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

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

Physical Exam

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

• Repeated exam to follow compartment swelling

Radiographic Evaluation

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

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

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

Associated Injuries

• Ipsilateral femur fx, “floating knee”

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

• Foot and ankle injury

Classification

• Numerous classification systems

• Important variablesPattern of fracture

location of fracture

comminution

associated fibula fracture

degree of soft tissue injury

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

Henley’s Classification

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

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

• 5-15%• HISTORY

Hi-Energy

Crush

• 4 leg compartments

Nerve is the Tissue most Sensitive to Ischemia

• PAIN first Symptom

• PAIN with Passive Stretch first Sign

Each Compartmenthas Specific Innervation

• Ant Comp - Deep Peroneal N.• Lateral - Sup Peroneal N.• Deep Post. - Tibial N.• Sup Post. - Sural N.

Anterior Compartment

• Dorsiflexes ankle

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

• Anterior tibial a./v.• deep peroneal n.

1st webspace sensation

Lateral Compartment

• Everts the foot

• Peroneus brevis and longus muscles

• Superficial peroneal n.dorsal foot

sensation

Superficial Posterior Compartment

• Plantarflexes ankle

• Gastrocnemius, soleus, popliteus, and plantaris muscles

• Sural nerveLateral heel sensation

• Greater and lesser saphenous veins

Deep Posterior Compartment

• Plantarflexion and inversion of foot

• FDL, FHL, Tib post muscles

• Post tibial vessels, peroneal a.

• tibial nervePlantar foot sensation

Compartment Syndrome is a Clinical Diagnosis

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

•Heckman JBJS 76

Clinical Monitoring

• Need Close Observation

• Repetitive Exams• Some instances

repetitive Pressure measurements

• Indwelling Monitors?

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

• Broad Spectrum of Injures w/ many treatments

• Nonsurgical management

• Intramedullary nails• Plates• External Fixation

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

• 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

• 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

Natural History

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

• Kristensen F/U: 20-29 yrAll patients >10 degree deformity

• Merchant & Dietz F/U: 29 yrs. Outcome not associated with ang., site, immob.

(37/108 patients)

Surgical Indications

• High energy fracture

• Moderate soft tissue injury

• Unstable fracture patternInability to maintain reduction

• Open fracture

• Compartment syndrome

• Ipsilateral femur fracture

• Pt cannot tolerate long-leg cast

Schmidt, et.al., ICL 52, 2003

Surgical Options

• Intramedullary nail

• ORIF with plate

• External Fixation

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.

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

• Nails superior to cast treatment

Hooper, JBJS-B, 1991

IM Nails – Bone, et.al.

Retrospective review 99 patients

Cast Nail

Time to union 26wks 18wks

SF-36 74 85

Knee score 89 96

Ankle score 84 97 Bone, et.al. JBJS, 1997

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 2005Bhandari, et.al., JOT 2000

Blachut JBJS 79A

Reamed Non-Reamed

# pts. 73 63

Nonunion 4% 11%

Malunion 4% 3%

Broken Bolts3% 16%

Reamed vs. Nonreamed Nails

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%

Court-Brown, JOT 1996

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

Neurological Complications

63 patients reviewedCompared type of anesthesia

4.1 X greater risk of Neurologic injury w/ epidural

Need to monitor exam postop

Disadvantages of IM Nail

*Court-Brown et al. JOT 96

• Anterior knee pain (up to 56.2%)

• Risk of infection• Increased hardware

failure with unreamed nails

Expanded Indications

• Proximal 1/3 fractures• Beware Valgus and Procurvatum

• Distal 1/3 fractures• Beware Varus or valgus

Proximal Tibia Fracture

• Entry site is critical

• Reference is Lateral Tibial Spine

Just Right

Too Low! Too Medial!Procurvatum Valgus

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

• Pulls patella proximally to allow straight starting angle.

• Universal distractor

Beuhler & Duwelius, JOT 1997

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

• Screws placed on concave side of deformity.

• Proximal or distal fractures

Distal Tibial Fractures

• Reduction before reaming

• Distractor• Fibula plate• Joy Stick• Calcaneal Traction

Universal Distractor Reduction

Beuhler & Duwelius, JOT 1997

Plate Fibula

Egol, et.al. JOT Feb 2006

Distal Tibia Joystick

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.

Plating of Tibial Fractures

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

• Newer periarticular plates available for metaphyseal fractures

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

Subcutaneous Tibial Plating

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

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

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

External Fixation

• Generally reserved for open tibia fractures or periarticular fractures

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

Advantages of External Fixator

• Can be applied quickly in polytrauma patient

• Allows easy monitoring of soft tissues and compartments

Outcomes of External Fixation

Anderson et al. Clin Orthop 1974Edge and Denham JBJS[Br] 1981

• 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

Conclusions

• Common fracture w/ several treatment options.

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

• Unstable fxs. often best treated by intramedullary nail