l10 closed tibia fracture](1)

7/28/2019 L10 Closed Tibia Fracture](1)

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Closed Fractures of theTibial Diaphysis

David L. Rothberg, MD

Erik N. Kubiak, MDUniversity 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


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Tibia Fractures

Most common long bone fracture

492,000 fractures yearly

Average 7.4 day hospital stay

100,000 non-unions per year


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History & Physical

Low Energy

Minimal soft-tissue injury

Less complicated fracturepattern and managementdecisions

76.5% closed

53.5% mild soft-tissue energy


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History & Physical

High Energy

High incidence of

neurovascular energyand open injury

Low threshold forcompartment syndrome

Complete soft-tissueinjury may not declareitself for several days


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Radiographic Evaluation

Full length AP and

Lateral Views

Check joint above &below

Oblique views may

be helpful in follow-up to assess healing


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Injuries Associated

30% of patients will

have multiple

injuries Ipsilateral Fibula

Fracture

Foot & Ankle injury

Syndesmotic Injury Ligamentous knee

injuries


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Injuries Associated

Ipsilateral Femur Fx

Floating Knee

Neurovascular Injury

More Common In:

High Energy

Proximal Fracture

Floating Knee

Knee Dislocation


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Classification

Numerous systems

Important variables Fracture Pattern

Location

Comminution

Associated Fibula Fx

Degree of soft-tissueinjury


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OTA Classification

Follows Johner& Wruh system

Describesrelationshipbetweenfracture pattern& mechanism

Comminution isprognostic fortime to union


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Henleys Classification

Applies Winquist &

Hansen Femur

classification tofractures of the

Tibia


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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


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Compartment Syndrome

Incidence: 5-15%

History High-Energy

Crush

Exam 4 Compartments

6 Ps Pain

Pain with passive stretch Parasthesias

Pulsless

Pallor

Paralysis


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Compartment Anatomy

Anterior

Deep Peroneal N.

Lateral Sup. Peroneal N.

Deep Post.

Tibial N.

Sup. Post.

Sural N.


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Anterior Compartment

Action

Ankle dorsiflexion

Muscles

Tib. Ant. EDL

EHL

Peroneus Tertius

Vessels Anterior Tibial A./V. Nerves

Deep Peroneal N.. 1st webspace sensation


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Lateral Compartment

Action

Foot Eversion

Muscles

Peroneus Brevis &

Longus

Nerves Superficial Peroneal

N.

Dorsal foot sensation


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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


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Superficial Posterior

Action Ankle Plantarflexion

Muslces

Gastrocnemius Soleus Popliteus Plantaris

Vessels Greater and Lesser

Saphenous V. Nerve

Sural N. Lateral heel sensation


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Compartment Syndrome

Remains a Clinical Diagnosis


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Pressure Measurements

May be helpful in borderline cases Basic Science

Muscle ischemia present at 20 mmHg below DBPand 30 mmHg below MAP

Various Thresholds P = 30 mmHg

P = 45 mmHg

Whitesides Theory P = DBP CP = < 30 mmHg


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Pressures Not Uniform

Highest at Fracture

Site

Highest Pressures

in:

Deep Posterior

Anterior

Heckman JBJS 76


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Clinical Monitoring

Close Observation

Repeat Exams

Repeat PressureMeasurements

Indwelling Monitors

Reserved for

intubated patient with

high suspicion


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Goals of Fasciotomy

Decompress thecompartment 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 locationof future incisionsand/or internal fixation


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Closed Tibial Shaft Fracture

Broad Spectrum of

Injures w/ many

treatments

Closed

Management

Intramedullary Nails

Plates

External Fixation


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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


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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


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Sarmiento

Union Rate

98.5%

Time to Union

18.1 weeks

Shortening


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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


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Post Tibia Fracture Ankle

Motion 25% Post Tibia

Fracture will lose

25% of Ankle ROM


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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


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Surgical Options

Intramedullary Nail

ORIF with Plate

External Fixation

Combination of fixation


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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


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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


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IM Nails

PRCT 62 pts

If displacement >50%angulation >10

Nails superior to casttreatment

Hooper JBJS-B 91


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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


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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 05Bhandari JOT 00


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Blachut JBJS 97

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

Reamed vs. Nonreamed Nails


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IM Nails Interlocking Bolts

Loss of alignment w/o interlocking

Spiral 7/22

Transverse 0/27

Metaphyseal 7/28

Templeman CORR 97


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Complications

Infection 1-5%

Union >90%

Knee Pain 56% w/ kneeling 90%

w/ running 56%

at rest 33%

Court-Brown JOT 96


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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% markedimprovement

3% worse Court-Brown JOT 96


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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


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Expanded Indications

Proximal 1/3 fractures Beware Valgus and Procurvatum

Distal 1/3 fractures Beware Varus or valgus

Beware of intraarticular extension


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Proximal Tibia Fracture

Entry site is

critical

Reference

Lateral Tibial

Spine


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Too Low! Too Medial!Procurvatum Valgus


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Semiextended Position

Neutralize quadriceps pull on proximalfragment

Medial parapatellar approach subluxate patella laterally

Use handheld awls to gently ream throughthe trochlear groove

Tornetta CORR 96


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Hyperextended position

Pulls patella

proximally to allow

straight startingangle

Universal distractor

Beuhler JOT 97


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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

procurvatumKrettek JBJS 99


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Technique

Screws placed on

concave side ofdeformity

Proximal or distal

fractures


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Distal Tibial Fractures

Reduction beforereaming

Distractor

Fibula plate/nail

Joy Stick

Calcaneal Traction


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Universal Distractor Reduction

Beuhler JOT 97


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Plate Fibula


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Distal Tibial Joystick


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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 continueto be the best method of treating tibial diaphyseal

fractures.

Court-Brown JOT 04


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Plating of Tibial Fractures

3.5 mm or Narrow

4.5mm DCP plate

can be used for

shaft fractures

Newer

periarticularplates available

for metaphyseal

fractures


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Subcutaneous Tibial Plating

Newer alternative is

use of limitedincisions and

subcutaneous

plating- requires

indirect reduction offracture and hybrid

screw fixation

options


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Advantages of Plating

Anatomic reduction

usually obtained

In low energy

fractures

97% G/E results

reported Ruedi Injury


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Disadvantages of Plating

Increased risk ofinfection and soft tissueproblems, especially in

high energy fractures

Higher rate hardwarefailure than IM nail

Delayed WB (loadbearing)

Johner CORR 83


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External Fixation

Generally

reserved for open

tibia fractures orperiarticular

fractures


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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 distalfragment

Butterfly fragment can be secured with interfragmentaryscrew

The AO articulating tension device can be secured toproximal part of plate to aid reduction

With fracture reduced, screws placed through plate oneither side of fracture


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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 whileclamps and connecting bar

applied


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Advantages of External

Fixator Can be applied quickly in

polytrauma patient

Allows easy monitoringof soft tissues and

compartments

Modifiable No long term deep HW


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Outcomes of External Fixation

Anderson CORR 74

Edge JBJS 81

95% union rate for

group of closed and

open tibia fractures

20% malunion rate

Loss of reduction

associated with

removing frameprior to union

Risk of pin track

infection


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Conclusions

Common fracture w/ several treatment

options

Closed stable fx can be treated in a cast

Unstable fx often best treated by

intramedullary nail


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Acknowledgments

1stEdition lecture R. Cantu M.D.

Cases Courtesy R. Winquist M.D.

E. Kubiak M.D.

Return toE mail OTA

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