compartmental anatomy

8/18/2019 Compartmental Anatomy

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COMPARTMENTAL ANATOMY

The anterior compartment contains the dorsiflexors of the ankle and toes: the tibialis anterior,

extensor hallucis lonus !in its distal half", and extensor diitoru# co##unis $ith

acco#%an&in %eroneus tertius' (ts neuro)ascular bundle consists of the anterior tibial arter&

and )eins, *oined in the %roxi#al %art of the co#%art#ent b& the dee% %eroneal ner)e' Thearter& is assessed distall& b& the dorsalis %edis %ulse' +o$e)er, flo$ #a& be retrorade fro#

the dee% %lantar arch and thus be %resent in s%ite of anterior tibial arter& loss' The dee%

%eroneal ner)e su%%lies an autono#ous sensor& one dorsall& on the foot bet$een the bases

of the first and second toes' (t %ro)ides #otor control for the anterior co#%art#ent #uscles as

$ell as the short toe extensors' -urin #ost of its course throuh the anterior co#%art#ent,

the neuro)ascular bundle lies dee% on the interosseous #e#brane lateral to the tibialis

anterior' +o$e)er, as this #uscle beco#es tendinous and thinner in the %roxi#al third of the

distal .uarter, the neuro)ascular bundle ad)ances anteriorl& across the lateral surface of the

tibia, $here it #a& be har#ed b& %ins inserted throuh the bone' A little #ore distall&, it lies

anteriorl& on the tibia bet$een the tendons of the tibialis anterior and extensor hallucis

#uscles'

The lateral compartment, su%erficial to the fibula, contains the %eroneus bre)is and lonus

#uscles, the e)ertors of the foot' The %eroneus lonus beins %roxi#all& on the lateral as%ect

of the fibular head' The co##on %eroneal ner)e %asses under this #uscle $here it co)ers the

neck of the fibula' Proxi#all&, the %eroneus bre)is is dee% to the lonus, until, distall&, it

beco#es anterior' Thus, behind the lateral #alleolus, the bre)is is the anterior of the t$o

tendons' The su%erficial %eroneal ner)e, $hich %ro)ides sensor& in%ut fro# the re#ainder of

the dorsu# of the foot and #otor function to the %eronei, lies $ithin the lateral co#%art#ent,

but no #a*or )ascular structures are %resent'

The superficial posterior compartment contains the trice%s surae, or %ri#ar& ankle flexors,

astrocne#ius, soleus, and %lantaris #uscles' The sural ner)e lies bet$een la&ers of the

%osterior fascia of this co#%art#ent and %ro)ides sensation to the lateral heel' No #a*or

arter& lies $ithin this co#%art#ent, $hich is the #ost distensible and least likel& to de)elo%

ele)ated %ressures after in*ur&'

The deep posterior compartment lies underneath !anterior to" the su%erficial co#%art#ent

and distal to the %o%liteal line, $ith its #uscles a%%lied to the %osterior surfaces of the tibia,

interosseous #e#brane, and fibula' /ithin it lie the %osterior tibial )essels and tibial ner)e,

$hich %ro)ides #otor function to the co#%art#ental #uscles and the %lantar intrinsic

#uscles and sensor& in%ut fro# the sole of the foot' Also %resent are the %eroneal )essels'The dee% %osterior co#%art#ent #uscles are the flexor diitoru# lonus #ediall&, the flexor

hallucis lonus laterall&, and, dee% to these, the tibialis %osterior' 0ro# %roxi#al to distal, the

tibial neuro)ascular bundle first lies %osterior to the %o%liteus and then %osterior to the #edial

border of the tibialis %osterior' The tibial nutrient arter& lea)es the %osterior tibial shortl& after

it is for#ed and reaches the bone throuh the %roxi#al %art of the tibialis %osterior' The

tendon of the tibialis %osterior %asses across the tibia and under the flexor diitoru# lonus to

lie anterior to it and establishes the $ell1kno$n relationshi% of the dee% %osterior

co#%art#ent structures behind the #edial #alleolus: tibialis %osterior, flexor diitoru#

lonus, %osterior tibial arter& and tibial ner)e, and flexor hallucis lonus23To#, -ick, ANd

+arr&4 ! Table 5617 "'

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2/19

The bon& %attern of tibial fractures is e)ident radiora%hicall&' (n addition to the fracture8s

location and dis%lace#ent, its sha%e and co##inution should be noted' The %attern #a& be

s%iral, obli.ue, trans)erse, or se#ental' Co##inution ranes fro# none to total

circu#ferential in)ol)e#ent' 9ohner and /ruhs used fracture #or%holo& to classif& tibial

shaft fractures treated $ith the Association for the tud& of (nternal 0ixation !AO;A(0"

techni.ues'?@ This classification has been ado%ted b& Mller and associates >=@ and theAO;A(0 rou% in their co#%rehensi)e classification of lon bone fractures, and

subse.uentl& b& the Ortho%aedic Trau#a Association'55@ (t is no$ the acce%ted classification

s&ste# for scientific studies of tibia shaft fractures ! 0i' 561B "'(ts results correlate

#oderatel& $ell $ith outco#e, but other factors are also i#%ortant in addition to fracture

%attern' 9ohner and /ruhs reconied the relationshi% bet$een fracture %attern and in*ur&

#echanis#: a s%iral %attern caused b& torsion an obli.ue or trans)erse %attern caused b&

)arious #odes of bendin, often $ith direct in*ur& and a se#ental or trans)erse hihl&

co##inuted %attern caused b& crushin' The& also used the extent of co##inution, $hich

correlates $ith absorbed ener&, as an indicator of se)erit&' Their resultin classification has

three #a*or cateories: A, si#%le, nonco##inuted %atterns D, %atterns $ith butterfl& or

3$ede4 fra#ents and C, co##inuted %atterns, includin se#ental fractures ! 0i' 5616 "'Althouh so#e$hat cu#berso#e to use $ith the =B se%arate cateories in its final for#, this

classification is de#onstrabl& $ell suited to the assess#ent of results after internal fixation of

closed tibial shaft fractures' (t is not a co#%rehensi)e tibial fracture classification because it

does not include the se)erit& of soft tissue in*ur&, althouh the authors clearl& e#%hasie the

i#%ortant influence this has on results' 0racture dis%lace#ent is also not considered, %erha%s

because it has little effect on the outco#e of fractures treated b& ex%ert internal fixation'

+o$e)er, it #a& be .uite sinificant if nono%erati)e treat#ent or ill1concei)ed o%eration is

chosen' Also excluded fro# 9ohner and /ruhs8 classification is the location of the fracture'

Proxi#al and distal fractures, $hich can encroach on the knee or ankle and can %reclude use

of (M nailin, #a& deser)e reconition as se%arate cateories of in*ur&' 0ro# 9ohner and

/ruhs8 re%orted results, it is e)ident that s%iral and obli.ue fractures ha)e the best %ronosis

after internal fixation' Their A7, A=, D7, and C7 fractures had 7 %ercent to 7?? %ercent ood

or excellent outco#es' Trans)erse fractures had inter#ediate results, $ith A> and D= ainin

6? %ercent to = %ercent ood or excellent outco#es' Co##inuted or crushin in*uries had

sinificantl& $orse results, $ith ood or excellent outco#es in B5 %ercent of D>, F6 %ercent

of C=, and 5? %ercent of C> tibial fractures'?@ A fracture classification s&ste# ouht to

%redict results and uide treat#ent' Decause in*uries res%ond differentl& to different

treat#ents, the choice of treat#ent #a& affect the )alidit& of a radin s&ste#' 0or exa#%le,

9ohner and /ruhs found faster reco)er& of trans)erse, hiher1ener& fractures treated $ith

(M nails and re%orted hiher infection !7BG" and i#%lant failure !5G" rates after %late

fixation of t&%e D> in*uries that #iht ha)e had lo$er rates of co#%lications if treated $ithclosed locked (M nailin'

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0(HIRE 561B AO;OTA classification of tibial shaft fractures' 3J=4 sinifies location as tibial

shaft' Three t&%es are assined: A, 3i#%le4 t$o1%art fracture, B, One se%arate 3$ede4 or

3butterfl&4 fra#ent, C, More co##inution is %resent' Each t&%e is subclassified into rou%s

and subrou%s, the for#er accordin to 9ohner and /ruhs' !0ro# MullKr, M'E' Naarian, '

och, P' chatker, 9' The Co#%rehensi)e Classification of 0ractures of Lon Dones' Derlin,%riner1erla, 7?, %' 75"'

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0(HIRE 5616 9ohner and /ruhs8 classification s&ste# for tibial shaft fractures, based on

fracture %attern $ithout directl& considerin dis%lace#ent or soft tissue $ound se)erit&'

MA, #otor )ehicle accident' !Redra$n fro# 9ohner, R' /ruhs, O' Clin Ortho% 7B6:B=5,

76>'" This s&ste# for#s the basis of the AO;OTA classification'

T(D(AL 0RACTIRE /(T+ COMPARTMENT YN-ROME

/hene)er it de)elo%s, on initial %resentation or durin the subse.uent course of a %atient

$ith a tibial fracture, a co#%art#ent s&ndro#e re.uires e#erenc& #anae#ent'


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Rather than an absolute tissue %ressure #easure#ent, it is i#%ortant to consider the

difference !▵P" bet$een tissue %ressure and #ean arterial %ressure, because this is a better

indicator of the risk of tissue ische#ia'? ## +' Onl& 7 of their 77F

tibial fracture %atients had a lo$er differential %ressure and re.uired fascioto#&' 7F@

Continued )iilance and re%eated #easure#ents or continuous #onitorin are needed if the

%atient8s neuroloic status %re)ents usin the usual clinical s%to#s and sins for disco)er&

of co#%art#ent s&ndro#e' +o$e)er, there does not see# to be #uch benefit fro#

continuous co#%art#ental %ressure #easure#ent in %atients $ho are alert and under

obser)ation'? to >5

## +" #iht dissuade the sureon fro# fascioto#&, it is i#%ortant to re#e#ber that the

%ressure #a& still be risin' Patients $ho are h&%otensi)e #a& de)elo% co#%art#ent

s&ndro#es $ith lo$er absolute %ressures' Patients $ith #ore direct #uscle in*ur& #a& also

ha)e a lo$er tolerance for ele)ated %ressure, the duration of $hich #ust also be considered'

ince %ressure is hihest in the reion of the tibial fracture, it should be #easured in this area'

0AC(OTOMY

Ade.uate fascioto#& allo$s unfettered s$ellin of in*ured #uscles $ithout ele)ation of

interstitial fluid %ressure' Local ca%illar& blood flo$ is %reser)ed' This %er#its sur)i)al of

ner)e and #uscle tissues that are sensiti)e to ische#ia' A $ide, trul& deco#%ressi)e

fascioto#& is needed if intraco#%art#ental %ressure is or #a& beco#e danerousl& ele)ated'

Inlike fascioto#ies for exercise1related co#%art#ent s&ndro#es, those re.uired after tibial

fractures are extensi)e' (t is safest and #ost a%%ro%riate to treat an& such le as thouh all

four co#%art#ents are in)ol)ed' Therefore, all four co#%art#ents are released to ensure

deco#%ression' T$o incisions, #edial and lateral, are reco##ended b& #an&

trau#atoloists' These should be %laced on the #id1#edial and #id1lateral sides of the li#b,

o)er #uscle to facilitate s%lit1thickness skin co)erae if necessar&' The fascia #ust be

di)ided for the entire lenth of each co#%art#ent ! 0i' 5617J " !see Cha%ter 7> "' A four1co#%art#ent fascioto#& usin a sinle lateral incision that is directed both anterior and

%osterior to the fibula has also been %ro%osed' This a%%roach has t$o dra$backs: it is less

likel& to %ro)ide ade.uate deco#%ression than the t$o1incision techni.ue, and it adds

sinificant soft tissue da#ae b& re.uirin circu#ferential fibular dissection' Althouh

fibulecto#& #a& theoreticall& deco#%ress all four co#%art#ents, it is ne)er a%%ro%riate in

the settin of a tibial fracture, because loss of the fibula #a& co#%ro#ise reconstruction of

the in*ured le'

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0(HIRE 5617J A, Antero%osterior %hoto sho$in incision %lace#ent for double1incision

fascioto#&' This %er#its reliable deco#%ression of all four fascial co#%art#ents of the le'

B, Cross1section diara#' To ensure that an ade.uate bride of anterior skin is left, %lace the

incisions on the #id1#edial and #id1lateral sides of the le' ufficient lenth of fascioto#&

incisions and release of internal fascial en)elo%es, such as that around the tibialis %osterior,are also i#%ortant' !A, Art$ork #odified fro# Lu#le&, 9''P' urface Anato#&, >rd ed'

Edinburh, Churchill Li)instone, =??=' Photora%h b& arah19ane #ith'"

OPEN T(D(AL 0RACTIRE

The tibial shaft is the #ost co##on site of sinificant o%en fractures !re)ie$ed in detail in

Cha%ter 7J "' The i#%ortant features of its #anae#ent are discussed here in so#e detail'

E)aluation and treat#ent are outlined in 0iure 56175 , our reco##ended alorith# for o%en

tibial fractures' Like closed tibial fractures, the s%ectru# of se)erit& is $ide, $ith se)eral

factors affectin outco#e' Therefore, $hile eneral %rinci%les hold true, allo$ances #ust be#ade for the s%ecific features of an indi)idual %atient8s in*ur&'


8/19

%roduce tibial fractures that are technicall& o%en' +o$e)er, if the& are due to lo$1ener&

#issiles, dbride#ent is rarel& re.uired and #anae#ent is si#ilar to that of closed fractures

$ith si#ilar co##inution and dis%lace#ent'


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The initial e)aluation is carried out as described %re)iousl&' The $ound is co)ered $ith a

sterile dressin, a s%lint is a%%lied to the le, and %eriodic neuro)ascular #onitorin is

instituted' A%%ro%riate tetanus %ro%h&laxis is %ro)ided: tetanus toxoid !?'5 #L", if #ore than

5 &ears ha)e ela%sed since the last tetanus toxoid in*ection, or if this ti#e is unkno$n' (f %rior

i##uniation is unkno$n or inco#%lete, tetanus i##unolobulin !=5? units" should be

ad#inistered' e%aratel&, acti)e i##uniation is then co#%leted $ith a tetanus toxoid series'(ntra)enous antibiotics are beun' Inless alleries indicate an alternati)e choice, a first1 or

second1eneration ce%halos%orin is routinel& ad#inistered, $ith an a#inol&coside for #ore

se)ere $ounds and hih1dose %enicillin if clostridial conta#ination is likel&'


10/19

$ounds is de)elo%in a#on ex%erienced trau#a sureons, and it is $ell reconied that

dela&ed closure of o%en fracture $ounds should occur $ithin a )er& fe$ da&s after in*ur&'


11/19

tissue, less hast& co)erae is ad)isable'=F@ One should not dela& once it is clear that the

$ound is free of necrotic tissue' 0ailure to achie)e ade.uate dbride#ent and ain $ound

co)erae $ithin the first 7 or = $eeks after in*ur& is associated $ith a hiher risk of %roble#s

after fla% co)erae' The reatest difficult& co#es $ith se)ere $ounds in $hich it is difficult

to deter#ine tissue )iabilit& until after se)eral dbride#ents' (t is not entirel& clear $hether

the dela& or the #ore se)ere $ound or both are res%onsible for the ackno$leded hiher rateof $ound co#%lications'

Atte#%ts to ain co)erae $ith local tissues b& usin 3relaxin incisions4 or local rotational

fla%s #a& be un$ise, es%eciall& $hen the a#ount of soft tissue da#ae is #ore se)ere'


12/19

The %atient is %ositioned recu#bent on an exa#inin or o%eratin table' Doth les are

e)aluated, so that that rotational alin#ent and contours of the nor#al li#b can uide

reduction and cast #oldin' This can be facilitated b& hanin both les o)er the end of the

table' Alternati)el&, the in*ured le can be abducted at the hi% and hun o)er the table8s side'

There #ust be enouh roo# to allo$ %addin and %laster to be rolled around the u%%er calf'

The cast is a%%lied in t$o %arts' Al#ost al$a&s !exce%t for )er& %roxi#al fractures" the lo$er %art is a%%lied first' The assistant holds the forefoot, stead&in the le and #aintainin its

alin#ent, es%eciall& reardin rotation and %lantirade foot %osition' /ith knee flexion, the

tibia can rotate sinificantl& on the fe#ur' (t is therefore i#%ortant to assess rotational

alin#ent usin the relationshi% of second toe to tibial tubercle, as de#onstrated b& the

o%%osite li#b' The assistant8s finers are %laced under the %lantar surface, $ith the thu#b

o)er the dorsu# of the foot' Thus, %lantar flexion and in)ersion !su%ination" are controlled,

both of $hich tend to occur and subse.uentl& interfere $ith $eiht1bearin in this cast'

Althouh ankle e.uinus is occasionall& the alternati)e to a%ex1%osterior anulation of a distal

tibial fracture site, it is usuall& a)oidable if, as ar#iento suests, the initial cast is a%%lied

$ith the foot in neutral'


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0(HIRE 5617F Hra)it& reduction and cast a%%lication' Most acute tibial shaft fractures $ill

reduce fairl& satisfactoril& $hen hun o)er the side of an exa#inin table $ith the foot

correctl& rotated and su%%orted in neutral %osition' A, The le #ust han far enouh a$a&

fro# the table to allo$ circu#ferential access' A %ad under the %roxi#al as%ect of the thih

hel%s' An assistant #ust hold the foot and stead& the le' The sureon ensures that thealin#ent is correct and a%%lies a#%le cast %addin, es%eciall& o)er the %osterior of the heel,

the #alleoli, the %roxi#al end of the fibula, the fracture site, and the lines $here the cast $ill

be cut' Plaster or fiberlass castin ta%e is rolled o)er the %addin $ith a se#ent of %addin

left ex%osed *ust belo$ the knee to be o)erla%%ed later b& the abo)e1knee %art of the cast'

Hentle #oldin b& the sureon often i#%ro)es alin#ent, es%eciall& b& #akin the distal

#edial tibial surface slihtl& conca)e to #atch that of the nor#al le' ix to eiht la&ers of

%laster, or a bit less fiberlass ta%e, is usuall& sufficient, %erha%s $ith extra reinforce#ent at

the knee and ankle' B, Once the lo$er %ortion of the cast is fir#, it is used to hold the li#b in

correct rotation and $ith the knee flexed a%%roxi#atel& 75' Cast %addin is then rolled o)er

the thih on to% of a %roxi#al se#ent of stockinet to %ro)ide a $ell1%added to% cuff' The

%atella and ha#strin tendons need extra %addin' Cast #aterial is then a%%lieda%%roxi#atel& t$o thirds of the $a& u% the thih, $ith the cast #aterial o)erla%%in the

lo$er %art of the cast b& J to F inches' The stockinet and %addin are turned do$n o)er the

to% of the cast and secured $ith a turn of the castin ta%e to a)oid a shar% ede' The le #ust

be su%%orted until the cast is hard' Rotational alin#ent is then checked b& co#%arison $ith

the o%%osite le' Antero%osterior and lateral radiora%hs of the full tibia are obtained and

assessed for anulation, dis%lace#ent, and shortenin'

o#e sureons belie)e that %laster is easier to a%%l& and #old than fiberlass' +o$e)er, it

should be left thin to si#%lif& alterations and a)oid unnecessar& $eiht' O)erl&in fiberlass

reinforce#ent can be a%%lied in 7 or = da&s, once it is clear that the cast $ill be left in %lace'

As the %laster sets, #oldin is carried out to #ake the sha%e of the #edial border of the cast

conca)e, si#ilar to the %atient8s o%%osite le a straiht cast %roduces )alus #alalin#ent'

The sureon should ensure that the foot %osition has been #aintained' (#%ro)ed $ater1

acti)ated fiberlass castin ta%e offers a lihter and #ore durable alternati)e to %laster' (

belie)e it is no$ .uite acce%table as an initial tibial fracture cast, althouh, like %laster,

ade.uate %addin and careful a%%lication are essential'

Once the lo$er le %ortion of the cast is fir#, it can be lifted and held horiontall&, $ith theknee flexed 7? to 75 and the thih sufficientl& clear of the table surface to allo$ %addin to

be extended %roxi#all& an inch be&ond the intended to% of the cast, a%%roxi#atel& t$o thirds

of the $a& u% the thih ! 0i' 5617FD "' Cast #aterial is then rolled on, o)erla%%in b& J to F

inches the to% of the %re)iousl& a%%lied lo$er %ortion' (t is essential that there be ade.uate

%addin at the *unction of the t$o se#ents, but no %addin should lie bet$een the la&ers of

the cast #aterial'

As soon as is %ractical, AP and lateral radiora%hs are obtained of the entire tibia $ithin the

cast and a decision is #ade as to the %ro)isional ade.uac& of reduction and cast a%%lication'

Onl& if there is #arked defor#it& or risk of skin co#%ro#ise should the a%%earance of these

radiora%hs lead to chanin the cast' Ad*ust#ents such as $edin, a%%l&in a ne$ cast, orchanin to another #ode of treat#ent are better deferred until s$ellin has resol)ed'

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The lon le cast *ust a%%lied #a& need to be loosened to acco##odate %otential or actual

s$ellin of the in*ured li#b' Althouh it is $ise al$a&s to antici%ate such s$ellin, #an&

lo$1ener& tibial fractures can re#ain in an intact, $ell1%added cast' Routine s%littin of all

initial tibial casts results in unnecessar& #ani%ulation and #a& co#%ro#ise the cast8s

stabilit&'

A cast #a& be loosened in se)eral $a&s' (f s$ellin is se)ere and likel& to %roress, the cast

should be con)erted to a %osterior trouh s%lint' This is done b& re#o)in the anterior third

of the cast and bendin both sides out$ard, $ide enouh to %er#it re#o)al of the le and to

a)oid an& %ressure on the sides of the li#b' The %addin is cut anteriorl& and folded out$ard

as $ell, so the %addin is not a source of constriction, and to allo$ exa#ination of the li#b'

Re#o)al of %art of the #edial cast $all at the ankle can allo$ assess#ent of the %osterior

tibial %ulse, if this is needed ! 0i' 5617B "' A %ractical concern about re#o)in stri%s and

$indo$s fro# casts is that the stabilit& of the cast #a& be co#%ro#ised' The result can be a

%laster cast that fails to i##obilie the in*ured li#b' uch an outco#e does not %re)ent %ain

and #a& cause additional tissue trau#a' 0iberlass used as the initial cast #aterial, or as

reinforce#ent, can i#%ro)e the #echanical %ro%erties of the initial cast' /hate)er #aterial isused, the ade.uac& of i##obiliation #ust be fre.uentl& reassessed'

0(HIRE 5617B O%ti#al %osterior s%lint' A cast can be loosened so#e$hat b& cuttin its

anterior surface fro# to% to botto#, usin a cast s%reader to o%en the cut, and bendin the

sides out and stretchin the cast %addin to loosen it as $ell' +o$e)er, this techni.ue #a&

not acco##odate sinificant s$ellin' (f s$ellin is a concern or if it is necessar& that a

se)erel& in*ured li#b be obser)ed $hile #aintainin an ade.uate s%lint, the lon le cast can

be con)erted into a trouh s%lint, after it has hardened, b& re#o)in an anterior stri%

a%%roxi#atel& one third of the cast8s circu#ference' The cast %addin is cut and turned back,

and the sides of the cast are bent out$ard to eli#inate %ressure on the le' The tri# line is

%laced %osteriorl&, if needed, in the area of the %osterior tibial %ulse to %er#it its %al%ation incase of %otential )ascular in*ur&'

Re#o)al of an anterior stri% of %laster interferes $ith onoin use of the cast' An alternati)e

is to s%lit the cast anteriorl& after it has hardened, $hich usuall& takes 7 or = hours for %laster,

and then $iden this cut sufficientl& $ith cast s%readers so that the %addin is stretched and

subse.uent loosenin of the cast $ill be eas&' This 3uni)al)ed4 cast #a& be sal)aed after

s$ellin recedes b& s.ueein it toether and encirclin it $ith adhesi)e ta%e *ust tihtl&

enouh to %ro)ide ade.uate su%%ort' Once a final ad*ust#ent has been #ade, fiberlassreinforce#ent is added to #ake the cast stron enouh to bein a#bulation' (t is i#%ortant to

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realie that this techni.ue of cast s%readin does not %ro)ide ade.uate deco#%ression in the

%resence of serious s$ellin, or if the cast #aterial cannot be bent o%en' o#e$hat better

deco#%ression #a& be %ro)ided b& 3bi)al)in4 a cast, $ith #edial and lateral lonitudinal

cuts %laced *ust a bit anteriorl& to the #id1lateral lines of the cast to #axi#ie stiffness and

durabilit& of the %osterior %ortion, but not so far anteriorl& that the o%enin is too narro$ for

re#o)al of the le' A bi)al)ed cast can be loosened as needed and held securel& toether $ithse)eral encirclin loo%s of adhesi)e ta%e' (n addition to lonitudinal cuts in the cast, $indo$s

#a& be re#o)ed to check .uestionable areas of skin, to relie)e %ressure o)er a bon&

%ro#inence, or to assess %ulses' The re#o)ed cast $indo$ should be retained and ta%ed

securel& in %lace $hen the o%enin is not in use' -oin this adds to the strenth of the cast

and #aintains enouh o)erl&in %ressure to a)oid 3$indo$ ede#a,4 or s$ellin of the soft

tissues into the $indo$ defect'

(f a cast is left intact around a fresh tibial fracture, there #ust be fail1safe arrane#ents for it

to be released if the %atient de)elo%s sinificant %ain or neuro)ascular co#%ro#ise' Althouh

tibial fracture %atients t&%icall& re.uire hos%italiation, one #a& occasionall& be sent ho#e

$ith a lo$1ener& in*ur&, if he or she is able to use crutches and %erfor# transfers, and hasade.uate assistance and %ro#%t trans%ortation back to the hos%ital' /hether as an out%atient

or in the hos%ital, the %atient should kee% the in*ured le slihtl& ele)ated and should be

obser)ed closel& for increasin %ain, decreasin sensation, and loss of %al%able toe #uscle

strenth' Pain after a tibial fracture is larel& relie)ed b& ade.uate s%lintin' Narcotic

analesics are usuall& re.uired, but standard doses of %arenteral or oral drus should be

effecti)e and should be re.uired %roressi)el& less fre.uentl&' After 7 or = da&s, oral

narcotics should be sufficient, %erha%s $ith a ti#ed1release ca%sule for# that #a& last

throuh the niht' Lack of res%onse to analesia suests neuro)ascular %roble#s'

-efiniti)e Treat#ent for Tibial 0racturesNONOPERAT(E !0INCT(ONAL CAT OR

DRACE"

ar#iento, %erha%s the #ost elo.uent ad)ocate and teacher of nono%erati)e functional

treat#ent of tibial fractures, re%orts i#%ressi)e results in selected %atients $ith less dis%laced,

usuall& lo$er1ener& tibial shaft fractures' +e ad)ises that functional closed treat#ent be

li#ited to closed in*uries that ha)e no #ore than 75 ## of initial shortenin, or are axiall&

stable, reduced trans)erse fractures'


16/19

0unctional bracin beins $ith a closed ra)it& realin#ent and a%%lication of an initial cast,

as described %re)iousl&' (n addition to in*ur& se)erit&, the ade.uac& of reduction in this cast

and the %atient8s subse.uent clinical course are the #ost i#%ortant deter#inants of $hether

closed functional treat#ent is a%%ro%riate' The a#ount of soft tissue da#ae deter#ines the

shortenin that #a& occur' Ilti#ate shortenin is usuall& %redictable fro# the a#ount of

shortenin a%%arent on the initial radiora%hs' Drace treat#ent is rarel& a%%ro%riate if there is#ore than 75 ## of shortenin, as #easured b& fra#ent o)erla% or b& a scanora# in the

cast' Poor control of anulation in a lon le cast is also a contraindication to functional

bracin, unless it is corrected b& rea%%lication of cast or brace' Anulation on either AP or

lateral radiora%h should not exceed 5'

inificant co##inution and dis%lace#ent of #ore than >? %ercent of the shaft dia#eter are

further contraindications to closed functional treat#ent because of their association $ith

dela&ed healin $hen this treat#ent is used'


17/19

#otion of fracture fra#ents felt inside the cast, and the benefits of %roressi)e $eiht1

bearin on the fractured li#b' (n addition to the exercise %rora#, %h&sical thera%& #a& hel%

$ith ait trainin on le)el surfaces, on stairs, and for transfers' Once %atients are co#fortable

and #obile enouh to #anae at ho#e, and an& necessar& assistance has been arraned, the&

are dischared to out%atient follo$1u%' The& are instructed to re%ort %ro#%tl& an& cast

%roble#s, increasin %ain, #otor or sensor& deficit, or excessi)e s$ellin that is not ra%idl&relie)ed b& rest, ele)ation, and #ilder analesics' An office or clinic )isit 7 or = $eeks after

dischare %er#its reassess#ent of co#fort, ait, s$ellin, neuro#otor function, cast interit&,

and clinical as $ell as radiora%hic alin#ent'

Althouh so#e %atients #a& benefit fro# a PTD $alkin cast, as oriinall& ad)ocated b&

ar#iento, a %refabricated functional PTD brace fro# knee to foot, $ith a hined ankle, has

larel& re%laced this, unless a satisfactoril& fittin brace is not a)ailable or offers inade.uate

control, as #a& ha%%en $ith a )er& distal fracture ! 0i' 56176 "' The PTD cast or brace is

a%%lied $hen the %atient can co#fortabl& bear %artial $eiht in the lon le cast and earl&

fracture consolidation has beun' This usuall& occurs bet$een > and 5 $eeks after in*ur&'

Proxi#al tibial fractures #a& be better controlled in a lon le cast' (f knee #otion is desiredfor such %atients, hines and a thih cuff can be added to its belo$1knee %ortion' An effecti)e

#ethod for doin this is to use a fiberlass belo$1knee cast, #olded as sho$n in 0iure 561

76A , to $hich are attached the hines and ad*ustable thih cuff of a co##erciall& a)ailable

#odular fracture brace' A %refabricated fracture brace that follo$s ar#iento8s %rinci%les

usuall& %ro)ides excellent fracture control $hile %er#ittin satisfactor& function for the

#a*orit& of %atients $ith lo$1ener& tibial shaft fractures' Alternati)el&, a custo#1#olded

bi)al)e total contact brace can be fabricated b& an orthotist' This #a& ha)e either a fixed or a

hined ankle, de%endin on the deree of i##obiliation desired' uch braces can be hel%ful

for %atients $ho are hard to fit $ith %refabricated ones' aorski sho$ed e.ui)alent

stabiliin efficienc& of %laster casts, custo# and %refabricated fracture braces, %lus no

additional benefit fro# the classic PTD %roxi#al extensions, for ex%eri#ental #id1shaft tibial

fractures'7@

17


18/19

0(HIRE 56176 A, A %atellar tendon1bearin !PTD" functional cast is a%%lied after the soft

tissue s$ellin has resol)ed and the fracture has beco#e so#e$hat UUstick&VV and less tender'

(f a neutral ankle %osition $as achie)ed $ith the initial cast, it should be eas& to #aintain in

the PTD cast' uch a $alkin cast is %ointless unless the foot is %lantirade, $hich is

necessar& for $eiht1bearin' The to% of the cast is tri##ed anteriorl& at the le)el of the

distal %ortion of the %atella, a little lo$er than oriinall& described b& ar#iento and lo$

enouh %osteriorl& to %er#it ? knee flexion' The u%%er %art of the PTD cast is #olded into

a trianular cross section so that it flares u%$ard and out$ard o)er the anterior surfaces of the

tibial %lateau !inset"' This alteration %roduces a bule o)er the %roxi#al end of the fibula and

%eroneal ner)e $hile %ro)idin a #olded fit for the anterior surfaces of the %roxi#al %art of

the tibia, thus su%%ortin it and ainin rotational control' The PTD cast is used chiefl& for

distal fractures in $hich a brace $ith ankle #otion #iht not %ro)ide ade.uate control andfor %atients in $ho# co##erciall& a)ailable %refabricated braces do not fit' B, A

%refabricated fracture brace is usuall& a%%lied to tibia fractures instead of a PTD cast' (t #a&

not fit $ell or %ro)ide ade.uate su%%ort for a distal fracture, and it t&%icall& re.uires %roxi#al

tri##in or %addin for co#fort and fracture su%%ort' The brace is a%%lied o)er a thick

elastic stockin' A sneaker or $alkin shoe oes on o)er the heel cu% and hel%s #aintain

alin#ent of the brace on the le'

Radiora%hs throuh the cast or brace are initiall& checked e)er& = to > $eeks to ensure#aintenance of satisfactor& alin#ent' Minor derees of anulation can be corrected $ith

18


19/19

cast chanes or $edin' +o$e)er, the latter #a& render the cast less suitable for $eiht1

bearin, so that once the fracture is 3stick&4 enouh to %er#it onl& bendin rather than

translation of fra#ents, it is better to chane the cast or #o)e on to a brace rather than ad*ust

alin#ent $ith $edin' inificant difficult& obtainin or #aintainin satisfactor& fracture

alin#ent $ith cast or brace suest the ad)isabilit& of surical reduction and fixation'

The fracture brace is a%%lied $hen the %atient can $alk in a lon le cast, and satisfactor&

fracture alin#ent has been #aintained' This in)ol)es re#o)in the cast, and a%%l&in a

thick elastic fracture1brace sock' Next, the fracture brace is secured snul& o)er it' Tri##in,

and occasionall& %addin the brace or #oldin it $ith the aid of a heat un, #a& be needed

for co#fort and o%ti#al fracture control' The heel cu% and ankle hine #ust be sied and

ad*usted correctl&' A lace1u% athletic shoe hel%s hold the brace in %lace' Drace tihtness is

ad*usted as needed b& the %atient to %ro)ide co#fortable su%%ort' Proressi)e $eiht1bearin

is aain encouraed' Crutches and cane can be discarded $hen tolerated and ait is

satisfactor&' Man& belie)e that sinificant $eiht1bearin $ithin F $eeks of in*ur& %ro#otes

fracture healin' ?@

compartmental anatomy

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