) (week)

The time to union was shown to be significantly longer in the external fixation group in pairwise comparisons with the elastic nail group (Bonferroni adjusted
P = 0.005) and the plate group (Bonferroni adjusted P = 0.005). Adjusted for other baseline factors in multivariate analysis.

multivariate model, only the fixation type (P = 0.016) and poly- of reduction (P = 0.99). Polytrauma was associated with a 4.17-
trauma (P = 0.023) remained significantly associated with an times (95% confidence interval 0.78–18.93) greater risk of loss of
increased time to union. This was found to be true even when we reduction, but this association did not reach signifi-
adjusted for baseline differences in risk factors for delayed healing. cance (P = 0.19).

Complications (Table 5) Reoperations (Table 6)

There was a loss of reduction of two (6%) of the 33 fractures in the
ESINF group, four (30%) of the 13 in the EF group, and none of
those in the plate group (P < 0.001). At the time of final follow-up,
malunion was noted in two of the 33 in the ESINF group, two of
the 13 in the EF group and two of the 37 in the plate group
(P = 0.73). The deformities ranged from 14 of varus to 13 of val-
gus and from 22 of procurvatum (apex-anterior) to 20 of recurva-
tum (apex-posterior). Three patients (one in the ESINF group and
two in the EF group) had a limb-length discrepancy of between 2.0
and 2.5 cm at the time of fracture union. Without an externally visi-
ble deformity or functional limitations secondary to the malalign-
ment or shortening, patients had not received any treatment by the
time of this report.
In the univariate analyses, the type of fixation (P < 0.001), frac-
ture pattern (specifically, spiral fractures) (P = 0.027) and poly-
trauma (P = 0.09) were associated with a clinically relevant loss of
reduction. In the multivariate analysis, only the fixation type
(EF) remained significantly associated with loss of reduction
(P = 0.039). EF was associated with a 7.56-times (adjusted odds
ratio) (95% confidence interval 3.74–29.87) greater risk of loss of
reduction and/or malunion (P = 0.004) than ESINF. PF were not
significantly different from ESINF with regard to subsequent loss
Four of the 33 fractures in the ESINF group required a reoperation.
There were two instances of loss of reduction. One fractures with
delayed union after ESINF was stabilized with rigid intramedullary
nailing at seven months after the initial operation.
In addition, there was one refracture in patients who had been
treated initially with ESINF.
Six of the 13 fractures treated with an external fixator required
total reoperations. Loss of reduction in four cases required readjust-
ments of the external fixator with the patient under general anaes-
thesia. There were one with malunion and one patient required
replacement of a pin because of an infection, respectively.
Two of the 37 fractures in the plate group required a reoperation.
The two with delayed union after PF were stabilized with rigid
intramedullary nailing at 25 months after the initial opera-
tion (Fig. 1).
Major complications
A major complication was defined as a clinically relevant loss of
reduction, a malunion or shortening, and/or a reoperation for any
reason other than routine hardware removal. In the multivariate
model, the factors that remained significantly associated with a

Table 5 Clinically relevant loss of reduction and/or malunion

Total (n = 83 Plate (n = 37
fractures, 79 Elastic nail (n = 33 External fixation (n = 13 fractures, 34
patients) fractures, 32 patients) fractures,13 patients) patients) P value

Loss of reduction (resulting in 6 2 (6%) 4 (31%) — <0.001 (0.042)

reoperation and/or malunion)
Malunion 6 2 (6%) 2 (15%) 2 (8%) 0.06
Limb-length discrepancy 3 1 (3%) 2 (15%) — 0.003
of ≥2 cm
Total 15 5 (15%) 8 (61%) 2 (8%) 0.04 (0.007)

In the pairwise comparisons, the rate of clinically relevant loss of reduction was significantly higher only in the external fixation group compared with the two other
fixation groups (Bonferroni adjusted P < 0.001 in all three comparisons). Adjusted for other baseline factors in multivariate analysis. The rate of clinically relevant
loss of reduction and/or malunion and/or limb-length discrepancy was shown to be significantly higher in the external fixation group in pairwise comparisons with
the elastic nail group (P = 0.002) and the plate group (P = 0.003). (All P values are Bonferroni adjusted for multiple comparisons.) No significant difference was
found between the elastic nail group and the plate (P = 0.66) group.

© 2017 Royal Australasian College of Surgeons

Fixation in adolescent tibial fracture 5

Table 6 Reoperation

Total (n = 83 Elastic nail (n = 33 External fixation (n = 13 Plate (n = 37 P

Reason for reoperation fractures, 79 patients) fractures, 32 patients) fractures, 13 patients) fractures, 34 patients) value

Loss of reduction 6 2 4 —
Malunion/shortening 2 — 1 —
Delayed union 3 1 — 2
Refracture — 1 — —
Infection 1 — 1 —
All reoperations (no. (%)) 12 4 6 2 0.021

Only the external fixation group had a significantly higher reoperation rate than the other groups.

Fig. 1. (a) A 14-year-old student with distal third tibial fracture. (b) Open reduction and PF was used. Two days after operation X-ray film showed a good
alignment of the fracture. (c) Twenty-five months after operation, X-ray film showed malalignment and delayed union occurred. (d) Post-operative radio-
graph showed reoperation with rigid intramedullary nailing. (e) Eight months after reoperation, X-ray film showed a good healing of the fracture.

major complication were fixation type (P = 0.001), polytrauma Discussion

(P = 0.009) and an open fracture (P = 0.036). After adjustment for
all other factors, the risk of a major complication was 7.2 times
greater with EF than it was with ESINF (P = 0.001). The risk of a
major complication did not differ significantly among the ESINF
and PF groups. The risk of a major complication associated with
polytrauma was 3.8 times (adjusted odds ratio) higher than that
associated with an isolated injury (P = 0.019).
There are few published studies that specifically deal with the oper-
ative treatment of tibial fractures in adolescents. Prospective trials
without the extrapolation of the optimal management of tibial frac-
tures in adolescents comparing different treatments for paediatric
tibial fractures have typically been limited to younger children.2 In
this study, we compared the results and complications associated

© 2017 Royal Australasian College of Surgeons

6 Lin et al.
with three different methods of operative fixation by adjusting for
baseline differences in patient, injury, and fracture characteristics
that very likely played a role in treatment selection.
We found that the time to union after EF was significantly longer
than that after ESINF. A prolonged healing time for tibial fractures
treated with EF has been reported in the literature.3,4 Whether this
is attributable to the treatment method itself or whether it reflects
the nature of the fractures that are typically treated with EF
(e.g. open fractures) was unclear. Indeed, the time for healing of
open tibial fractures has been reported to be longer than that
required for closed fractures.5 In our cohort, open fractures, high-
energy injuries and polytrauma were each significantly associated
with a prolonged time to union. We found that EF as well as the
presence of other injuries remained significantly associated with a
prolonged healing time, even after we adjusted for those risk
factors.
Few investigators have examined the results of ESINF in adoles-
cents, and concerns have been raised about the appropriateness of
this technique in older children.6 Say et al. reported a higher com-
plication rate in children of school-age than younger children.7
There is a concern that, as the body weight and size of adolescents
approaches those of adults, elastic nails may not provide sufficient
stability to prevent loss of reduction. In a study of 234 fractures
treated with ESIN in different centres, a five-times greater risk of a
poor outcome in children whose weight exceeded 49 kg.8 Kaiser
et al. found a significant association between obesity and complica-
tions with EF and with intramedullary nailing, reporting a compli-
cation rate of 40% in obese children.9
In contrast, there is no association between age and/or body
weight and the rate of complications in the entire cohort or within
any group. The mean weight of the entire cohort was 47.2 kg, with
a maximum of 74 kg. Although the adolescents who were treated
with PF were on the average heavier, the ESINF group is with a
mean weight of 43.4 kg and a maximum of 68 kg.
Complication rates after ESINF have been associated with the
severity of the comminution10 and the fracture stability.11 In our
study, neither the extent of the comminution nor the fracture pattern
had a significant association with loss of reduction or malunion in
the ESINF group. It is hard to study separately the theoretical
advantage of submuscular bridge plates included by PF with few
researches.
Ours was a retrospective cohort study of patients treated by six
surgeons in a single centre. Hence, the choice of fixation was inevi-
tably subject to selection bias. However, the relatively large sample
size and the efforts made to account for baseline differences in
these groups with use of multivariate analyses provide some reas-
surance that these findings are valid.
In conclusion, all three treatments had satisfactory outcomes but,
after adjustment for baseline differences, they were associated with
specific complications and EF had a significantly higher complica-
tion rate than did the other three groups. We concluded that ESINF
was especially used in obviously swelling soft tissue and not suit-
able to extramedullary fixation; compression or bridge PF was suit-
able to be used in slight injury in skin parenchyma and not suitable
to extramedullary fixation; EF were commonly used in the patients
with severe open injuries in soft tissue combining poor condition of
skin parenchyma. We believe that, when the principles of elastic
nailing are followed, titanium elastic nails can perform at least as
well as other devices and most of the complications associated with
this form of fixation are preventable.12 We found no association
between age or weight and the risk of reduction loss or malunion
after the use of this technique. Nevertheless, not all fractures may
be suitable for ESINF. Indeed, no current single technique is uni-
versally applicable to all tibial fractures in adolescents. Until evi-
dence to the contrary is available, the choice of fixation will remain
influenced by the surgeon’s preference based on expertise and
experience, patient and fracture characteristics, and patient and fam-
ily preferences, which can be guided by the findings of this study.
Conflicts of interest
None declared.
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© 2017 Royal Australasian College of Surgeons