22. Deep Posterior Compartment
• Plantarflexion and
inversion of foot
• FDL, FHL, Tib post
muscles
• Post tibial
vessels, peroneal a.
• tibial nerve
Plantar foot sensation
24. Classification
• Numerous classification systems
• Important variables
Pattern of fracture
location of fracture
comminution
associated fibula fracture
degree of soft tissue injury
25. OTA Classification
• Follows Johner &
Wruh system
• Relationship between
fracture pattern and
mechanism
• Comminution is
prognostic for time
to union
Johner and Wruhs, Clin Orthop 1983
27. 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
28.
29. History & Physical
• Pain, inability to bear weight, and deformity
• Local swelling and edema variable
• Careful inspection of soft tissue
envelope, including compartment swelling
• Thorough neurovascular assessment including
motor/sensory exam and distal pulses
30. Physical Exam
• Soft tissue injury with high-energy crush
mechanism may take several days to fully
declare itself
• Repeated exam to follow compartment
swelling
31. Radiographic Evaluation
AP and Lateral
views of entire
tibia from knee to
ankle
Oblique views can
be helpful in
follow-up to
assess healing
32. Associated Injuries
• Up to 30% of patients
with tibial fractures have
multiple injuries
• Ipsilateral fibula fracture
common
• Ligamentous injury of
knee with high energy
tibia fractures
Browner and Jupiter, Skeletal Trauma, 3rd Ed
33. Associated Injuries
• Ipsilateral femur fx,
“floating knee”
• Neuro/vascular injury less
common than in proximal
tibia fx or knee dislocation
• Foot and ankle injury
36.
Limit soft tissue damage.
Preserve or restore soft tissue cover.
Prevent or recognize & treat Compartment
Syndrome.
To obtain & hold fracture alignment.
Early weight bearing.
To start joint movements as early as possible.
37.
Depends on the type of fracture.
◦ Open / Closed
◦ High Energy / Low Energy
40.
Minimal soft tissue damage
Stable fracture pattern
< 5 varus/valgus
< 10 pro/recurvatum
< 1 cm shortening
Ability to bear weight in cast or fx brace
Frequent follow-up
Schmidt, et.al., ICL 52, 2003
41.
Closed Functional Treatment
◦
1,000 Tibial Fractures
60% Lost to F/u
All < 1.5cm shortening
Only 5% more than 8 varus
Average 3.7wks in long leg cast, then
◦ Functional fracture brace
Sarmiento, JBJS 1984
42.
Long-term angular deformities may be well
tolerated without associated knee or ankle
arthrosis
Kristensen
F/U: 20-29 yr
All patients >10 degree deformity
Merchant & Dietz
F/U: 29 yrs.
◦ Outcome not associated with ang., site, immob.
(37/108 patients)
44. Advantages of IM Nail
• Less malunion and
shortening
• Earlier weight bearing
• Early ankle and knee
motion
• Possibly cheaper than
casting if time off
work included
Tovainen, Ann Chir Gynaecol, 2000
45. Disadvantages of IM Nail
Anterior knee pain
(up to 56.2%)
Risk of infection
Increased
hardware failure
with unreamed
nails
*Court-Brown et al. JOT 96
46. Plating of Tibial Fractures
• Narrow 4.5mm
DCP plate can be
used for shaft
fractures
• Newer periarticular
plates available for
metaphyseal
fractures
47. Advantages of Plating
Anatomic reduction
usually obtained
In low energy fractures
97% very good/good
results have been
reported
Ruedi et al. Injury vol 7
48. Disadvantages of Plating
• Increased risk of
infection and soft
tissue
problems, especially in
high energy fractures
• Higher rate hardware
failure than IM nail
Johner and Wruhs, Clin Orthop 1983
50. Technique of External Fixation
• Unilateral frame with half pins
• 5mm half pins („near-near and
far-far‟)
• Pre-drilling of pins recommended
• Fracture held reduced while
clamps and connecting bar
applied
51. Advantages of External Fixator
• Can be applied quickly
in polytrauma patient
• Allows easy
monitoring of soft
tissues and
compartments
52. 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 et al. Clin Orthop 1974
Edge and Denham JBJS[Br] 1981
53.
Common fracture w/ several treatment
options.
Closed stable fxs. can be treated in a cast.
Unstable fxs. often best treated by
intramedullary nail
56.
Controversial issue
◦ Classically <6hrs
◦ Currently urgent, not emergent
Early antibiotics may be more critical
More wound contamination requires more
urgency and more frequency
-Bosse, JAAOS, 2002
-Skaggs, JBJS 2005
57.
Meticulous debridement
Explore/Extend wound
Deliver bone ends for full exposure
Excise all foreign material, necrotic
muscle, unattached bone fragments, exposed
fat and fascia
◦ Infection 21% vs 9% w/ improved debridement
Fasciotomy as indicated
-Edwards, CORR 1988
-Patzakis, JAAOS 2003
58.
D & I “Debridement & Irrigation”
No consensus on volume required
Pulse lavage
◦ May remove debris vs. harmful to osteoblasts
Antibiotics vs. Soap
-Anglen, JBJS 2005
59. Bead Pouches
Tobra 1.2g per packet
of PMMA
Seal wound to create
antibiotic-laden seroma
Reduced risk of
infection
◦ 12% vs 4%
Reduced
aminoglycoside toxicity
-Ostermann, JBJS-B 1995
63. 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 et al. Clin Orthop 1974
Edge and Denham JBJS[Br] 1981
64. Advantages of IM Nail
Less malunion and
shortening
Earlier weight
bearing
Early ankle and
knee motion
Reduced time to
union
-Shannon, J. Trauma 2002
69.
Primary closure controversial
◦ Surgical judgement gained with experience
◦ If in doubt, repeat debridement 24-72hrs
Type I and some Type II wounds can be
closed primarily or after repeat I+D
Type II and Type IIIa can be closed after
repeat debridement if clean
-Bosse, JAAOS 2002
70.
Type IIIB fractures
require local rotation
flap, split-thickness
skin graft, or free flap
◦ “reconstructive ladder”
◦ within 7 days
◦ <72 hrs may be better
Reduced need for
complex flaps with
negative pressure
wound therapy
-Parrett, Plast & Recon Surg, 2006
-Gopal, JBJS-B, 2000
71.
Proximal third tibia
fractures gastrocnemius
rotation flap
Middle third tibia
fractures - soleus
rotation flap
Distal third fractures
- free flap or reverse
sural rotation flap
72.
Typically no acute bone grafting due to risk
of infection
Bone graft substitutes
BMP-2, OP-1
◦ BESST trial w/ BMP-2 in open fxs
◦ Safe, fewer infections, faster fracture healing
◦ Unknown cost effectiveness
-Govender, et.al. JBJS 2002
73.
Low energy missiles
rarely require
debridement and can
often be treated like
closed injuries
Fractures due to high
energy missiles (eg
assault rifle or close
range shot gun) treated
as standard open
injuries
75.
Definition varies from
3 months to one year
Rule out infection
Treatment options:
◦ onlay bone grafts
◦ Bone graft substitutes
◦ free vascularized bone
grafts
◦ reamed exchange
nailing
◦ compression plating
◦ Ilizarov ring fixator
76.
Varus malunion more of a
problem than valgus
May not be symptomatic
For symptomatic patients
with significant deformity
treatment is osteotomy
-Kristensen et al. Acta Orthop Scand 1
77.
Ex-fix pin tracts
Should respond to elevation and appropriate
antibiotics (typically gram + cocci coverage)
High index of suspicion for deep infection
with repeat debridement required
79.
Sometimes seen during rehab after
prolonged non-weight bearing
Can present with localized tenderness in
metatarsal, calcaneus, or distal fibula
Bone scan or MRI may be required to make
diagnosis as plain radiographs often normal
Treatment is temporary reduction in weight
bearing
80.
Usually due to delayed
union or nonunion
Rule out infection
Treatment depends on
type of failure:
plate or nail breakage
often requires revision
locking screw in nail may
not require operative
intervention
82.
An attempt to help
guide between
primary
amputation vs.
limb salvage
Score of 7 or
higher was
predictive of
amputation
-Johansen et al. J Trauma 1991
83.
Host factors
◦ Type A – healthy
◦ Type B – minimal
comorbidities
◦ Type C – Multiple
comorbidites, tobacc
o use, poor social
support
The four “D’s”
◦
◦
◦
◦
Disabled
Destitute
Drunk
Divorced
