Closed fractures of the tibial diaphysis
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Closed Fractures of the Tibial Diaphysis. Much emphasis to High Energy fractures In Fact: 76.5% are closed 53.5% have mild soft tissue damage. Tibial Fractures. Most common long bone fracture 492,000 fractures yearly Average 7.4 day hospital stay 100,000 nonunions per year.

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Closed Fractures of the Tibial Diaphysis

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Closed fractures of the tibial diaphysis

Closed Fractures of the Tibial Diaphysis


Closed fractures of the tibial diaphysis

Much emphasis to High Energy fractures

In Fact: 76.5% are closed

53.5% have mild soft tissue damage


Tibial fractures

Tibial Fractures

  • Most common long bone fracture

  • 492,000 fractures yearly

  • Average 7.4 day hospital stay

  • 100,000 nonunions per year


Closed fractures of the tibial diaphysis

History & Physical

  • Pain, inability to bear weight, and deformity

  • Local swelling and edema variable

  • Careful inspection of soft tissue envelope, including compartment swelling

  • Thorough neurovascular assessment including motor/sensory exam and distal pulses


Closed fractures of the tibial diaphysis

Physical Exam

  • Soft tissue injury with high-energy crush mechanism may take several days to fully declare itself

  • Repeated exam to follow compartment swelling


Closed fractures of the tibial diaphysis

Radiographic Evaluation

  • AP and Lateral views of entire tibia from knee to ankle

  • Oblique views can be helpful in follow-up to assess healing


Closed fractures of the tibial diaphysis

Associated Injuries

  • Up to 30% of patients with tibial fractures have multiple injuries

  • Ipsilateral fibula fracture common

  • Ligamentous injury of knee with high energy tibia fractures

  • Browner and Jupiter, Skeletal Trauma, 3rd Ed


Closed fractures of the tibial diaphysis

Associated Injuries

  • Ipsilateral femur fx, “floating knee”

  • Neuro/vascular injury less common than in proximal tibia fx or knee dislocation

  • Foot and ankle injury


Closed fractures of the tibial diaphysis

Classification

  • Numerous classification systems

  • Important variables

    • Pattern of fracture

    • location of fracture

    • comminution

    • associated fibula fracture

    • degree of soft tissue injury


Closed fractures of the tibial diaphysis

OTA Classification

  • Follows Johner & Wruh system

  • Relationship between fracture pattern and mechanism

  • Comminution is prognostic for time

  • to union

Johner and Wruhs, Clin Orthop 1983


Closed fractures of the tibial diaphysis

Henley’s Classification

  • Applies Winquist & Hansen grading of femur to fractures of the tibia


Closed fractures of the tibial diaphysis

Tscherne Classification of Soft Tissue Injury

  • Grade 0- negligible soft tissue injury

  • Grade 1- superficial abrasion or contusion

  • Grade 2- deep contusion from direct trauma

  • Grade 3- Extensive contusion and crush injury with possible severe muscle injury, compartment syndrome


Compartment syndrome

Compartment Syndrome

  • 5-15%

  • HISTORY

    Hi-Energy

    Crush

  • 4 leg compartments


Nerve is the tissue most sensitive to ischemia

Nerve is the Tissue most Sensitive to Ischemia

  • PAIN first Symptom

  • PAIN with Passive Stretch first Sign


Each compartment has specific innervation

Each Compartmenthas Specific Innervation

  • Ant Comp - Deep Peroneal N.

  • Lateral - Sup Peroneal N.

  • Deep Post. - Tibial N.

  • Sup Post. - Sural N.


Closed fractures of the tibial diaphysis

Anterior Compartment

  • Dorsiflexes ankle

  • Tib ant, EDL, EHL, and peroneus tertius muscles

  • Anterior tibial a./v.

  • deep peroneal n.

    • 1st webspace sensation


Closed fractures of the tibial diaphysis

Lateral Compartment

  • Everts the foot

  • Peroneus brevis and longus muscles

  • Superficial peroneal n.dorsal foot sensation


Closed fractures of the tibial diaphysis

Superficial Posterior Compartment

  • Plantarflexes ankle

  • Gastrocnemius, soleus, popliteus, and plantaris muscles

  • Sural nerve

    • Lateral heel sensation

  • Greater and lesser saphenous veins


Closed fractures of the tibial diaphysis

Deep Posterior Compartment

  • Plantarflexion and inversion of foot

  • FDL, FHL, Tib post muscles

  • Post tibial vessels, peroneal a.

  • tibial nerve

    • Plantar foot sensation


Compartment syndrome is a clinical diagnosis

Compartment Syndrome is a Clinical Diagnosis


Pressure measurements are helpful

Pressure Measurements are Helpful

  • Various Thresholds

    P = 30

    P = 45

    ∆ P < 30

    = Diastolic BP - Compartment Pressure

McQueen, JBJS-B, 1990


Pressures not uniform

Highest at Fracture Site

Highest Pressures in Posterior & Anterior Compartments

Pressures Not Uniform

+++

++

+

  • Heckman JBJS 76


Clinical monitoring

Clinical Monitoring

  • Need Close Observation

  • Repetitive Exams

  • Some instances repetitive Pressure measurements

  • Indwelling Monitors?


Goals of fasciotomy

Goals of Fasciotomy

  • Decompress The Compartment

  • Do Not Strip Muscle From The Bone

  • Single vs. Two incisions

  • Plan for fracture fixation

  • Plan for wound closure


Closed tibial shaft fractures

Closed Tibial Shaft Fractures

  • Broad Spectrum of Injures w/ many treatments

  • Nonsurgical management

  • Intramedullary nails

  • Plates

  • External Fixation


Nonoperative treatment indications

Nonoperative Treatment Indications

  • Minimal soft tissue damage

  • Stable fracture pattern

    • < 5° varus/valgus

    • < 10° pro/recurvatum

    • < 1 cm shortening

  • Ability to bear weight in cast or fx brace

  • Frequent follow-up

  • Schmidt, et.al., ICL 52, 2003


    Fracture brace

    Fracture Brace

    • Closed Functional Treatment

      1,000 Tibial Fractures

      60% Lost to F/u

    • All < 1.5cm shortening

    • Only 5% more than 8° varus

    • Average 3.7wks in long leg cast, then

      Functional fracture brace

    Sarmiento, JBJS 1984


    Sarmiento

    Sarmiento

    • Union 98.5%

    • Time 18.1 Wks.

    • Short >20mm 1.4%

    Initial shortening = final shortening


    Ankle motion after tibia fractures

    25% patients with 25% loss of ankle-ROM

    Ankle Motion after tibia fractures


    Natural history

    Natural History

    • Long-term angular deformities may be well tolerated without associated knee or ankle arthrosis

    • Kristensen F/U: 20-29 yr

      All patients >10 degree deformity

    • Merchant & Dietz F/U: 29 yrs.

      Outcome not associated with ang., site, immob. (37/108 patients)


    Surgical indications

    Surgical Indications

    • High energy fracture

    • Moderate soft tissue injury

    • Unstable fracture pattern

      Inability to maintain reduction

    • Open fracture

    • Compartment syndrome

    • Ipsilateral femur fracture

    • Pt cannot tolerate long-leg cast

    Schmidt, et.al., ICL 52, 2003


    Closed fractures of the tibial diaphysis

    Surgical Options

    • Intramedullary nail

    • ORIF with plate

    • External Fixation


    Closed fractures of the tibial diaphysis

    Advantages of IM Nail

    • Less malunion and shortening

    • Earlier weight bearing

    • Early ankle and knee motion

    • Possibly cheaper than casting if time off work included

    Tovainen, Ann Chir Gynaecol, 2000


    Im nails hooper et al

    IM Nails – Hooper, et.al.

    • In a prospective study if displacement >50% angulation >10°

    • Nails superior to cast treatment

    Hooper, JBJS-B, 1991


    Im nails bone et al

    IM Nails – Bone, et.al.

    Retrospective review 99 patients

    CastNail

    Time to union26wks18wks

    SF-36 74 85

    Knee score 89 96

    Ankle score 84 97

    Bone, et.al. JBJS, 1997


    Reamed vs nonreamed nails

    Reamed vs. Nonreamed Nails

    • Reamings (osteogenic)

    • Larger Nails (& locking bolts)

      Hardware failure rare w/ newer nail designs

    • Damage to endosteal blood supply?

      Clinically proven safe even in open fx

    Forster, et.al. Injury Mar 2005

    Bhandari, et.al., JOT 2000


    Blachut jbjs 79a

    Reamed vs. Nonreamed Nails

    Blachut JBJS 79A

    ReamedNon-Reamed

    # pts. 73 63

    Nonunion 4% 11%

    Malunion4% 3%

    Broken Bolts3% 16%


    Im nails interlocking bolts

    IM Nails – Interlocking Bolts

    • Loss of alignment w/out interlocking

    • Spiral 7/22

    • Transverse 0/27

    • Metaphyseal 7/28

    • Templeman CORR 1997


    Complications

    Infection 1-5%

    Union >90%

    Knee Pain 56%

    w/ kneeling 90%

    w/ running 56%

    at rest 33%

    Complications

    Court-Brown, JOT 1996


    Im nail removal knee pain

    IM Nail Removal – Knee Pain

    • Pain resolved 27%

    • Marked improvement 69%

    • Pain worse 3%

    • No difference in knee pain based on tendon sparing approach

    Court-Brown, JOT 1996


    Iaquinto am j orth 1997

    Iaquinto, Am J. Orth 1997

    63 patients reviewed

    Compared type of anesthesia

    4.1 X greater risk of Neurologic

    injury w/ epidural

    Need to monitor exam postop

    Neurological Complications


    Closed fractures of the tibial diaphysis

    Disadvantages of IM Nail

    • Anterior knee pain (up to 56.2%)

    • Risk of infection

    • Increased hardware failure with unreamed nails

    *Court-Brown et al. JOT 96


    Expanded indications

    Expanded Indications

    • Proximal 1/3 fractures

      • Beware Valgus and Procurvatum

  • Distal 1/3 fractures

    • Beware Varus or valgus


  • Proximal tibia fracture

    Proximal Tibia Fracture

    • Entry site is critical

    • Reference is

      Lateral Tibial Spine


    Just right

    Just Right


    Too low too medial

    Too Low!Too Medial!

    Valgus

    Procurvatum


    Semiextended position

    Semiextended Position

    • Neutralize quadriceps pull on proximal fragment

    • Medial parapatellar approach – sublux patella laterally

    • Use handheld awls to gently ream through the trochlear groove

    Tornetta, CORR Jul 1996


    Hyperextended position

    Hyperextended position

    • Pulls patella proximally to allow straight starting angle.

    • Universal distractor

    Beuhler & Duwelius, JOT 1997


    Blocking poller screws

    Blocking (Poller) Screws

    • Functionally narrows IM canal

    • Increases strength and rigidity of fixation

    • 21 patients

    • All healed within 3-12 months

    • Mean alignment 1 degree valgus, procurvatum 2 degrees.

    Krettek C, et al. JBJS 81B: 963, 1999


    Technique

    Technique

    • Screws placed on concave side of deformity.

    • Proximal or distal fractures


    Distal tibial fractures

    Distal Tibial Fractures

    • Reduction before reaming

    • Distractor

    • Fibula plate

    • Joy Stick

    • Calcaneal Traction


    Universal distractor reduction

    Universal Distractor Reduction

    Beuhler & Duwelius, JOT 1997


    Plate fibula

    Plate Fibula

    Egol, et.al. JOT Feb 2006


    Distal tibia joystick

    Distal Tibia Joystick


    Closed fractures of the tibial diaphysis

    Outcomes of IM Nailing

    • 859 closed tibia fractures

    • 92.5% union rate

    • 18.5 weeks to union

    • 1.9% infection rate

    • 4.4% aseptic nonunion

    • “Reamed intramedullary nailing will probably continue to be the best method of treating tibial diaphyseal fractures.”

    Court-Brown, JOT Feb. 2004.


    Closed fractures of the tibial diaphysis

    Plating of Tibial Fractures

    • Narrow 4.5mm DCP plate can be used for shaft fractures

    • Newer periarticular plates available for metaphyseal fractures


    Closed fractures of the tibial diaphysis

    AO Technique of Tibia Plating

    • Anterior longitudinal incision

    • Plate on medial border of tibia

    • 4.5mm LCDCP plate secured to bone on distal fragment

    • Butterfly fragment can be secured with interfragmentary screw

    • The AO articulating tension device can be secured to proximal part of plate to aid reduction

    • With fracture reduced, screws placed through plate on either side of fracture


    Closed fractures of the tibial diaphysis

    Subcutaneous Tibial Plating

    • Newer alternative is use of limited incisions and subcutaneous plating- requires indirect reduction of fracture


    Closed fractures of the tibial diaphysis

    Advantages of Plating

    • Anatomic reduction usually obtained

    • In low energy fractures 97% very good/good results have been reported

    • Ruedi et al. Injury vol 7


    Closed fractures of the tibial diaphysis

    Disadvantages of Plating

    • Increased risk of infection and soft tissue problems, especially in high energy fractures

    • Higher rate hardware failure than IM nail

    Johner and Wruhs, Clin Orthop 1983


    Closed fractures of the tibial diaphysis

    External Fixation

    • Generally reserved for open tibia fractures or periarticular fractures


    Closed fractures of the tibial diaphysis

    Technique of External Fixation

    • Unilateral frame with half pins

    • 5mm half pins (‘near-near and far-far’)

    • Pre-drilling of pins recommended

    • Fracture held reduced while clamps and connecting bar applied


    Closed fractures of the tibial diaphysis

    Advantages of External Fixator

    • Can be applied quickly in polytrauma patient

    • Allows easy monitoring of soft tissues and compartments


    Closed fractures of the tibial diaphysis

    Outcomes of External Fixation

    • 95% union rate for group of closed and open tibia fractures

    • 20% malunion rate

    • Loss of reduction associated with removing frame prior to union

    • Risk of pin track infection

    Anderson et al. Clin Orthop 1974

    Edge and Denham JBJS[Br] 1981


    Conclusions

    Conclusions

    • Common fracture w/ several treatment options.

    • Closed stable fxs. can be treated in a cast.

    • Unstable fxs. often best treated by intramedullary nail


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