1) Closed tibial shaft fractures are a common injury, with over 492,000 occurring per year in the US. They can be treated nonoperatively with casting or surgically with intramedullary nailing, plating, or external fixation. 2) Intramedullary nailing is now the preferred surgical treatment, as studies have shown it results in higher union rates and fewer complications compared to other options. However, anterior knee pain remains a common complication after nailing. 3) External fixation is generally reserved for open or periarticular fractures, as it is associated with higher malunion rates compared to nailing. Plating risks higher infection and soft tissue complications.

1. Closed Fractures of
the Tibial Diaphysis
David Templeman, MD
Robert Cantu, MD

2. Anatomy
• 4 compartments of leg
• Canal expands and
cortex thins
proximally and
distally at
metaphyseal-
diaphyseal junctions
• Blood supplyvia single
nutrient artery and periosteal
arteries

3. • Much emphasis to Hi E fractures
• In Fact: 76.5% are closed & 53.5% are Tscherne
C1 Injuries

4. Tibial Fractures
• 492,000 per year (incidence)
• 100,000 nonunions per year (prevelance)

5. Physical Exam
• Pain, inability to bear weight, and deformity may
be seen
• Local swelling and edema variable
• Careful inspection of soft tissue envelope
necessary, including compartment swelling
• Thorough neurovascular assessment including
motor/sensory exam and distal pulses

6. Physical Exam
• Soft tissue injury with high-energy crush
mechanism may take several days to fully
declare itself
• Repeated exam often necessary to follow
compartment swelling

7. Radiographic Evaluation
• AP and Lat views of entire tib/fib required
from knee to ankle
• Oblique views can be helpful in follow-up
to assess healing

8. Associated Injuries
• Up to 30% of patients
with tibial fractures have
multiple injuries*
• Fracture of the ipsilateral
fibula common
• Ligamentous injury of
knee common in high
energy tibia fractures
*Browner and Jupiter, Skeletal Trauma, 2nd
Ed

9. Associated Injuries
• Ipsilateral femur fx, so
called “floating knee”, seen
in high energy injuries
• Neuro/vascular injury less
common than in proximal
tibia fx or knee dislocation
• Foot and ankle injury should
be assessed on physical
exam and x-ray if needed

10. Classification
• Numerous classification systems have been
proposed
• Important variables are pattern and location
of fracture, associated fibula fracture, extent
of comminution, and degree of soft tissue
injury

11. Johner and Wruh’s Classification
• Recognizes
relationship between
fracture pattern and
mechanism
• Extent of comminution
prognostic for time
to union

12. Henley’s Classification
• Applies Winquist and
Hansen grading of
femur fractures to the
tibia

13. 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

14. Compartment Syndrome
• 5-15%
• HISTORY
Hi-Energy
Crush

15. Nerve is the Tissue most
Sensitive to Ischemia
• PAIN first Symptom
• PAIN with Passive Stretch first Sign

16. Each Compartment
has Specific Innervation
• Ant Comp Deep- - Peroneal
• Lateral -Sup Peroneal N.
• Deep Post. - Tibial N.
• Sup Post. - Sural N.

17. Anterior Compartment
• Dorsiflexes ankle
• Tib ant, EDL, EHL,
and peroneus tertius
muscles
• Anterior tibial a. +v.,
deep peroneal n.

18. Lateral Compartment
• Everts the foot
• Peroneus brevis and
longus muscles
• Superficial peroneal n.
supplies motor to PB
and PL and sensation
to dorsum of foot,
except first web space

19. Superficial Posterior
Compartment
• Plantar flexes ankle
• Gastrocnemius,
soleus,popliteus, and
plantaris muscles
• Sural nerve provides
sensation to lateral heel
• Greater and lesser
saphenous veins

20. Deep Posterior Compartment
• Plantar flexion and
inversion of foot
• FDL, FHL, Tib post
muscles
• Post tibial vessels,
peroneal a., and tibial
nerve

21. Fundamental Problem
• ? Pressure Of Ischmia
• Aerobic - Anaerobic
• Clinical Need to Obtain Tissue Pressures

22. Pressures Not Uniform
• Highest at Fracture
Site
• Highest Pressures in
Posterior
&
Anterior
Compartments
• Heckman Jbjs 76

23. Compartment Syndrome is a
Clinical Diagnosis

24. Pressure Measurement are
Helpful
• Delta P
• Diastolic BP - Compartment Pressure
• > 30 is considered ‘Safe’

25. Clinical Monitoring
• Need Close Observation
• Repetitive Exams
• Some instances repetitive Pressure
measurements

26. Compartment Pressures
• Various Thresholds
P = 30
P = 45
∆ P < 30

27. ∆ P
• Difference between diastolic BP &
Compartment Pressure
• When less than 30 + clinical findings
perform fasciotomy

28. Goals of Fasciotomy
• Decompress The Compartment
• Fixation
• Closure
• Do Not Strip Muscle From The Bone

29. Single vs. two Incisions
• Wide Release
• Arterial Injury to the Anterior Tibial Artery

30. Closed Tibial Shaft Fractures
• Broad Spectrum of Injures No Single
Treatment
• Dependent on Mechanism of Injury

31. Extensive Soft
Tissue Injury
Due to Crushing
Mechanism
of Injury

32. Natural History
• Studies Indicate that angular deformities
tolerated without associated Knee or Ankle
Arthrosis

33. • Kristensen >10-deg F/U:
20-29 yr
• Merchant F/U 29 yrs. No assoc.
with ang., site, immob. (37/108)

34. Nonoperative Treatment
• Casts
• Functional Bracing
• Nondisplaced & Low Energy Injuries

35. Sarmiento
• Closed Functional Treatment
About 1,000 Tibial Fractures
• 60% Lost to F/u
• No Report on Rom

36. Initial shortening should <
1.4mm.
• Union 98.5%
• Time 18.1 Wks.
• Short >20mm 1.4%

37. Angulation
• No clear scientific proof that angulation
causes arthrosis of knee or ankle in these 2
studies

38. Ankle Motion
• 25% patients with
25% loss of ankle-
ROM

39. Surgical Options
• Intramedullary nail
• ORIF with plate
• External Fixation

40. Advantages of IM Nail
• Advantages include
less malunion and less
shortening than closed
treatment or ex-fix
• Earlier weight bearing
may be allowed with
insertion large nail

41. Hooper
• In a prospective study found that when
displacement >50% and angulation >10 deg.
• Nails superior to cast treatment

42. F/U 4.4years
Cast Nail
• SF36 74 85
• KNEE 89 96
• ANKLE 84 97
• BONE JBJS JULY 1998

43. Reamed vs. Nonreamed
IM Nailing
for
Displaced Tibial Fractures

44. Variables
• Reamings (osteogenic)
• Larger Nails (bolts)

45. • Studies Comparing reamed vs. nonreamed
also compare nail diameters and stronger
constructs

46. Reamed vs. Nonreamed
Nail Size
0
5
10
15
20
25
30
8 9 10 11 12 13 14
Nail Diameter
No. Used
Reamed
Unreamed

47. Stability

48. When
To
Interlock?

49. Loss of Alignment without
Interlocking Nails
• Spiral 7/22
• Transverse 0/27
• Metaphyseal 7/28
• Templeman CORR 1997

50. Expanded Indications
• Proximal 1/3
• Distal 1/3
• Increased Problems

51. Reduction

53. • Proximal Fractrues are technically more
challenging
• Prone to Valgus &
• Pro-curvatum deformities

55. Technique
• Screws placed on
concave side of
deformity.

56. Blocking (Poller) Screws
• Functionally narrow im canal
• Increase strength and rigidity of fixation

57. The Use of Poller Screws as Blocking
Screws in Stabilising Tibial Fractures
Treated with Small Diameter Nails
• 21 patients
• All healed within 3-12 months
• Mean alignment 1 degree valgus, antecurvatum 2
degrees.
Krettek C, et al. JBJS 81B: 963, 1999

58. • Entry Site for Proximal
fractures Critical
• Reference is
Lateral Tibial Spine

61. Nailing
Distal
Tibia

63. Reduction of Distal Tibial
Fractures
• Distractor
• Joy Stick
• Fibular Plating
• Calcaneal Traction

70. Pin
//
Ankle

79. Plate
Fibula
+ Alignment
- Dynamization

85. Proximal and Distal Cases Courtesy
of
R. Winquist M.D.
Seattle, Wa.

86. Results
Reamed and Nonreamed techniques are
comparable; more bolt breakage with
smaller nonreamed implants

87. Blachut JBJS 79A
+R -R
73 63
N/U 4% 11%
Mal. 4% 3%
Screws 3% 16%

88. Complications
• Infection 1-5%
• Union >90%
• Knee Pain
Common

89. Anterior Knee Pain
• Severe 9%
• Moderate 22%
• Mild 68%

90. Knee Pain
• Severe 9%
• Moderate 22%
• Mild 68%
• Kneeling 92%
• Running 57%
• Rest 37%

91. Nail Removal
• Resolved 27%
• Marked improv 69%
• Complete 44%
• Partial 34%
• No - 20%

92. Iaquinto 1998
Epidural
4.1 X
Neurological Complications

93. Disadvantages of IM Nail
• Disadvantages include anterior knee pain
(up to 56.2% *), risk of infection, increased
hardware failure with unreamed nails
*Court-Brown et al. JOT 97

94. External Fixator
• External fixation
generally reserved
for open tibia
fractures or
periarticular
fractures

95. Technique of External Fixation
• For tibial shaft fracture, unilateral
frame with half pins usually
sufficient
• Two half pins(5mm for most
adults) placed near fracture and and
two half pins placed far away from
fracture(‘near-near and far-far’)
• Pre-drilling of pins recommended
• Fracture held reduced while clamps
and connecting bar applied

96. Advantages of External Fixator
• Can be applied
quickly in polytrauma
patient
• Allows easy
monitoring of soft
tissues and
compartments

97. Disadvantages of External
Fixator
• Increased incidence of malunion compared
to IM nail
• Risk of pin tract infection, cellulitis

98. Plating of Tibial Fractures
• Narrow 4.5mm DCP
plate can be used for
shaft fractures
• Newer periarticular
plates available for
metaphyseal
fractures

99. Technique of Tibial Plating
• Anterior longitudinal incision allows placement of plate on
medial border of tibia
• 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

100. Technique of Tibial Plating
• Newer alternative is
use of limited
incisions and
subcutaneous plating-
requires indirect
reduction of fracture

101. 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

102. Disadvantages of Plating
• Increased risk of
infection and soft
tissue problems,
especially in high
energy fractures
• Higher rate hardware
failure than IM nail

103. Outcomes of Tibial Shaft
Fractures
• Casting followed by functional
bracing shown to have good
results for low energy, isolated
fractures with less than 12mm
initial shortening and acceptable
angular and rotational alignment.
In one study the nonunion rate was
1.1% and final angulatory
deformity in any plane was less
than or equal to 6 degrees in 90%
of patients.*
• *Sarmiento et al. CORR 95

104. Outcomes of Plate Fixation
• For low energy tibial fractures 97% ‘very good/good’
results have been reported, although most studies not this
favorable*
• Complications such as hardware failure and infection have
been as high as 48% after plating comminuted fractures**
*Ruedi et al. Injury,7,252-257
**Johner and Wruhs, Clin Orthop 1983

105. Outcomes of External Fixation
• 95% union rate has been reported for group of closed and
open tibia fractures, but 20% malunion rate*
• Most common complications are pin track infections and
malunion**
• Loss of reduction associated with removing frame prior to
union
*Anderson et al. Clin Orthop 1974
**Edge and Denham JBJS[Br] 1981

106. Outcomes of IM Nailing
• In a study of 200 closed, low-energy tibia fractures treated
with cast versus IM nail, the results for nailing were: union
rate=98%, malunion rate=0, infection=3.3%. The results
of casting were: union rate=90%, malunion rate=4.3%, and
infection=1.4%*
* Puno et al. Clin Orthop 1986

107. Outcomes of IM Nailing
• Another large group of tibia fractures treated with reamed
IM nail had 98% union rate and 3% infection rate*
• Most common complication after IM nailing remains
anterior knee pain **
*Williams et al. JOT 1995
** Court-Brown et al. JBJS 1990
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Index