Hello ...im dr zamin abbas...i completed my residency from shifa international hospital islamabad...these are one of my presentations i want to share with other colleagues
Fracture shaft of tibia is a very common injury which we deal as a trauma surgeon
2. Epidemiology
• most common long bone fx
• make up about 17% of all lower extremity
fractures
• account for 4% of all fractures seen in the
Medicare population
3. Demographics
• M > F
• bimodal distribution
• Anatomic location
• proximal 1/3 tibia fractures account for 5-10%
of tibial shaft fractures
8. Oestern and Tscherne Classification
o Grade 0
• Injuries from indirect forces with negligible soft-tissue
damage
o Grade I
• Superficial contusion/abrasion, simple fractures
o Grade II
• Deep abrasions, muscle/skin contusion, direct trauma,
impending compartment syndrome
o Grade III
• Excessive skin contusion, crushed skin or destruction of
muscle, subcutaneous degloving, acute compartment
syndrome, and rupture of major blood vessel or nerve
14. Imaging
o Radiographs
• full-length AP and lateral views of the affected
tibia
• AP, lateral and oblique views of ipsilateral knee
and ankle
• repeat radiographs recommended after splinting
or fracture manipulation
15. Imaging
o CT
• intra-articular fracture extension or suspicion of
plateau/plafond involvement
• distal 1/3 or spiral tibia fracture
• used to exclude posterior malleolar fracture
• also used to identify nonunion
17. Indications
• closed, low energy fractures with acceptable
alignment
• < 5 degrees varus-valgus angulation
• < 10 degrees anterior/posterior angulation
• > 50% cortical apposition
• < 1 cm shortening
• < 10 degrees rotational malalignment
• certain patients who may be non-ambulatory (ie.
paralyzed), or those unfit for surgery
18. OUTCOMES
• Angulation and rotational alignment are well
maintained with casting, however, shortening
is hard to control
• risk of shortening higher with oblique and
comminuted fracture patterns
• mean shortening is 4 mm
19. • risk of varus malunion with midshaft tibia
fractures and an intact fibula
• high success rate if acceptable alignment
maintained
• non-union occurs in approximately 1% of
patients treated with closed reduction
20. OPERATIVE
• I&D + antibiotics
• external fixation
• IM Nailing
• open reduction and internal fixation
• amputation
21. I&D + antibiotics
o Indications
• all open tibia fractures require an emergent I&D
• surgical debridement within 12-24 hours of injury
• wounds should be irrigated and dressed with saline-
soaked gauze in the emergency department before
splinting
• all open tibia fractures require immediate antibiotics
&should be administered within 3 hours of injury
• tetanus vaccination status should be confirmed and
appropriate prophylaxis should be administered if
necessary
22. Outcomes
• early antibiotic administration is the most
important factor in reducing infection
• emergent and thorough surgical debridement
is also an important factor
23.
24.
25. External fixation
o Indications
• damage control for polytrauma patients
• open fractures with soft tissue
defects/contamination
• proximal or distal metaphyseal fractures
• should be converted to intramedullary nail within
7-21 days, ideally less than 7 days
26. Outcomes
• longer time to union and worse functional
outcomes with definitive external fixation
compared to IM nailing in type III open tibia
fractures
• higher incidence of malalignment compared to
IM nailing
• high rate of pin tract infections; avoid intra-
articular placement given risk for septic arthritis
27. IM Nailing
o Indications
• unacceptable alignment with closed reduction
and casting
• soft tissue injury that will not tolerate casting
• segmental fx
• comminuted fx
• ipsilateral limb injury (i.e., floating knee)
• polytrauma
• bilateral tibia fx
• morbid obesity
28. Techniques
• reamed vs. unreamed nailing
• reamed nailing allows for larger diameter nail
• suprapatellar vs. infrapatellar nailing
• provisional reduction techniques (blocking
screws, plating, etc)
• particularly useful for proximal 1/3 tibial shaft
fractures
29.
30. Outcomes
• union rates >80% for closed tibia fractures
treated with nailing
• risks for nonunion: gapping at fracture site,
open fracture and transverse fracture pattern
• shorter immobilization time, earlier time to
weight-bearing, and decreased time to union
compared to casting
• decreased malalignment compared to
external fixation
32. reamed vs. unreamed nails
• reamed nails are safe for use with open fractures, with no
evidence of decreased nonunion rates in open fractures
• recent studies show no adverse effects of reaming
(infection, embolism, nonunion)
• reaming with the use of a tourniquet is not associated with
thermal necrosis of the tibial shaft, despite prior studies
suggesting otherwise
• higher rate of locking screw breakage with unreamed
nailing
33. Open reduction and internal fixation
o Indications
• proximal tibia fractures with inadequate
proximal fixation from IM nailing
• distal tibia fractures with inadequate distal
fixation from IM nail
• tibia fractures in the setting of adjacent
implant/hardware (i.e. prior total knee
arthroplasty)
34. Outcomes
• compared to IM nailing of tibia fractures:
• larger incision
• increased risk of wound complications and
hardware irritation
• similar rates of union in closed fractures
• more difficult hardware removal
35. • greater radiation exposure intraoperatively
• possibly less angular deformity
• risk of damage to the superficial peroneal
nerve during percutaneous screw insertion
• holes 11,12, and 13 (proximally) of a 13 hole
plate place nerve at risk
36. Amputation
o Indications
• no current scoring system to determine if an
amputation should be performed
• relative indications for amputation include
• significant soft tissue trauma
• warm ischemia > 6 hrs
• severe ipsilateral foot trauma
37. Outcomes
• LEAP study
• most important predictor of eventual amputation is
the severity of ipsilateral extremity soft tissue injury
• most important predictor of infection other than early
antibiotic administration is transfer to definitive
trauma center
• study shows no significant difference in functional
outcomes between amputation and salvage
• loss of plantar sensation is not an absolute indication
for amputation
39. Anterior knee pain
• >30-50% with IM nailing
o risk factors
• infrapatellar nailing with patellar tendon splitting and paratendon
approach
• suprapatellar nailing may have lower rate of anterior knee pain
• more common if nail left proud proximally
• lateral radiograph is best radiographic views to evaluate proximal
nail position
o treatment
• removal of nail
• pain relief unpredictable with nail removal
40. Malunion
• all tibial shaft fractures - between 8-10%
• higher in proximal 1/3 tibia fractures - up to
50%
41. valgus/procurvatum deformity
• patellar tendon pulls proximal fragment into
extension, while hamstring tendons and
gastrocnemius pull the distal fragment into
flexion (procurvatum)
• distal 1/3 fractures have a higher rate of valgus
malunion with IM nailing compared to plating
• definitive management with casting or external
fixation
42. Varus malunion
• most common deformity is varus with
nonsurgical management
• varus malunion may place patient at risk for
ipsilateral ankle pain and stiffness
• starting point too medial with IM nailing
• poor reduction intraoperatively
43. treatment
• prevention is most important
• adequate reduction, proper start point when nailing
• if malalignment is noted immediately after surgery,
return to operating room is appropriate with removal
of nail, reduction and nail reinsertion
• if malunion is appreciated at later followup, eventual
nail removal and tibial osteotomy can be considered
44. Nonunion (no healing at 9 months)
• estimated between 2-10%
• risk factors
• open fracture
• cortical contact <50%
• transverse fracture pattern
45. treatment
• rule out infection
• nail dynamization if axially stable
• exchange nailing if not axially stable
• reamed exchange nailing most appropriate for aseptic, diaphyseal
tibial nonunions
• oblique tibial shaft fractures have the highest rate of union when
treated with exchange nailing
• consider revision with plating in metaphyseal nonunions
46. • posterolateral bone grafting if significant bone loss
• BMP-7 (OP-1) has been shown equivalent to autograft
•
• often used in cases of recalcitrant non-unions
• compression plating has been shown to have a 92-96%
union rate after open tibial fractures initially treated with
external fixation
• fibular osteotomy of tibio-fibular length discrepancy
associated with healed or intact fibula
47. Malrotation
• highest after IM nailing of distal 1/3 tibia fractures
• increases risk of adjacent ankle arthrosis
• treatment
• should always assess rotation in operating room
• obtain perfect lateral fluoroscopic image of knee, then
rotate c-arm 105-110 degrees to obtain mortise view
of ipsilateral ankle
• may have reduced risk with adjunctive fibular plating
48. Compartment syndrome
• estimated between 1-9%
• can occur in both closed and open tibia shaft
fractures
• risk factors
• high energy injuries
• significant soft tissue injuries
• treatment
• emergent four-compartment fasciotomy
49. Nerve injury
• believed to be a rare complication
• risk factors
• LISS plate application without opening for distal screw
fixation near plate holes 11-13 put superficial peroneal
nerve at risk of injury due to close proximity
• saphenous nerve can be injured during placement of
locking screws
• transient peroneal nerve palsy can be seen after closed
nailing
• EHL weakness and 1st dorsal webspace decreased
sensation
50. • treatment
• usually nonoperatively with variable recovery
expected
• may need AFO if foot drop present
51. Infection
• approximately 5%
• risk factors
• open fracture
• severe soft tissue injury with contamination
• longer time to definitive soft tissue coverage
• treatment
• may require I&D or eventual removal of hardware
• use of wound vacuum-assisted closure does not
decrease risk of infection
