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![Reamed or unreamed nails?
Closed tibial fractures [CM Court-Brown et al 1996]
Reamed nails
• Union (weeks) 15.4
• Nonunion 0%
• Malunion 0%
• Screw breakage 4%
• Nail breakage 0%
Unreamed nails
• Union (wks) 22.8
• Nonunion 20%
• Malunion 16%
• Screw breakage 52%
• Nail breakage 4%
Reamed mechanically and biologically superior.](https://image.slidesharecdn.com/ueholyb9qymqzjw0dvma-signature-adb10c2637e590b7c6a491acd596fa5528ae126ffab840d71ae72dd1362a57b8-poli-160422234113/85/Closed-tibial-shaft-28-320.jpg)
More Related Content
Closed tibial shaft
- 1. AOTrauma Principles Course Closedtibial shaft fractures Piet de Boer, UK John Wilber, US
- 2. Closed tibial shaftfractures • Assessment of the injury • Nonoperative/operative options • Choice of implants (their advantages and disadvantages) • Importance of the closed soft-tissue injury
- 3. Tibial diaphyseal fractures Problem •Most common long bone fracture - 492,000 fractures/year • Most common open fracture • Significant cost - 569,000 hospital days - Major cause of disability • Significant complications - 50,000 nonunions/year
- 4. Assessment of tibialdiaphyseal fractures Classification • Fracture • Soft Tissue
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- 6. Tibial diaphyseal fractures TypeGroup Subgroup
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- 10. Soft-tissue injury Complications and prognosisare directly related to the degree of soft- tissue injury
- 11. Assessment—energy of injury •Accumulative biologic injury • Pre-existing condition • Injury • Treatment Threshold for Complication
- 12. Assessment —energy ofinjury
- 13. Assessment • History: velocityof injury • Clinical examination • General ATLS (advanced trauma life support) • Local soft tissues • Neurovascular
- 14. Assessment • X-rays: A/Pand lateral • Special investigations: - Pressure monitoring - Angiography - CT (computed tomography, never immediate)
- 15. Nonoperative treatment • Nonoperativetreatment does NOT mean no treatment • Closed reduction and plaster of Paris application achieve good results • Nonoperative treatment is difficult and demanding
- 16. Nonoperative treatment • Plastercan prevent lateral shift • Plaster can prevent angulation • Plaster can control rotation • Plaster can NOT prevent shortening
- 17. “A fracture inplaster of Paris will not displace more than its previous maximal displacement” Sarmiento,York 1998
- 18. Nonoperative treatment • Children •Undisplaced fractures • “Stable” reduced fractures • Contraindication for surgery: - Patient - Health care team
- 19. Tibial fixation options •Plate • Ex Fix • IMN
- 20. Operative treatment—nailing • Destroysendosteal circulation • Indirect reduction which preserves soft-tissue attachments • Allows movement at fracture site which results in early union with callus formation • Anatomical reduction rare but restoration of length, axis, and rotation is usual
- 21. Nailing—mechanics • Nails functionas internal splints • Nails can withstand heavy loads • Nails can be mobilized with early weight bearing
- 22. Intramedullary nailing Indications • Closeddiaphyseal fractures • Open diaphyseal fractures • Segmental fractures • Floating knee • Nonunions Treatment of choice for the vast majority of fractures
- 23. Insertion principles Starting point •Proximal • Central • Anterior
- 24. Locking Principles In thevast majority of cases static locking is carried out Locking • None • Static • Dynamic Indications • Length • Rotation • Alignment
- 25. Problems with nailingin proximal and distal fractures • Malalignment • Instability • Failure • Malunion • Nonunion
- 26. Techniques available forproximal and distal nailing • Blockings screws • Reduction plate • Fibular fixation • Percutaneous clamp Fractures must be reduced and held during insertion!
- 28. Reamed or unreamednails? Closed tibial fractures [CM Court-Brown et al 1996] Reamed nails • Union (weeks) 15.4 • Nonunion 0% • Malunion 0% • Screw breakage 4% • Nail breakage 0% Unreamed nails • Union (wks) 22.8 • Nonunion 20% • Malunion 16% • Screw breakage 52% • Nail breakage 4% Reamed mechanically and biologically superior.
- 29. Operative treatment—compression plating • Destroysperiosteal circulation • Direct reduction will destroy soft-tissue attachments • Rigid fixation will result in slow union without callus formation • Anatomical reduction • Implant failure possible if technique is not perfect
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- 31. Compression plating—indications • Simplemetaphyseal fractures • Corrective osteotomy for malunion • Plating for hypertrophic nonunion
- 32. Operative treatment—MIPO (minimally invasiveplate osteosynthesis) • Indirect reduction preserves soft tissues but imperfect reduction leading to malunion is a problem • Bridge plating produces stable fixation resulting in early healing with callus formation
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- 34. Plating—mechanics • Plates cannotwithstand weight-bearing forces • Plates will not permit early full weight bearing
- 35. Operative treatment—external fixator •Useful in severe soft-tissue damage • Rarely used as definitive treatment
- 36. Complications of tibialnailing—specific to nailing • Anterior knee pain • Thermal necrosis • Latrogenic fracture
- 37. Anterior knee pain •May be related to leaving end of nail proud • Will not be cured by nail removal unless proximal end of the nail is very prominent
- 38. Anterior knee pain •Incidence varies from series to series • 0–40% • Related to surgical approach—may be more common in patella tendon splitting approaches • NB: Centre of tibial head is just medial to patellar tendon
- 39. Tibial nailing • Highincidence of compartment syndromes • High index of suspicion • Avoid local anesthetic techniques
- 40. Compartment syndrome • Variablereported incidence in published series: 1–7% • Occurs in both reamed and unreamed nailing • A high index of suspicion will lead to a high level of diagnosis • Diagnosis is clinical and not dependant on measuring pressures
- 41. Closed tibial shaftfractures • Decision-making • Fracture • Limb • Patient: - other injuries - other pathologies • Health care environment
- 42. Closed tibial shaftfractures • Assessment of the injury • Nonoperative/operative options • Choice of implants—their advantages and disadvantages • Surgical technique • Importance of the closed soft-tissue injury