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Closed Fractures of the Tibial Diaphysis David L. Rothberg, MD Erik N. Kubiak, MD Closed Fractures of the Tibial Diaphysis David L. Rothberg, MD Erik N. Kubiak, MD University 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 l Most common long bone fracture l 492, 000 fractures yearly l Tibia Fractures l Most common long bone fracture l 492, 000 fractures yearly l Average 7. 4 day hospital stay l 100, 000 non-unions per year

History & Physical l Low Energy – Minimal soft-tissue injury – Less complicated fracture History & Physical l Low Energy – Minimal soft-tissue injury – Less complicated fracture pattern and management decisions l 76. 5% closed l 53. 5% mild soft-tissue energy

History & Physical l High Energy – High incidence of neurovascular energy and open History & Physical l 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 l Full length AP and Lateral Views – Check joint above & Radiographic Evaluation l Full length AP and Lateral Views – Check joint above & below l Oblique views may be helpful in followup to assess healing

Injuries Associated l 30% of patients will have multiple injuries – Ipsilateral Fibula Fracture Injuries Associated l 30% of patients will have multiple injuries – Ipsilateral Fibula Fracture – Foot & Ankle injury – Syndesmotic Injury – Ligamentous knee injuries

Injuries Associated l Ipsilateral Femur Fx – “Floating Knee” l Neurovascular Injury – More Injuries Associated l Ipsilateral Femur Fx – “Floating Knee” l Neurovascular Injury – More Common In: l l High Energy Proximal Fracture Floating Knee Dislocation

Classification l Numerous systems l Important variables – Fracture Pattern – Location – Comminution Classification l Numerous systems l Important variables – Fracture Pattern – Location – Comminution – Associated Fibula Fx – Degree of soft-tissue injury

OTA Classification l Follows Johner & Wruh system l Describes relationship between fracture pattern OTA Classification l Follows Johner & Wruh system l Describes relationship between fracture pattern & mechanism l Comminution is prognostic for time to union

Henley’s Classification l Applies Winquist & Hansen Femur classification to fractures of the Tibia Henley’s Classification l Applies Winquist & Hansen Femur classification to fractures of the Tibia

Tscherne Classification of Soft -Tissue Injury • Grade 0 • negligible soft tissue injury 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 l Incidence: – 5 -15% l History – High-Energy – Crush l Compartment Syndrome l Incidence: – 5 -15% l History – High-Energy – Crush l Exam – 4 Compartments – 6 P’s l l l Pain with passive stretch Parasthesias Pulsless Pallor Paralysis

Compartment Anatomy l Anterior – Deep Peroneal N. l Lateral – Sup. Peroneal N. Compartment Anatomy l Anterior – Deep Peroneal N. l Lateral – Sup. Peroneal N. l Deep Post. – Tibial N. l Sup. Post. – Sural N.

Anterior Compartment Action • Ankle dorsiflexion • Muscles • Tib. Ant. • EDL • Anterior Compartment Action • Ankle dorsiflexion • Muscles • Tib. Ant. • EDL • EHL • Peroneus Tertius • Vessels • • • Anterior Tibial A. /V. Nerves • Deep Peroneal N. . l 1 st webspace sensation

Lateral Compartment • Action • Foot Eversion • Muscles • Peroneus Brevis & Longus Lateral Compartment • Action • Foot Eversion • Muscles • Peroneus Brevis & Longus • Nerves • Superficial Peroneal N. • Dorsal foot sensation

Deep Posterior • Actions • Muscles • Vessels • Nerve • Ankle plantarflexion • Deep Posterior • Actions • Muscles • Vessels • Nerve • Ankle plantarflexion • Foot inversion • FDL • FHL • Tib. Post. • Post Tibial A. /V. • Peroneal A. • Tibial N. l Plantar foot sensation

Superficial Posterior • Action • Muslces • Ankle Plantarflexion • • • Gastrocnemius Soleus Superficial Posterior • Action • Muslces • Ankle Plantarflexion • • • Gastrocnemius Soleus Popliteus Plantaris Vessels • Greater and Lesser Saphenous V. • Nerve • Sural N. l Lateral heel sensation

Compartment Syndrome Remains a Clinical Diagnosis Compartment Syndrome Remains a Clinical Diagnosis

Pressure Measurements l May be helpful in borderline cases – Basic Science l l Pressure Measurements l May be helpful in borderline cases – Basic Science l l Muscle ischemia present at 20 mm. Hg below DBP and 30 mm. Hg below MAP Various Thresholds – P = 30 mm. Hg – P = 45 mm. Hg – Whiteside’s Theory l ∆ P = DBP – CP = < 30 mm. Hg

Pressures Not Uniform l Highest at Fracture Site l Highest Pressures in: – Deep Pressures Not Uniform l Highest at Fracture Site l Highest Pressures in: – Deep Posterior – Anterior l Heckman JBJS ’ 76

Clinical Monitoring l Close Observation – Repeat Exams – Repeat Pressure Measurements l Indwelling Clinical Monitoring l Close Observation – Repeat Exams – Repeat Pressure Measurements l Indwelling Monitors – Reserved for intubated patient with high suspicion

Goals of Fasciotomy l Decompress the compartment – Minimize further soft- tissue damage l Goals of Fasciotomy l Decompress the compartment – Minimize further soft- tissue damage l Single vs. Two incisions – Go long l l l 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 l Broad Spectrum of Injures w/ many treatments Closed Management Closed Tibial Shaft Fracture l Broad Spectrum of Injures w/ many treatments Closed Management l Intramedullary Nails l Plates l External Fixation l

Non-Operative Treatment Indications l Minimal soft tissue damage l Non-intact fibula l Higher rate Non-Operative Treatment Indications l Minimal soft tissue damage l Non-intact fibula l Higher rate of nonunion & varus with intact fibula l Stable fracture pattern < 5° varus/valgus l < 10° pro/recurvatum l < 1 cm shortening l l Ability to bear weight in cast or fx brace – Requires frequent follow-up

Fracture Brace l Closed Functional Treatment – – l 1, 000 Tibial Fractures 60% Fracture Brace l Closed Functional Treatment – – l 1, 000 Tibial Fractures 60% Lost to F/U Fracture Characteristics – All < 1. 5 cm shortening – Non with intact fibula – Only 5% more than 8° varus l Treatment Course – Average 3. 7 wks in long leg cast – Transition to Function Fracture Brace • Sarmiento JBJS ‘ 84

Sarmiento l Union Rate – 98. 5% l Time to Union – 18. 1 Sarmiento l Union Rate – 98. 5% l Time to Union – 18. 1 weeks l Shortening – <1. 4% l Initial Shortening = Final Shortnening

Natural History l Long-term angular deformities – Well tolerated without associated knee or ankle Natural History l Long-term angular deformities – Well tolerated without associated knee or ankle arthrosis – Kristensen l l All patients >10 degree deformity No radiographic Ankle arthrosis – Merchant & Dietz l l 22 pt F/U: 20 -29 yrs 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 l 25% Post Tibia Fracture will lose 25% of Post Tibia Fracture Ankle Motion l 25% Post Tibia Fracture will lose 25% of Ankle ROM

Surgical Indications l Patient Characteristics – Obesity – Poor compliance with non- operative management Surgical Indications l Patient Characteristics – Obesity – Poor compliance with non- operative management – Need for early mobility l Injury Characteristics – – – High Energy Moderate soft-tissue injury Open Fracture Compartment Syndrome Ipsilateral Femur Fx Vascular Injury l Fracture Characteristics Meta-Diaphyseal location Oblique fracture pattern Coronal Angulation > 5° Sagittal Angulation > 10° Rotation > 5° Shortening > 1 cm Comminution > 50% cortical circumference – Intact fibula – – – –

Surgical Options • Intramedullary Nail • ORIF with Plate • External Fixation • Combination Surgical Options • Intramedullary Nail • ORIF with Plate • External Fixation • Combination of fixation

Advantage of IM Nail l l Less malunion Early weight-bearing Early motion Early WB Advantage of IM Nail l l Less malunion Early weight-bearing Early motion Early WB (load sharing) Patient satisfaction l l L Bone, JBJS Cost – Less expensive to society when compared to casting – Busse Acta Ortho ‘ 05

Disadvantages of IM Nail l Anterior knee pain l 2/3, improve w/in year • Disadvantages of IM Nail l Anterior knee pain l 2/3, improve w/in year • Risk of infection Increased hardware failure with unreamed nails l Thermal Necrosis l Medial HW prominence l

IM Nails l PRCT 62 pts – If displacement >50% angulation >10° – Nails IM Nails l 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 Time to union IM Nails – Bone et. al. Retrospective review 99 patients Cast Time to union 26 wks SF-36 74 Knee score 89 Ankle score 84 Nail 18 wks 85 96 97 Bone JBJS ‘ 97

Reamed vs. Nonreamed Nails l Reamings l Larger (osteogenic) Nails (& locking bolts) – Reamed vs. Nonreamed Nails l Reamings l Larger (osteogenic) Nails (& locking bolts) – Hardware failure rare w/ newer nail designs l Damage to endosteal blood supply? – Clinically proven safe even in open fx Forster Injury ‘ 05 Bhandari JOT ‘ 00

Reamed vs. Nonreamed Nails # pts. Nonunion Malunion Broken Bolts Reamed 73 4% 4% Reamed vs. Nonreamed Nails # pts. Nonunion Malunion Broken Bolts Reamed 73 4% 4% 3% Non-Reamed 63 11% 3% 16% Blachut JBJS ‘ 97 Time to Union 16. 7 wks 25. 7 wks Larsen JOT ‘ 04

IM Nails – Interlocking Bolts l Loss of alignment w/o interlocking l Spiral l IM Nails – Interlocking Bolts l Loss of alignment w/o interlocking l Spiral l Transverse l Metaphyseal 7/22 0/27 7/28 Templeman CORR ‘ 97

Complications Infection l Union l Knee Pain l – w/ kneeling – w/ running Complications Infection l Union l Knee Pain l – w/ kneeling – w/ running – at rest 1 -5% >90% 56% 33% Court-Brown JOT ‘ 96

Knee Pain after IMN l Incidence – Varied in lit. 10 -86% l Attributed Knee Pain after IMN l Incidence – Varied in lit. 10 -86% l Attributed to: – – – Skin Incision Approach Insertion Site Quad weakness Nail Prominence l Removal – 27% resolved – 69% marked improvement – 3% worse Court-Brown JOT ‘ 96

Neurologic Complications l 63 pts – compared types of anesthesia – Epidural Anesthesia l Neurologic Complications l 63 pts – compared types of anesthesia – Epidural Anesthesia l 4. 1 x greater risk of neurologic injury – Illustrates need to monitor post-op exam • Iaquinto Am J Orth ‘ 97

Expanded Indications l Proximal l 1/3 fractures Beware Valgus and Procurvatum l Distal 1/3 Expanded Indications l Proximal l 1/3 fractures Beware Valgus and Procurvatum l Distal 1/3 fractures Beware Varus or valgus l Beware of intraarticular extension l

Proximal Tibia Fracture l Entry site is critical l Reference – Lateral Tibial Spine Proximal Tibia Fracture l Entry site is critical l Reference – Lateral Tibial Spine

Too Low! Procurvatum Too Medial! Valgus Too Low! Procurvatum Too Medial! Valgus

Semiextended Position l Neutralize quadriceps pull on proximal fragment l Medial parapatellar approach – Semiextended Position l Neutralize quadriceps pull on proximal fragment l Medial parapatellar approach – subluxate patella laterally l Use handheld awls to gently ream through the trochlear groove Tornetta CORR ‘ 96

Hyperextended position Pulls patella proximally to allow straight starting angle l Universal distractor l Hyperextended position Pulls patella proximally to allow straight starting angle l Universal distractor l Beuhler JOT ‘ 97

Blocking (Poller) Screws l Functionally narrows IM canal – Increases strength and rigidity of Blocking (Poller) Screws l Functionally narrows IM canal – Increases strength and rigidity of fixation – Place on concave side of deformity l 21 patients – All healed within 3 -12 months – Mean alignment 1° valgus, 2° procurvatum Krettek JBJS ‘ 99

Technique l Screws placed on concave side of deformity l Proximal or distal fractures Technique l Screws placed on concave side of deformity l Proximal or distal fractures

Distal Tibial Fractures l Reduction reaming before Distractor l Fibula plate/nail l Joy Stick Distal Tibial Fractures l Reduction reaming before Distractor l Fibula plate/nail l Joy Stick l Calcaneal Traction l

Universal Distractor Reduction Beuhler JOT ‘ 97 Universal Distractor Reduction Beuhler JOT ‘ 97

Plate Fibula Plate Fibula

Distal Tibial Joystick Distal Tibial Joystick

Outcomes of IM Nailing • • • 859 closed tibia fractures 92. 5% union 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. 5 mm DCP Plating of Tibial Fractures • 3. 5 mm or Narrow 4. 5 mm 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- 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 l Anatomic reduction usually obtained l In low energy fractures – Advantages of Plating l Anatomic reduction usually obtained l In low energy fractures – 97% G/E results reported • Ruedi Injury

Disadvantages of Plating • Increased risk of infection and soft tissue problems, especially in 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 External Fixation • Generally reserved for open tibia fractures or periarticular fractures

AO Technique of Tibia Plating • Anterior longitudinal incision • • 1 cm lateral 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. 5 mm 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 • 5 mm half Technique of External Fixation • Unilateral frame with half pins • 5 mm 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 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 95% union rate for group of closed and open tibia Outcomes of External Fixation 95% union rate for group of closed and open tibia fractures l 20% malunion rate l Loss of reduction associated with removing frame prior to union l Risk of pin track infection l Anderson CORR ‘ 74 Edge JBJS ‘ 81

Conclusions l Common fracture w/ several treatment options l Closed stable fx can be Conclusions l Common fracture w/ several treatment options l Closed stable fx can be treated in a cast l Unstable fx often best treated by intramedullary nail

Acknowledgments l 1 st Edition lecture R. Cantu M. D. l Cases Courtesy R. Acknowledgments l 1 st Edition lecture R. Cantu M. D. l Cases Courtesy R. Winquist M. D. E. Kubiak M. D. If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an e-mail to [email protected] org Return to Lower Extremity Index