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 follow up 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

Henley’s 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 P’s       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.

Nerves • Deep Peroneal N..

 1 st 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 Whiteside’s 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 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

 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  Stable fracture pattern  < 5 ° varus/valgus  < 10 ° pro/recurvatum  < 1 cm shortening  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 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 > 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  2/3, improve w/in year Risk of infection  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 # pts. Reamed Nonunion 4% Non-Reamed 73 63 11% Malunion Broken Bolts 4% 3% 3% 16% Blachut JBJS ‘97 Time to Union 16.7 wks 25.7 wks Larsen JOT ‘04

IM Nails – Interlocking Bolts

 Loss of alignment w/o interlocking  Spiral 7/22  Transverse 0/27  Metaphyseal 7/28 Templeman CORR ‘97

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 ° procurvatum valgus, 2 ° Krettek JBJS ‘99

Technique

 Screws placed on concave deformity side of  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



1 st Edition lecture R. Cantu M.D.



Cases Courtesy R. Winquist M.D.

E. Kubiak M.D.

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