Tibial Fractures- Mini Mi Sing Complication

8/8/2019 Tibial Fractures- Mini Mi Sing Complication

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Introduction

* Fractures of the tibial shaft range from low energy

minimally displaced fractures to limb-threateninginjuries with associated nerve and arterial damage andmajor damage to the soft-tissue envelope.

* Common problems include deformity afterintramedullary nail fixation of fractures in theproximal one-third of the tibia, infections after openfractures & aseptic nonunions.


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Intramedullary Fixation of Proximal

Tibial Fractures* Fractures in the proximal one-third of the tibia are

prone to malalignment & delayed healing

* Malalignment are apex-anterior & valgus

* When there is comminution of the posterior cortex,the

nail may not be contained within the proximalfragment, leading to apex angulation


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continue

* To minimize problems with apex-anterior and valgus

angulations, the starting point should be as proximalas possible and the guide wire should be advancedparallel to the anterior cortex .

* If the leg is externally rotated, the starting point maybe more medial than desired.


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* The fracture must be reduced by manipulation, and

reduction must be maintained while the tibia isreamed and until interlocking is completed.

* In Tibial shaft fractures ,the starting point may be

found with the use of a threaded guide pin or awl, butfor these difficult proximal fractures better to usethreaded guide pin

* Use of a semiextended knee position.


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Techniques to keep the fracture

reduced

* Use of a starting point parallel to the anterior cortex of

the tibia and in line with the lateral intercondylareminence, use of femoral distractor, &/oraugmentation of fixation with short plate

*If plate is used to augment fixation it can be left inplace.


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* Semi extended knee position for nail insertion.

* Performed a medial parapatellar arthrotomy and

sublux the patella laterally(this minimize apex-anterior angulation)

* In this technique, the knee was not flexed more than10 to15.


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Use of blocking screws* Blocking screws are placed where the surgeon does not

want the nail to go.

* The screw is placed lateral to the central axis then nailpasses medial to the screw, and, as it passes across thefracture site, valgus angulation is avoided.

* Blocking screw is placed posterior to the central axis,

with the nail passing anterior to it, to prevent apex-anterior angulation.


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Alternatives treatment

* Plate fixation

patient must have a good soft-tissue envelope orthe risk of a complication is excessive.

* External fixation is another alternative


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Infection* In closed tibial shaft fractures infection is 1%.

* In open fractures :a) 5% for Gustilo & Anderson Type I

b) 10% for Type II

c) >15% for Type IIIB


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Sign & symptom of infection

* Prolonged or increasing pain is the clue that the

patient has an Infection

* Swelling

* Erythema

* Fever

* Chills and purulent drainage


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infection

* Acute period- < 4 WKS after the injury

* It also can occur several months to years after theinjury.


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Factor prone for infection* Major crush component

* Soft-tissue devitalization

* open fracture sustained in a contaminatedenvironment

* The nutritional status is important.

* Immunocompromised patient more prone (diabetes,

tobacco , or abuse drugs or alcohol


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* The patients nutritional status is evaluated bymeasuring the blood glucose level, serum prealbuminlevel, total protein level, and lymphocyte count.

* Smokers are more prone to infection, and it is wellknown that their fracture-healing time is more.

* Systemic disease such as rheumatoid arthritis pt.taking medications that interfere with healing andprone to infection.


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Prevention of infection1 Debridement

2 Early definative fixation

3 Early soft tissue coverage4 Appropriate systemic antibiotic therapy


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* key to preventing infection following an open tibial

fracture begins with the initial debridement

* All nonviable tissue should be removed. If there is anydoubt regarding the viability of the tissue or bone, it

should be removed.

* The exception is articular cartilage and thesubchondral bone, which should be preserved if

possible.


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If external fixator is initially used, it is best to convertit to a definitive internal fixation device with in thefirst seven days, as increased infection rates have been

reported in association with delayed conversion


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Wound coverage* Early soft tissue coverage of Type-III fractures helps to

prevent infection.

* Highest rate of complications occurs when flapcoverage > 2 wks.

* It is believed that the wound contaminated withbacteria initially but becomes colonized during thefirst two weeks and this is leads to increased risk of

infection associated with delayed closure. A flapplaced early provides healthy environment, promoteshealing, & increases blood supply, leading to re-epithelialization.


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* Direct application of antibiotics seems to be beneficial,and a variety of options are available to deliver a high

concentration of local antibiotics.

*Polymethylmethacrylate beads mixed with antibioticscan be used.

*Calcium sulfate pellets used as alternative. These can bemixed with antibiotics and do not require removal.


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Monitoring

* The erythrocyte sedimentation rate and C-reactiveprotein level assists in the determination of when the

infection is controlled.* It is also important to routinely monitor renal and

hepatic function when drugs that are cleared throughthose major organ systems


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when the

implant should be removed* When infection develops before any healing occurs

patient should be treated with aggressive

debridement, wound closure, and suppressiveantibiotics without removal of the hardware.

* If Infection is diagnosed >four wks after the injury, thehardware has to be removed to eradicate the infection.

* If the fixation is unstable, the implant should beremoved, the infected area should be debrided, andappropriate antibiotics should be administered to treatthe infection.


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* An external fixation device may be needed to control

the unstable fracture.* If necessary, internal fixation may be performed later,

but only after wound specimens are culture-negativeand the patient is receiving an appropriate systemic

antibiotic.* If fixation is stable and the soft tissues are healthy but

the fracture is not healed, it may be possible to retainthe hardware, perform a thorough debridement, and

use local and systemic antibiotics. If the infectionreturns or if signs of deep infection persist, theimplant should be removed.


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Aseptic Nonunion* Food and Drug Administration (FDA) has defined

nonunion as --a fracture that occurred a minimum of

nine months previously and has no radiographic signsof progression toward healing for three consecutivemonth

*Aseptic nonunion occurs after approximately 3% ofclosed tibial shaft fractures , 15% in open fractures.

*An amputation may eventually be needed


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1.Hypertrophic Hypertrophic nonunions haveabundant callus surrounding the bone but a persistentradiolucent line at the fracture site.

2. Atrophic nonunions -are seen to have little or nocallus on radiographs


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factors* Patients with DM, smokers, NSAIDS & phosphonates

having more healing time.

* Transverse fracture pattern was associated with anincreased need for a reoperation to promote healing.

* Open fractures are more prone to non union thanclosed fractures, with the higher non union rate

probably due to periosteal stripping and disruption ofthe soft tissue envelope


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Treatment of non union* Reaming is actually beneficial when done judiciously and indeed

may lead to higher union rates.(ROCKWOOD -The clinicalliterature strongly indicates that reaming is beneficial, resulting

in a shorter union time and a lower incidence of asepticnonunion. The effect of reaming has an inverse relationship withthe degree of soft tissue damage associated with the fracture. Theless soft tissue damage there is, the greater the beneficial effectof reaming will be. Thus, in Tscherne C1 fractures, reamingproduces a considerable osteogenic response, but if the fracture

is Gustilo IIIb in severity, the extensive soft tissue damagedictates the prognosis nullifying any beneficial effect of reaming)

* A large nail can be used and stability can be achieved. Staticinterlocking of tibial nails proximally and distally


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nonoperative option1 Weight-bearing in a cast

2 Low-intensity pulsed ultrasound

3 Electrical stimulation*Diagnostic ultrasound determine which are candidates

for surgical intervention, and find out whether there iscallus formation in the early healing period


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operative1 Dynamization

2 Exchange Nailing

3 Bone-grafting -The authors concluded that theprocedure is safe for closed and minor open fracturesbut cautioned that it was associated with an increasedinfection rate when used for Type-IIIB fractures.


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4 Plate fixation

5 External fixation, such as the Ilizarov method


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Adjuncts

* Two types Bone morphogenetic proteins(BMPs), tostimulate bone-healing.

* Recombinant human bone morphogenetic protein-7(rhBMP-7) was shown to promote union in prospectivestudy

* Results suggest that BMP is just as effective as autogenousbone graft for the treatment of tibial non unions, and, onthe basis of these results, the FDA approved the use ofBMP-7 under a humanitarian device exemption.


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* The use of rhBMP-2 decreased the risk of secondaryintervention by 41% and reduced the nonunion rate by29%.

* Overall there was a 44% reduction in the infection rateas well

* The authors concluded that allograft with rhBMP-2was an alternative to autogenous bone graft for thetreatment of tibial fractures with a bone defect.


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* The FDA has approved rhBMP-2 for use in open tibialfractures treated with intramedullary fixation withinthe first fourteen days after the injury.

* The use of rhBMP-2 in the acute stages may decreasethe rates of nonunion and infection


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OverviewIn conclusion, it is a challenge to obtain optimum results

following a tibial shaft fracture. The surgeon should

evaluate the factors that are controllable and planproperly.

Documents

Tibial Fractures- Mini Mi Sing Complication