Closed Fractures of the Tibial Diaphysis

1
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

2
Tibia Fractures

• Most common long bone fracture
• 492,000 fractures yearly
• Average 7.4 day hospital stay
• 100,000 non-unions per year

3
History Physical

• Low Energy
• Minimal soft-tissue injury
• Less complicated fracture pattern and management
  decisions
• 76.5 closed
• 53.5 mild soft-tissue energy

4
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

5
Radiographic Evaluation

• Full length AP and Lateral Views
• Check joint above below
• Oblique views may be helpful in follow-up to
  assess healing

6
Injuries Associated

• 30 of patients will have multiple injuries
• Ipsilateral Fibula Fracture
• Foot Ankle injury
• Syndesmotic Injury
• Ligamentous knee injuries

7
Injuries Associated

• Ipsilateral Femur Fx
• Floating Knee
• Neurovascular Injury
• More Common In
• High Energy
• Proximal Fracture
• Floating Knee
• Knee Dislocation

8
Classification

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

9
OTA Classification

• Follows Johner Wruh system
• Describes relationship between fracture pattern
  mechanism
• Comminution is prognostic for time to union

10
Henleys Classification

• Applies Winquist Hansen Femur classification to
  fractures of the Tibia

11
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

12
Compartment Syndrome

• Incidence
• 5-15
• History
• High-Energy
• Crush
• Exam
• 4 Compartments
• 6 Ps
• Pain
• Pain with passive stretch
• Parasthesias
• Pulsless
• Pallor
• Paralysis

13
Compartment Anatomy

• Anterior
• Deep Peroneal N.
• Lateral
• Sup. Peroneal N.
• Deep Post.
• Tibial N.
• Sup. Post.
• Sural N.

14
Anterior Compartment

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

15
Lateral Compartment

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

16
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

17
Superficial Posterior

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

18
Compartment Syndrome Remains a Clinical Diagnosis
19
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
• Whitesides Theory
• ? P DBP CP lt 30 mmHg

20
Pressures Not Uniform

• Highest at Fracture Site
• Highest Pressures in
• Deep Posterior
• Anterior
• Heckman JBJS 76

21
Clinical Monitoring

• Close Observation
• Repeat Exams
• Repeat Pressure Measurements
• Indwelling Monitors
• Reserved for intubated patient with high suspicion

22
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

23
Closed Tibial Shaft Fracture

• Broad Spectrum of Injures w/ many treatments
• Closed Management
• Intramedullary Nails
• Plates
• External Fixation

24
Non-Operative Treatment Indications

• Minimal soft tissue damage
• Non-intact fibula
• Higher rate of nonunion varus with intact
  fibula
• Stable fracture pattern
• lt 5 varus/valgus
• lt 10 pro/recurvatum
• lt 1 cm shortening
• Ability to bear weight in cast or fx brace
• Requires frequent follow-up
• Schmidt ICL 52, 2003

25
Fracture Brace

• Closed Functional Treatment
• 1,000 Tibial Fractures
• 60 Lost to F/U
• Fracture Characteristics
• All lt 1.5cm shortening
• Non with intact fibula
• Only 5 more than 8 varus
• Treatment Course
• Average 3.7 wks in long leg cast
• Transition to Function Fracture Brace
• Sarmiento JBJS 84

26
Sarmiento

• Union Rate
• 98.5
• Time to Union
• 18.1 weeks
• Shortening
• lt1.4
• Initial Shortening Final Shortnening

27
Natural History

• Long-term angular deformities
• Well tolerated without associated knee or ankle
  arthrosis
• Kristensen 22 pt F/U 20-29 yrs
• All patients gt10 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

28
Post Tibia Fracture Ankle Motion

• 25 Post Tibia Fracture will lose 25 of Ankle ROM

29
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 gt 5
• Sagittal Angulation gt 10
• Rotation gt 5
• Shortening gt 1cm
• Comminution gt 50 cortical circumference
• Intact fibula

30
Surgical Options

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

31
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

32
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

33
IM Nails

• PRCT 62 pts
• If displacement gt50 angulation gt10
• Nails superior to cast treatment

Hooper JBJS-B 91
34
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
35
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 05 Bhandari JOT 00
36
Blachut JBJS 97
Reamed vs. Nonreamed Nails

• Reamed Non-Reamed
• pts. 73 63
• Nonunion 4 11
• Malunion 4 3
• Broken Bolts 3 16
• Time to Union 16.7 wks 25.7 wks
• Larsen JOT 04

37
IM Nails Interlocking Bolts

• Loss of alignment w/o interlocking
• Spiral 7/22
• Transverse 0/27
• Metaphyseal 7/28

Templeman CORR 97
38
Complications

• Infection 1-5
• Union gt90
• Knee Pain 56
• w/ kneeling 90
• w/ running 56
• at rest 33

Court-Brown JOT 96
39
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
40
Neurologic Complications

• 63 pts compared types of anesthesia
• Epidural Anesthesia
• 4.1 x greater risk of neurologic injury
• Illustrates need to monitor post-op exam
• Iaquinto Am J Orth 97

41
Expanded Indications

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

42
Proximal Tibia Fracture

• Entry site is critical
• Reference
• Lateral Tibial Spine

43
Too Low! Too Medial!
Valgus
Procurvatum
44
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
45
Hyperextended position

• Pulls patella proximally to allow straight
  starting angle
• Universal distractor

Beuhler JOT 97
46
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
47
Technique

• Screws placed on concave side of deformity
• Proximal or distal fractures

48
(No Transcript)
49
Distal Tibial Fractures

• Reduction before reaming
• Distractor
• Fibula plate/nail
• Joy Stick
• Calcaneal Traction

50
Universal Distractor Reduction
Beuhler JOT 97
51
Plate Fibula
52
Distal Tibial Joystick
53
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
54
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

55
Subcutaneous Tibial Plating

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

56
Advantages of Plating

• Anatomic reduction usually obtained
• In low energy fractures
• 97 G/E results reported
• Ruedi Injury

57
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
58
External Fixation

• Generally reserved for open tibia fractures or
  periarticular fractures

59
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

60
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

61
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

62
Outcomes of External Fixation

• 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

Anderson CORR 74 Edge JBJS 81
63
Conclusions

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

64
Acknowledgments

• 1st Edition lecture R. Cantu M.D.
• 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 ota_at_ota.org
Return to Lower Extremity Index