Tibial fracture

1. 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

2. Tibia Fractures
 Most common long bone fracture
 492,000 fractures yearly
 Average 7.4 day hospital stay
 100,000 non-unions per year

3. History & Physical
 Low Energy
– Minimal soft-tissue injury
– Less complicated fracture
pattern and management
decisions
 76.5% closed
 53.5% mild soft-tissue energy

4. 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

5. Radiographic Evaluation
 Full length AP and
Lateral Views
– Check joint above &
below
 Oblique views may
be helpful in follow-
up to assess healing

6. Injuries Associated
 30% of patients will
have multiple
injuries
– Ipsilateral Fibula
Fracture
– Foot & Ankle injury
– Syndesmotic Injury
– Ligamentous knee
injuries

7. Injuries Associated
 Ipsilateral Femur Fx
– “Floating Knee”
 Neurovascular Injury
– More Common In:
 High Energy
 Proximal Fracture
 Floating Knee
 Knee Dislocation

8. Classification
 Numerous systems
 Important variables
– Fracture Pattern
– Location
– Comminution
– Associated Fibula Fx
– Degree of soft-tissue
injury

9. OTA Classification
 Follows Johner
& Wruh system
 Describes
relationship
between
fracture pattern
& mechanism
 Comminution is
prognostic for
time to union

10. Henley’s Classification
 Applies Winquist &
Hansen Femur
classification to
fractures of the
Tibia

11. 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

12. Compartment Syndrome
 Incidence:
– 5-15%
 History
– High-Energy
– Crush
 Exam
– 4 Compartments
– 6 P’s
 Pain
 Pain with passive stretch
 Parasthesias
 Pulsless
 Pallor
 Paralysis

13. Compartment Anatomy
 Anterior
– Deep Peroneal N.
 Lateral
– Sup. Peroneal N.
 Deep Post.
– Tibial N.
 Sup. Post.
– Sural N.

14. Anterior Compartment
• Action
• Ankle dorsiflexion
• Muscles
• Tib. Ant.
• EDL
• EHL
• Peroneus Tertius
• Vessels
• Anterior Tibial A./V.
• Nerves
• Deep Peroneal N..
 1st webspace sensation

15. Lateral Compartment
• Action
• Foot Eversion
• Muscles
• Peroneus Brevis &
Longus
• Nerves
• Superficial Peroneal
N.
• Dorsal foot sensation

16. 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

17. Superficial Posterior
• Action
• Ankle Plantarflexion
• Muslces
• Gastrocnemius
• Soleus
• Popliteus
• Plantaris
• Vessels
• Greater and Lesser
Saphenous V.
• Nerve
• Sural N.
 Lateral heel sensation

18. Compartment Syndrome
Remains a Clinical Diagnosis

19. 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

20. Pressures Not Uniform
 Highest at Fracture
Site
 Highest Pressures
in:
– Deep Posterior
– Anterior
 Heckman JBJS ’76

21. Clinical Monitoring
 Close Observation
– Repeat Exams
– Repeat Pressure
Measurements
 Indwelling Monitors
– Reserved for
intubated patient with
high suspicion

22. 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

23. Closed Tibial Shaft Fracture
 Broad Spectrum of
Injures w/ many
treatments
 Closed
Management
 Intramedullary Nails
 Plates
 External Fixation

24. 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

25. 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

26. Sarmiento
 Union Rate
– 98.5%
 Time to Union
– 18.1 weeks
 Shortening
– <1.4%
 Initial Shortening = Final Shortnening

27. 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

28. Post Tibia Fracture Ankle
Motion
 25% Post Tibia
Fracture will lose
25% of Ankle ROM

29. 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

30. Surgical Options
• Intramedullary Nail
• ORIF with Plate
• External Fixation
• Combination of fixation

31. 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

32. 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

33. IM Nails
 PRCT 62 pts
– If displacement >50%
angulation >10°
– Nails superior to cast
treatment
Hooper JBJS-B ‘91

34. 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

35. 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

36. 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

37. IM Nails – Interlocking Bolts
 Loss of alignment w/o interlocking
 Spiral 7/22
 Transverse 0/27
 Metaphyseal 7/28
Templeman CORR ‘97

38. Complications
 Infection 1-5%
 Union >90%
 Knee Pain 56%
– w/ kneeling 90%
– w/ running 56%
– at rest 33%
Court-Brown JOT ‘96

39. 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

40. 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

41. Expanded Indications
 Proximal 1/3 fractures
 Beware Valgus and Procurvatum
 Distal 1/3 fractures
 Beware Varus or valgus
 Beware of intraarticular extension

42. Proximal Tibia Fracture
 Entry site is
critical
 Reference
– Lateral Tibial
Spine

43. Too Low! Too Medial!
Procurvatum Valgus

44. 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

45. Hyperextended position
 Pulls patella
proximally to allow
straight starting
angle
 Universal distractor
Beuhler JOT ‘97

46. 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°
procurvatum Krettek JBJS ‘99

47. Technique
 Screws placed on
concave side of
deformity
 Proximal or distal
fractures

49. Distal Tibial Fractures
 Reduction before
reaming
 Distractor
 Fibula plate/nail
 Joy Stick
 Calcaneal Traction

50. Universal Distractor Reduction
Beuhler JOT ‘97

51. Plate Fibula

52. Distal Tibial Joystick

53. 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

54. 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

55. Subcutaneous Tibial Plating
• Newer alternative is
use of limited
incisions and
subcutaneous
plating- requires
indirect reduction of
fracture and hybrid
screw fixation
options

56. Advantages of Plating
 Anatomic reduction
usually obtained
 In low energy
fractures
– 97% G/E results
reported
• Ruedi Injury

57. 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

58. External Fixation
• Generally
reserved for open
tibia fractures or
periarticular
fractures

59. 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

60. 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

61. 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

62. 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 frame
prior to union
 Risk of pin track
infection

63. Conclusions
 Common fracture w/ several treatment
options
 Closed stable fx can be treated in a cast
 Unstable fx often best treated by
intramedullary nail

64. Acknowledgments
 1st Edition lecture R. Cantu M.D.
 Cases Courtesy R. Winquist M.D.
E. Kubiak M.D.
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