Closed Fractures of the Tibial Diaphysis

David L. Rothberg, MD

Erik N. Kubiak, MDUniversity of Utah

Original Authors: Robert V. Cantu, MD and David Templeman, MD; March 2004

Interim Authors: David Templeman and Darin Friess, MD; Revised June 2006

New Authors: David L. Rothberg, MD & Erik N. Kubiak, MD; Revised June 2010

Tibia Fractures

Most common long bone fracture

492,000 fractures yearly

Average 7.4 day hospital stay

100,000 non-unions per year

History & Physical

Low Energy

– Minimal soft-tissue injury

– Less complicated fracture pattern and management decisions

76.5% closed

53.5% mild soft-tissue energy

History & Physical High Energy

– High incidence of neurovascular energy and open injury

– Low threshold for compartment syndrome

– Complete soft-tissue injury may not declare itself for several days

Radiographic Evaluation

Full length AP and Lateral Views– Check joint above &

below

Oblique views may be helpful in follow-up to assess healing

Injuries Associated

30% of patients will have multiple injuries– Ipsilateral Fibula

Fracture– Foot & Ankle injury– Syndesmotic Injury– Ligamentous knee

injuries

Injuries Associated

Ipsilateral Femur Fx– “Floating Knee”

Neurovascular Injury– More Common In:

High Energy Proximal Fracture Floating Knee Knee Dislocation

Classification

Numerous systems

Important variables– Fracture Pattern

– Location

– Comminution

– Associated Fibula Fx

– Degree of soft-tissue injury

OTA Classification

Follows Johner & Wruh system

Describes relationship between fracture pattern & mechanism

Comminution is prognostic for time to union

Henley’s Classification

Applies Winquist & Hansen Femur classification 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 Incidence:

– 5-15% History

– High-Energy– Crush

Exam– 4 Compartments– 6 P’s

Pain Pain with passive stretch Parasthesias Pulsless Pallor Paralysis

Compartment Anatomy

Anterior– Deep Peroneal N.

Lateral– Sup. Peroneal N.

Deep Post.– Tibial N.

Sup. Post.– Sural N.

Anterior Compartment

• Action• Ankle dorsiflexion

• Muscles• Tib. Ant. • EDL • EHL • Peroneus Tertius

• Vessels• Anterior Tibial A./V.

• Nerves• Deep Peroneal N..

1st webspace sensation

Lateral Compartment

• Action

• Foot Eversion

• Muscles

• Peroneus Brevis & Longus

• Nerves

• Superficial Peroneal N.

• Dorsal foot sensation

Deep Posterior

• Actions• Ankle plantarflexion• Foot inversion

• Muscles• FDL • FHL • Tib. Post.

• Vessels• Post Tibial A./V.• Peroneal A.

• Nerve• Tibial N.

Plantar foot sensation

Superficial Posterior

• Action• Ankle Plantarflexion

• Muslces• Gastrocnemius • Soleus• Popliteus• Plantaris

• Vessels• Greater and Lesser

Saphenous V.• Nerve

• Sural N. Lateral heel sensation

Compartment Syndrome Remains a Clinical Diagnosis

Pressure Measurements

May be helpful in borderline cases– Basic Science

Muscle ischemia present at 20 mmHg below DBP and 30 mmHg below MAP

Various Thresholds– P = 30 mmHg– P = 45 mmHg– Whiteside’s Theory

∆ P = DBP – CP = < 30 mmHg

Pressures Not Uniform

Highest at Fracture Site

Highest Pressures in:– Deep Posterior– Anterior

Heckman JBJS ’76

Clinical Monitoring

Close Observation– Repeat Exams– Repeat Pressure

Measurements

Indwelling Monitors– Reserved for

intubated patient with high suspicion

Goals of Fasciotomy

Decompress the compartment– Minimize further soft-

tissue damage Single vs. Two incisions

– Go long No increased morbidity No difference in long-term

outcome Plan for fracture fixation Plan for wound closure Coordinate with location

of future incisions and/or internal fixation

Closed Tibial Shaft Fracture

Broad Spectrum of Injures w/ many treatments

Closed Management Intramedullary Nails Plates External Fixation

Non-Operative Treatment Indications

Fracture Brace

SarmientoUnion Rate

– 98.5%Time to Union

– 18.1 weeksShortening

– <1.4%

Initial Shortening = Final Shortnening

Natural History

Long-term angular deformities – Well tolerated without associated knee or

ankle arthrosis

– Kristensen 22 pt F/U: 20-29 yrs All patients >10 degree deformity No radiographic Ankle arthrosis

– Merchant & Dietz 37 pt F/U: 29 yrs 76% of Ankles had G/E radiographic results 92% of Knees had G/E radiographic results

Post Tibia Fracture Ankle Motion

25% Post Tibia Fracture will lose 25% of Ankle ROM

Surgical Indications Patient Characteristics

– Obesity– Poor compliance with non-

operative management– Need for early mobility

Injury Characteristics– High Energy– Moderate soft-tissue injury– Open Fracture– Compartment Syndrome– Ipsilateral Femur Fx– Vascular Injury

Fracture Characteristics– Meta-Diaphyseal location– Oblique fracture pattern– Coronal Angulation > 5°– Sagittal Angulation > 10°– Rotation > 5°– Shortening > 1cm– Comminution > 50%

cortical circumference– Intact fibula

Surgical Options

• Intramedullary Nail

• ORIF with Plate

• External Fixation

• Combination of fixation

Advantage of IM Nail Less malunion Early weight-bearing Early motion Early WB (load sharing) Patient satisfaction

L Bone, JBJS

Cost– Less expensive to society when

compared to casting

– Busse Acta Ortho ‘05

Disadvantages of IM Nail

Anterior knee pain 2/3, improve w/in year

• Risk of infection Increased hardware

failure with unreamed nails

Thermal Necrosis Medial HW

prominence

IM Nails

PRCT 62 pts

– If displacement >50% angulation >10°

– Nails superior to cast treatment

Hooper JBJS-B ‘91

IM Nails – Bone et.al.

Retrospective review 99 patients

Cast Nail

Time to union 26 wks 18 wks

SF-36 74 85

Knee score 89 96

Ankle score 84 97 Bone JBJS ‘97

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 Injury ‘05Bhandari JOT ‘00

Blachut JBJS ‘97

Reamed Non-Reamed

# pts. 73 63

Nonunion 4% 11%

Malunion 4% 3%

Broken Bolts 3% 16%

Time to Union 16.7 wks 25.7 wksLarsen JOT ‘04

Reamed vs. Nonreamed Nails

IM Nails – Interlocking Bolts

Loss of alignment w/o interlocking

Spiral 7/22Transverse 0/27Metaphyseal 7/28

Templeman CORR ‘97

Complications

Infection 1-5% Union >90% Knee Pain 56%

– w/ kneeling 90%– w/ running 56%– at rest 33%

Court-Brown JOT ‘96

Knee Pain after IMN

Incidence– Varied in lit. 10-86%

Attributed to:– Skin Incision– Approach– Insertion Site– Quad weakness– Nail Prominence

Removal– 27% resolved– 69% marked

improvement– 3% worse Court-Brown JOT ‘96

Neurologic Complications

Expanded Indications

Proximal 1/3 fractures Beware Valgus and Procurvatum

Distal 1/3 fractures Beware Varus or valgus Beware of intraarticular extension

Proximal Tibia Fracture

Entry site is critical

Reference– Lateral Tibial

Spine

Too Low! Too Medial!Procurvatum Valgus

Semiextended Position

Neutralize quadriceps pull on proximal fragment

Medial parapatellar approach – subluxate patella laterally

Use handheld awls to gently ream through the trochlear groove

Tornetta CORR ‘96

Hyperextended position

Pulls patella proximally to allow straight starting angle

Universal distractor

Beuhler JOT ‘97

Blocking (Poller) Screws

Functionally narrows IM canal– Increases strength and rigidity of fixation– Place on concave side of deformity

21 patients– All healed within 3-12 months– Mean alignment 1° valgus, 2° procurvatum

Krettek JBJS ‘99

Technique

Screws placed on concave side of deformity

Proximal or distal fractures

Distal Tibial Fractures

Reduction before reaming

Distractor Fibula plate/nail Joy Stick Calcaneal Traction

Universal Distractor Reduction

Beuhler JOT ‘97

Plate Fibula

Distal Tibial 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 ‘04

Plating of Tibial Fractures• 3.5 mm or Narrow

4.5mm DCP plate can be used for shaft fractures

• Newer periarticular plates available for metaphyseal fractures

Subcutaneous Tibial Plating

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

Advantages of Plating

Anatomic reduction usually obtained

In low energy fractures– 97% G/E results

reported• Ruedi Injury

Disadvantages of Plating

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

• Higher rate hardware failure than IM nail

• Delayed WB (load bearing)

Johner CORR ‘83

External Fixation

• Generally reserved for open tibia fractures or periarticular fractures

AO Technique of Tibia Plating• Anterior longitudinal incision

• 1 cm lateral to tibial crest• Maintain AT paratenon and periosteum

• Plate on medial border of tibia

• 3.5 mm or 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

Technique of External Fixation

• Unilateral frame with half pins

• 5mm half pins• near-near and far-far• Stay out of zone of injury

• 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

• Modifiable• No long term deep HW

Outcomes of External Fixation

Anderson CORR ‘74Edge JBJS ‘81

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 fx can be treated in a cast

Unstable fx often best treated by intramedullary nail

Acknowledgments

1st Edition lecture R. Cantu M.D.Cases Courtesy R. Winquist M.D.

E. Kubiak M.D.

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