Tibial Shaft Fractures

台中榮民總醫院 骨科部王舜平 醫師

General concept Stable, low-energy fractures Nonsurgical management Unstable and high-energy fractures ORIF

External fixation (uniplanar and multiplanar) Plate fixation Intramedullary nailing

Open tibial shaft fractures the associated bone and soft tissue loss

Trauma Mechanism Direct or indirect trauma

Low-energy trauma: Simple falls, twisting injuries Sports injuries

High-energy trauma : motor vehicle or motorcycle crashes

Classification Fracture classification : AO/OTA fracture classification

AO/OTA fracture classification

Physical examination

Patient’s skin Gross deformity of the extremity Neurovascular examination : Nerve function and Pulse Identify associated injuries :

ipsilateral hip, knee, and ankle

Suspicion risk of compartment syndrome !!

Compartment syndrome Younger patients High-energy tibia fractures Patients with diaphyseal tibia fractures

(8.1%) 【 proximal (1.6%) and distal (1.4%) 】

Difficult to assess “cardinal signs – 5P” due to fracture pain Anterior and deep posterior

compartments are susceptible

J Orthop Trauma. 2009 Aug;23(7):514-8

Compartment syndrome

Intra-compartmental pressures Delta pressure < 30 mm Hg (diastolic pressure - tissue pressure)

Should not be measured after anesthesia (diastolic pressure ↓)

Four-compartment fasciotomy Anterior compartment is most frequently incompletely released

Radiographic examination

Antero-posterior, lateral radiographs of the entire tibia

Ipsilateral knee and the ankle

Associated injuries Intra-articular knee injuries Tibial plateau or ankle fracture Posterior malleolus fracture (high association to spiral tibia fractures)

Concomitant Ipsilateral fractures of the left tibial plateau and left tibial pilon

Nonsurgical Treatment

Nondisplaced, low-energy tibia fractures Initial immobilization : long leg splinting (Not casting) an ipsilateral fibula fracture is a relative

contraindication

Results : High union rates with angulation(<8°) and shortening(<12 mm)

Surgical indication

Absolute indications Open fractures Concomitant vascular injuries or

compartment syndrome, Irreducible or unstable fractures Failure of closed treatment

Displacement : > 50% of shaft Angulation : > 5° to 10° Rotation : > 10° Shortening : > 1 cm

Surgical Treatment - External Fixation

Minimally invasive Relative stability Easier wound care

Temporary usage Damage control techniques

Definitive usage soft-tissue injury bone loss

Surgical Treatment - Plate Fixation

An open surgical approach MIPPO technique

Three different approaches Anteromedial incisions – wound healing

problems and prominent hardware Anterolateral or Posteromedial – preferred

Minimally invasive percutaneous plating

Medial or anteromedial plating Hardware, wound breakdown, and

saphenous vein and nerve injury Anterolateral percutaneous plating

injury to the superficial peroneal nerve (distal screws)

For comminuted fractures bridge plating techniques

Surgical Treatment - Plate Fixation

Higher rates of complications (19% to 30%) and worse outcomes

For specific indications Periprosthetic fractures Open physes Too small of a medullary canal s/p cruciate ligament reconstruction Open wound provides the surgical exposure

Surgical Treatment Intramedullary Nailing

The gold standard

for displaced tibial shaft fractures

Complication Anterior knee pain(67%) Decreased ankle motion(42%) Knee or ankle arthrosis(35%)

Proximal and distal tibia fractures

Malunion (84%) of proximal tibial fracture Lower (58%) in distal tibial fractures Improved reduction :

blocking or Pöller screws

Open Tibia Fractures

Urgent management Early antibiotic Wound coverage - sterile Tetanus prophylaxis Surgical débridement Fracture stabilization

Open Tibia Fractures

Choice of antibiotics : Gustilo-Anderson classification

Type 1 or 2 – gram(+) bacteria, a 1st or 2nd generation cephalosporin Type 3 – gram(-) bacteria, Aminoglycoside

With soil contamination,

Penicillin (gram(+) anaerobes)

Open Tibia Fractures Fracture stabilization

Soft-tissue healing Prevention of infection

External fixation : an excellent alternative to nailing or plating

Conversion to nailing : < 2 weeks

Open Tibia Fractures

Immediate nailing : up to type IIIB fractures (reamed or unreamed)

Plating : a higher rate of infection

Soft tissue coverage Split-thickness skin grafts (STSG) Flaps reconstruction – bone, nerves…

Proximal : rotational gastrocnemius flap middle third : a soleus flap Distal defects : a sural flap or free flap

Complication - Nonunion

定義 : Not healed at 6 months or no progressive healing for 3 consecutive months

Patient factors : Smoking or medical comorbidities (diabetes)Poor nutritionUnderlying metabolic or endocrine disorders

Surgeon factors : Distraction of the fractureExcessive soft-tissue strippingExcessive reaming

Complication - Nonunion

Surgical treatment Hypertrophic non-unions : Exchange nail Atrophic non-unions : bone graft or orthobiologics Infected nonunions - ring (Ilizarov) E.F

Tibial Plafond Fractures (Pilon fractures)

Tibial Plafond Fractures

Higher energy with axial load Significant articular damage More compromised soft-tissue

envelopes High complication rate

At Emergency Room

Clinical evaluation : associated injuries Associated fracture (calcaneus…..) Neurologic or vascular compromise Compartment syndrome

Radiographic evaluation X-ray : AP, mortise, and lateral view CT scan : useful The timing of CT : after external fixation X

Classification Ruedi and Allgöwer system : articular displacement and comminution AO/OTA system : base on continuity to the tibial shaft

Type I Type II Type III

Ruedi and Allgöwer system

Articular Surface Fracture

A : anterolateral or Chaput fragment M : medial malleolar fragment P : posterior malleolar or Volkmann fragment

※ Additional articular pieces are created via secondary fracture lines

Primary fracture lines

J Bone Joint Surg 2005;87:692-697

Surgical Treatment

Immediate ORIF External Fixation Staged ORIF

Immediate ORIF

Principles Reconstruction of the fibula Anatomic reconstruction of the

articular surface Cancellous grafting of defects Plating via the medial aspect of the

tibia

Immediate ORIF

Complication (Ruedi and Allgöwer type III )

Wound dehiscence Infection Hardware failure

Related to Energy associated with the injury Experience of the surgeons !!

External Fixation With/Without Limited ORIF

For complex Pilon fractures The goal of preventing major

complications Worse quality of reduction

Timing to open surgery “ Wrinkle sign “

Staged ORIF

Advantages of an open approach while minimizing complications

Temporizing spanning E.F secondary soft-tissue trauma Pain control Provisional reductions via ligamentotaxis Improved soft-tissue evaluation

Staged ORIF Approaches – medial / lateral With the no-touch technique (no retraction of the soft tissues)

Approach 的選擇 : Fracture pattern: Articular/Metadiaphysis Direction of talar displacement Soft-tissue quality Necessity of fibular fixation Surgeon preference

Orthopedics, October 2010, 33 (10), p734-8

Staged ORIF

Multiple approaches Maximizing the interval between the

approaches may be safely less than 7 cm apart Wound complications/infection

J Orthop Trauma2008;22(5):299-305

Complications

Wound-healing and deep infections Malunions and nonunions Postoperative scarring and stiffness Hardware prominence Posttraumatic arthritis

How to get Better outcome ?

Changes in treatment techniques and implant design Staged management Soft-tissue handling Less extensile approaches Indirect reduction techniques Lower profile plates definitive external fixation

Honest assessments of individual capabilities ! ( 該轉就轉 !!)

Take home message Poor soft tissue envelope around ankle Be aware of compartment syndrome Respect soft tissue in surgery “No touch technique” Choose correct treatment strategy

Honest assessments of individual capabilities ! ( 該轉就轉 !!)

Thanks for your attentions !!