title: A prospective multi-center study of intramedullary nailing vs casting of stable tibial shaft fractures.
abstract: BACKGROUND
  The purpose of this study was to determine optimal treatment of stable tibial shaft fractures using intramedullary nailing (IMN) or casting.
  
  
  METHODS
  We performed a multi-center prospective study cohort. Patients with stable tibia shaft fractures meeting Sarmiento's criteria (isolated closed fractures with less than 12 mm of shortening and 10° of angulation) were enrolled prospectively and treated with either a reamed IMN with static interlocking screws or closed reduction followed by long-leg casting. Both groups were weight bearing following surgery. Radiographs were taken until union, and range of motion of knee and ankle joints was assessed. Malalignment (>5°) and malunion (>10°) were determined. Functional outcome measures using short musculoskeletal assessment scores (SMFA) and a knee pain score were scheduled at 6 weeks, 3 months and 6 months.
  
  
  RESULTS
  At 3 months, differences between the casting and IMN groups were noted in return to work (6/15 vs 3/17, P < 0.05); ankle dorsiflexion (7° vs 12°, P < 0.05); plantar flexion (28° vs 39°, P < 0.05); and SMFA domains of Dysfunction Index, Bother Index, daily activities, emotional status, and arm/hand function (P < 0.05). The SMFA mobility function demonstrated a significant trend (P = 0.065). At 6 months, malalignment was present in 3/15 in the casting group and in 1/17 in the IMN group (P = 0.02). Malunion was present in 1/15 in the cast group. One fracture in the casting group went on to nonunion and required late IMN placement at 7 months and eventually healed. There were no differences in ankle motion, SMFA scores, or return to work. There was no difference in knee pain between the groups as measured by VAS and Court-Brown pain scale at 6 months.
  
  
  CONCLUSIONS
  Patients with stable tibia fractures treated with intramedullary nailing have improved clinical and functional outcomes at 3 months compared with those treated with casting, but there are no differences in any other outcome measure. Patients treated in a cast may have a higher incidence of malalignment or malunion.
  
  
  METHODS
  Level-II prognostic.
authors: Vanderbilt University Medical Center, 1215 21st Avenue South, MCE South Tower, Suite 4200, Nashville, TN, 37232, USA. william.obremskey@vanderbilt.edu.
authors: William T
authors: WT
authors: Obremskey
authors: Vanderbilt University Medical Center, 1215 21st Avenue South, MCE South Tower, Suite 4200, Nashville, TN, 37232, USA.
authors: Norele
authors: N
authors: Cutrera
authors: Vanderbilt University Medical Center, 1215 21st Avenue South, MCE South Tower, Suite 4200, Nashville, TN, 37232, USA.
authors: Christopher M
authors: CM
authors: Kidd
mesh_terms: D000328:Adult; D001858:Bone Nails; D002370:Casts, Surgical; D005260:Female; D005500:Follow-Up Studies; D005594:Fracture Fixation, Intramedullary; D017102:Fracture Healing; D005596:Fractures, Closed / Q000503:physiopathology / Q000628:therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D016059:Range of Motion, Articular; D020127:Recovery of Function; D013978:Tibial Fractures / Q000503:physiopathology / Q000628:therapy*; D016896:Treatment Outcome; D016474:Weight-Bearing
keywords: Casting; Intramedullary nail; Non-operative treatment; Tibial shaft fracture