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

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 followup 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

Henleys 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 Ps

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.

Deep Peroneal N..

Nerves
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 Whitesides 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 longterm 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

Minimal soft tissue damage Non-intact fibula

Higher rate of nonunion & varus with intact fibula < 5 varus/valgus < 10 pro/recurvatum < 1 cm shortening

Stable fracture pattern

Ability to bear weight in cast or fx brace

Requires frequent follow-up

Fracture Brace

Closed Functional Treatment

1,000 Tibial Fractures 60% Lost to F/U

Fracture Characteristics
All < 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

Sarmiento

Union Rate
98.5%

Time to Union
18.1 weeks

Shortening
<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-

Fracture Characteristics

operative management Need for early mobility

Injury Characteristics

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

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

Risk of infection

2/3, improve w/in year

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 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

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

Reamed vs. Nonreamed Nails

Reamed 73 4% 4% 3% Non-Reamed 63 11% 3% 16%
Blachut JBJS 97

# pts. Nonunion Malunion Broken Bolts

Time to Union 16.7 wks 25.7 wks

Larsen JOT 04

IM Nails Interlocking Bolts

Loss

of alignment w/o interlocking 7/22 0/27 7/28

Templeman CORR 97

Spiral Transverse Metaphyseal

Complications

Infection Union Knee Pain

w/ kneeling
w/ running at rest

1-5% >90% 56%

90% 56% 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

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

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!
Procurvatum

Too Medial!
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 Krettek JBJS 99

procurvatum

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

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

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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