Closed Tibial Fracture

Epidemiology

 

Most common long bone fracture

 

Aetiology

 

Young patients / sports

 

Elderly / simple falls

 

MVA - often compound

 

Anatomical Classification

 

Proximal

- proximal metaphysis

 

Shaft / Middle

 

Tibial Midshaft Fracture

 

Distal

- distal metaphysis

 

Tibial Fracture AP

 

Tscherne Soft Tissue Classification

 

Grade 0

- nil ST injury

 

Grade 1

- superficial abrasion / contusion

- ST injury from pressure from within

 

Grade 2

- deep contusion / abrasion

- due to direct trauma

 

Grade 3

- extensive contusion and crush

- subcutaneous tissue avulsion

- severe muscle injury

 

Issues

 

Acceptable alignment

 

No scientific data

- can probably accept a reasonable amount of deformity

- up to and including 10o without risk knee / ankle OA

 

Usually don't accept this

 

Operative v Non operative

 

Littenberg et al JBJS Am 1998

- meta-analysis of 19 papers

- non operative prevents infection

- ORIF more likely to result in union

 

Sarmiento 1000 patients closed treatment

- 60% lost to follow up

- non union rate 1.1%

- 10% short > 1 cm

- 5% > 8o varus

- comminution longer to unite

- intact fibula more rapid union but increased risk angular deformity

 

IMN v cast

 

Hooper et al JBJS 1998

- IMN more rapid union, less malunion and earlier RTW

- improved outcome when > 50% displacement or angulation > 10o

 

Puno et al Clin Orthop 1986

- 200 closed tibial fractures

- IMN union 98%, malunion 0%, infection 3%

- cast 90%, malunion 4%

 

Advantages cast

- no infection

- no knee pain

- no hardware to removed

 

Advantage IMN

- faster union

- reduced non union

- reduced malunion

- earlier ROM

- able to weight bear early

 

Non Operative Treatment / Plaster Cast

 

Indications 

 

Low energy injury

Minimal ST injury

Stable fracture / minimal / acceptable displacement

 

Acceptable

 

Coronal < 5o

Sagittal < 10o

Rotation < 10o

Shortening < 1cm

> 50% apposition

 

Technique

 

Gavity assist over edge of bed

Application SL initially

Extend with knee slightly flexed

 

Union rate 

 

90%

 

Tibial Shaft Fracture Non Operative Treatment BeforeTibial Shaft Fracture Non Operative Treatment After

 

Operative Treatment

 

Options

 

1.  IM Nail

2.  Plate

3.  External Fixation

 

1.  IMN Nail

 

Tibial Midshaft Fracture IMN APTibial Midshaft Fracture IMN Post op

 

A.  IMN Tibial Shaft

 

Locking

 

Provides rotatory stability

- required with spiral / comminution / metaphyseal

- may not be necessary with transverse fractures

 

Reaming

 

Larsen et al J Orthop Trauma 2004

- RCT of reamed v unreamed

- significantly longer time to union in unreamed

 

Reason

- reaming also bone grafts fracture site

- large nail provides greater stability

 

SPRINT trial JBJS Am 2008

- multicentred trial of over 1000 tibial IMN

- demonstrated a possible benefit for reaming

 

B.  IMN Proximal tibial fractures

 

Issue

 

High incidence malunion

- typically valgus 

- flexion / procurvatum

- posterior translation of distal segment

 

Proximal Tibial Fracture Poorly Nailed

 

Reason

 

Standard medial and anterior entry points

- mismatch to distal canal 

- canal becomes triangular

- pushes fracture into the above deformities

 

Surgical Points

 

1.  Change entry point

- match entry point to distal IM canal

- lateral and posterior

- in line with lateral tibial spine

- through or lateral to PT

- entry with knee semi-extended

 

2.  Blocking screws

- also lateral and posterior

- functionally narrow IM canal

- on concave side of deformity

- same positions as entry point

- posterior in proximal segment

- lateral in proximal segment

 

C.  IMN Distal tibial fractures

 

Distal Tibial FractureDistal Tibial Nail APDistal Tibial Nail Lateral

 

Design

 

Distal tibial nails

- multiple distal screws

- some within 5 mm of end of nail

- usually 2 medial-lateral and 1 AP

 

Technique

 

Most important is to centre guide wire over talus

- in lateral and AP

 

1.  Use finger reduction tools and pass across fracture site

2.  Use temporary external fixator

3.  Pins in distal tibia / calcaneum to control distal fragment

4.  Plate fibula

5.  Blocking screws

 

2.  ORIF with plate

 

Indications

- metaphyseal / periarticular fractures

- tibial fractures in children

 

A.  Midshaft tibial ORIF

 

Tibial Midshaft PlateTibial Midshaft Plate Lateral

 

Risk

- poor skin / blood supply / muscle cover

- high risk of wound breakdown

- must strip bone to apply plate

 

Technique

- minimally invasive

- indirect reduction techniques

 

Complications

 

Nonunion

- excessive soft tissue stripping

- inability for fracture to compress

 

Distal Tibial ORIF Nonunion

 

B.  Distal Tibial ORIF

 

Indications

- too distal to nail

 

Technique

- may need initial external fixation

- hold reduction

- enable swelling to reduce

- ORIF as per tibial plafond fracture

 

Distal Tibial Fracture DisplacedDistal Tibial Fracture External FixationDistal Tibial Fracture ORIF

 

3.  External fixation

 

Indications

 

Contaminated wound

Vascular injury

Damage Control Orthopedics

Segmental bone loss - Ilizarov

 

Technique

 

Unilateral

- 4 or 5 mm half pin

- predrill to decrease thermal necrosis

- 2 near fracture and 2 far from cortex

- 2 bars / close to skin (2 cm)

 

Complications

 

Compartment syndrome

 

5 - 15 %

- pain from nerve ischaemia first symptom

- pain with passive stretch first sign

 

Normal compartment pressures

- > 30 mm Hg less than DBP

- < 30 mm Hg

 

Infection

- 3%

 

Delayed / non union

 

SPRINT trial JBJS Am 2008

- incidence of non union of 4%

 

Malunion

 

Most common in proximal and distal tibial fracture

 

Anterior Knee Pain after IMN

 

Most common complication

 

Vaisto et al J Trauma 2008

- RCT of paratendinous v transtendinous nail insertion

- no difference in incidence of knee pain

 

Nail removal

- resolves in 1/2 after removal of nail

- improves in 1/4

- no improvement in 1/4