Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling...

Tibial Shaft FracturesMr Krishna Vemulapalli

Consultant Orthopaedics Surgeon

Queens & King George Hospitals

29/03/2018 Vemulapalli

Queens Hospital14/03/2018 Google Maps

https://www.google.co.uk/maps/@51.5689712,-0.2549157,10z 1/1

Map data ©2018 Google 10 km


Orthopaedics Department

• Covers > 800000- 1M population

• 12 Trauma & Orthopaedics Consultants

• 2 Trauma Consultants

• One of the Busy Trauma department

• 24 Trauma lists per week

• 600-700 Hip fractures per year


29/03/2018

Paediatric

Orthopaedics

FOOT AND ANKLE

Vemulapalli

Services

• Ponseti Treatment- Club foot/ Talipes

• DDH

• Diabetic Foot Service


Courses

• Queens Ponseti Course

• Queens FRCS(orth) Clinical course-www.queensfrcscourse.com

• Queens Orthopaedics for Emergency staff (A&E)

• Queens Foot & Ankle Course


Tibial shaft fractures

• Surgical anatomy

• Epidemiology

• Investigations

• Classification

• Treatment• Plaster cast- non operative

• Operative treatment

• Open Fractures

• Compartment syndrome


Anatomy- structure & function

• Tibia- Latin word- means Flute

• 2nd largest bone in body

• Articulates with Femur above and talus below

• Carries 5 times the body weight

• Tibia is subcutaneous for much of its course- prone for direct trauma


Surgical Anatomy

Strong, Noncompliant fascia completely surrounds the muscle accompanying the tibia


Epidemiology

• Most common long bone fracture

• Incidence-26/100000

• Most fractures are found in young males

• Male-41/100000. Average Age 31

• Female-12.3/100000. Average Age 54yrs

• Second peak in elderly patients.


Why is it important?

• Most common Long bone fracture-492,000 fractures/year

• Most common Open Fracture

• Significant cost• 569,000 hospital days• Major cause of disability

• Significant complications• 50,000 non unions /year


Mechanism of injury & Presentation

• Direct trauma- sports

• RTA

• Unable to weight bear

• Pain; swelling and deformity of the leg

• ? Bleeding from open wound


Diagnosis

• Fracture-Very Obvious

• Soft tissue assesment

• Open or closed



Investigations

• X-ray- AP/Lat• Knee and Ankle to be included


Investigations……

• CT scan• Planning the operation

• For assessing the # extension into the joints


Radiographs

1. The location and morphology of the fracture

2. Presence of secondary fracture lines

3. Presence of Comminution, signifying a high energy injury

4. Bone defects/missing bone

5. Fracture lines extending into the knee or ankle


AO Classification


Treatment Goals

1. Establishing Bone union

2. Establishing and Maintaining normal length, alignment and rotation

3. Establishing and maintaining the normal anatomical relationship between the knees and ankles for weightbearing, motion and Propulsion


Treatment Options

• Non operative• Cast or Braces

• Operative• IM Nailing

• Plating

• External fixator• Mono or Circular


Non-operative Treatment


Nonoperative treatment

• Non operative treatment does NOT mean no treatment

• Closed reduction and plaster of Paris application achieve

good results

• Non operative treatment is difficult and demanding


Cast Treatment-Indications

• Low- energy

• Stable

• Un displaced or Minimally Displaced

• Isolated Tibial shaft Fractures


Cast Treatment-Contraindications

• High Energy

• Unstable

• Segmental

• Off-ended

• Excessive shortened ( >1 cm)

• Neuro vascular damage


• Macerated/damaged Skin

• Polytrauma


Advantages of Cast

• No infection

• No need of sophisticated equipment

• Can be readily performed under most Spartan conditions

• Cast failure is easier to correct than implant failure

• It does not make subsequent operative treatment impossible


Disadvantages of Cast

• Requires a compliant patient

• Patient must accept some deformity- Malunion; Delayed union

• Accept the possibility of prolong treatment

• Ankle & Subtalar Stiffness


Non operative treatment

• Plaster can prevent lateral shift

• Plaster can prevent angulation

• Plaster can control rotation

• Plaster can NOT prevent shortening


Cast Treatment

• Weight bearing Long Cast application with 5-10 degrees flexion of knee for 4 weeks

• Patellar tendon-bearing cast / brace for 4-6 weeks

• Weekly X-rays for the first 3 -4 weeks

• Continue brace until osseous union demonstrated on X-rays


Cast Application- Treatment

• Under Analgesia or Spinal or General

• Leg Hanging of table with knee flexed ( Relax Gastrocs and allows traction by Gravity)

• Fracture reduced

• Padding starting from toes with extra padding over the heel, malleoli, fibula neck

• Plaster applied from toes to just above the Tibial tubercle


Cast application….

• Molding with palms done over medial tibia, behind both malleoli, over the arch of the foot

• No molding over the fibular head or Tibial tubercle

• Plaster extended proximally 2 finger breadths below the greater trochanter

• Knee flexed 5-10 degrees


Following cast

• Xray to confirm the position

• For Angular deformity corrections <10 degrees-Wedging


Cast wedging

• Can be Open or Close Wedging

• Open wedging- Minor risk of distraction of fracture

• Close wedging- Pinch or compress the skin-Necrosis

• Can be at site of fracture-Watson or junction of long axis of 2 fragments


Stop Casting Operative Rx

• Malposition of >100

• Shortening of > 1 cm

• Repeated wedging

• Wedging more than 100


Operative Treatment

• Internal fixation

• IM Nails

• Reamed or Un reamed

• Plates

• Classic or MIPO

• External fixation

• Unilateral

• Circular

• Hybrid


Indications of internal fixation

• Failed Closed treatment

• Unstable tibial fractures

• Ipsilateral tibial & femoral fractures

• Fractures with intra articular extension

• Segmental fractures

• Bilateral tibial fractures

• Open fractures

• Pathological fractures

• Fractures with vascular complications & compartment syndrome


Internal Fixation- IM nailing

• Work Horse

• Indicated in most of the shaft fractures

• Fracture Zone should be 5 cm below Knee and 5 cm Above Ankle

• Reamed Vs Unreamed

• Locking Vs Unlocking


Operative treatment-Nailing- Advantages

• Indirect reduction which preserves soft-tissue attachments

• Allows movement at fracture site which results in early union with callus formation

• Anatomical reduction rare but restoration of length, axis and rotation is usual


Nailing-Advantages

• Nails function as internal splints

• Nails can withstand heavy loads

• Nails can be mobilized with early weight bearing


Complications of IM nail

• Anterior knee pain

• Thermal necrosis

• Destroys endosteal circulation

• Iatrogenic fracture

• Compartmental syndrome


Plate & Screws


Internal fixation-Plates & Screws-Indications• Metaphyseal fractures

• Fractures extending into Knee or Ankle joint

• Malunions

• Nonunions


Internal fixation- compression plate- facts

• Destroys periosteal circulation

• Direct reduction will destroy soft tissue attachments

• Rigid fixation will result in slow union without callus formation

• Anatomical reduction

• Plates cannot withstand weight-bearing forces

• Plates will not permit early weight bearing


Internal fixation- Plates & Screws

• Disadvantage• Skin Necrosis*• Wound Dehiscence• Infection• Restricted weight bearing• Non union• Re fracture (After plate removal)

• *avoid tourniquets ( <20%)


Ex-fix


Ex-Fix

• Mainly used in

• Sick patient

• Sick limb


External fixation-Indications

• Open fractures• Fractures with bone loss• Nonunion• Malunion• Infected nonunion• Closed fractures

complicated by• Compartment

syndrome• Vascular injury• Head injury• Burns• Impaired sensation


Types of Ex fix

• Mono

• Circular

• Hybrid


Disadvantages

• Pin track infections

• High rate malunion

• High Reoperation rate

• Requires frequent adjustments

• Visual reminder of the disability (social & psychological effect)

• Fractures through pin sites


Summary of Fixation devices


Tibial Fixation Options

• Plate• Ex Fix• IM nail


Complications of Tibial Shaft Fractures

• Delayed / Non Union

• Infections

• Malunion & Shortening

• Vascular injuries

• Compartmental syndrome

• Joint Stiffness & Ankylosis

• Traumatic arthritis

• RSD

• Fat embolism


Open fractures


Open fractures

• An open fracture is one in which a break in the skin and underlying soft tissue directly communicates with the fracture and its hematoma


Gustilo And Anderson ClassificationType Wound Level of

ContaminationSoft Tissue Injury Bone Injury

I <1 cm long Clean Minimal Simple, Minimal comminution

II >1 cm long Moderate Moderate, Some muscle damage

Moderate Comminution

III

A >10 cm High Severe with Crushing Usually Comminuted; Soft-tissue Coverage of bone possible

B >10 cm High Very Severe loss of coverage

Bone Coverage poor; usually requires soft-tissue reconstructive surgery

C >10 cm High Very severe loss of coverage plus vascular injury requiring repair

Bone coverage poor Usually requires soft-tissue reconstructive surgery


Tschern classification of soft tissuesGrade-0 Minimum soft tissue injury

Simple # pattern

Grade-1 Superficial AbrasionMild to moderate # pattern

Grade-2 Deep AbrasionImpending compartment syndromeSevere # pattern

Grade-3 Extensive crushSevere # pattern +/- Vascular injuryCompartmental syndrome29/03/2018 Vemulapalli

Complications and Prognosis are directly related to degree of soft tissue injury


Compartment syndrome


Compartment syndrome

• Pain• Excessive to fracture

• Pain• Passive stretching of toes

• Pain• Uncontrollable with normal

analgesia


Compartmental syndrome

• Anterior compartment very common

• Deep Posterior second commonest

• Lateral compartment always associated with ant of post compartment syndrome


Diagnosis

• High Index of suspicion

• Clinical Hx & Examination

Vemulapalli29/03/2018

Compartment syndrome- Diagnosis

• High Index of Suspicion

• Pain; Pain; Pain

• Tight/ Tense Compartments

• Nerve paresthesia

• Compartmental pressure monitors


Treatment

Fasciotomy


Summary

• Tibial fractures are very common

• Young people fracture

• Can be treated non-op or operatively

• Open fractures are common

• High index of suspicion for diagnosing compartmental syndrome


Vemulapalli

THANKYOU

29/03/2018

• “A fracture in plaster of Paris will not displace more than its previous maximal displacement”

Sarmiento,York 1998


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