Closed Fractures of the Tibial Diaphysis David L. Rothberg, MD Erik N. Kubiak, MD University of Utah...
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Transcript of Closed Fractures of the Tibial Diaphysis David L. Rothberg, MD Erik N. Kubiak, MD University of Utah...
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Closed Fractures of the Tibial Diaphysis
David L. Rothberg, MD
Erik N. Kubiak, MDUniversity of Utah
Original Authors: Robert V. Cantu, MD and David Templeman, MD; March 2004
Interim Authors: David Templeman and Darin Friess, MD; Revised June 2006
New Authors: David L. Rothberg, MD & Erik N. Kubiak, MD; Revised June 2010
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Tibia Fractures
Most common long bone fracture
492,000 fractures yearly
Average 7.4 day hospital stay
100,000 non-unions per year
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History & Physical
Low Energy
– Minimal soft-tissue injury
– Less complicated fracture pattern and management decisions
76.5% closed
53.5% mild soft-tissue energy
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History & Physical High Energy
– High incidence of neurovascular energy and open injury
– Low threshold for compartment syndrome
– Complete soft-tissue injury may not declare itself for several days
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Radiographic Evaluation
Full length AP and Lateral Views– Check joint above &
below
Oblique views may be helpful in follow-up to assess healing
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Injuries Associated
30% of patients will have multiple injuries– Ipsilateral Fibula
Fracture– Foot & Ankle injury– Syndesmotic Injury– Ligamentous knee
injuries
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Injuries Associated
Ipsilateral Femur Fx– “Floating Knee”
Neurovascular Injury– More Common In:
High Energy Proximal Fracture Floating Knee Knee Dislocation
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Classification
Numerous systems
Important variables– Fracture Pattern
– Location
– Comminution
– Associated Fibula Fx
– Degree of soft-tissue injury
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OTA Classification
Follows Johner & Wruh system
Describes relationship between fracture pattern & mechanism
Comminution is prognostic for time to union
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Henley’s Classification
Applies Winquist & Hansen Femur classification to fractures of the Tibia
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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
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Compartment Syndrome Incidence:
– 5-15% History
– High-Energy– Crush
Exam– 4 Compartments– 6 P’s
Pain Pain with passive stretch Parasthesias Pulsless Pallor Paralysis
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Compartment Anatomy
Anterior– Deep Peroneal N.
Lateral– Sup. Peroneal N.
Deep Post.– Tibial N.
Sup. Post.– Sural N.
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Anterior Compartment
• Action• Ankle dorsiflexion
• Muscles• Tib. Ant. • EDL • EHL • Peroneus Tertius
• Vessels• Anterior Tibial A./V.
• Nerves• Deep Peroneal N..
1st webspace sensation
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Lateral Compartment
• Action
• Foot Eversion
• Muscles
• Peroneus Brevis & Longus
• Nerves
• Superficial Peroneal N.
• Dorsal foot sensation
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Deep Posterior
• Actions• Ankle plantarflexion• Foot inversion
• Muscles• FDL • FHL • Tib. Post.
• Vessels• Post Tibial A./V.• Peroneal A.
• Nerve• Tibial N.
Plantar foot sensation
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Superficial Posterior
• Action• Ankle Plantarflexion
• Muslces• Gastrocnemius • Soleus• Popliteus• Plantaris
• Vessels• Greater and Lesser
Saphenous V.• Nerve
• Sural N. Lateral heel sensation
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Compartment Syndrome Remains a Clinical Diagnosis
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Pressure Measurements
May be helpful in borderline cases– Basic Science
Muscle ischemia present at 20 mmHg below DBP and 30 mmHg below MAP
Various Thresholds– P = 30 mmHg– P = 45 mmHg– Whiteside’s Theory
∆ P = DBP – CP = < 30 mmHg
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Pressures Not Uniform
Highest at Fracture Site
Highest Pressures in:– Deep Posterior– Anterior
Heckman JBJS ’76
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Clinical Monitoring
Close Observation– Repeat Exams– Repeat Pressure
Measurements
Indwelling Monitors– Reserved for
intubated patient with high suspicion
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Goals of Fasciotomy
Decompress the compartment– Minimize further soft-
tissue damage Single vs. Two incisions
– Go long No increased morbidity No difference in long-term
outcome Plan for fracture fixation Plan for wound closure Coordinate with location
of future incisions and/or internal fixation
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Closed Tibial Shaft Fracture
Broad Spectrum of Injures w/ many treatments
Closed Management Intramedullary Nails Plates External Fixation
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Non-Operative Treatment Indications
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Fracture Brace
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SarmientoUnion Rate
– 98.5%Time to Union
– 18.1 weeksShortening
– <1.4%
Initial Shortening = Final Shortnening
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Natural History
Long-term angular deformities – Well tolerated without associated knee or
ankle arthrosis
– Kristensen 22 pt F/U: 20-29 yrs All patients >10 degree deformity No radiographic Ankle arthrosis
– Merchant & Dietz 37 pt F/U: 29 yrs 76% of Ankles had G/E radiographic results 92% of Knees had G/E radiographic results
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Post Tibia Fracture Ankle Motion
25% Post Tibia Fracture will lose 25% of Ankle ROM
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Surgical Indications Patient Characteristics
– Obesity– Poor compliance with non-
operative management– Need for early mobility
Injury Characteristics– High Energy– Moderate soft-tissue injury– Open Fracture– Compartment Syndrome– Ipsilateral Femur Fx– Vascular Injury
Fracture Characteristics– Meta-Diaphyseal location– Oblique fracture pattern– Coronal Angulation > 5°– Sagittal Angulation > 10°– Rotation > 5°– Shortening > 1cm– Comminution > 50%
cortical circumference– Intact fibula
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Surgical Options
• Intramedullary Nail
• ORIF with Plate
• External Fixation
• Combination of fixation
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Advantage of IM Nail Less malunion Early weight-bearing Early motion Early WB (load sharing) Patient satisfaction
L Bone, JBJS
Cost– Less expensive to society when
compared to casting
– Busse Acta Ortho ‘05
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Disadvantages of IM Nail
Anterior knee pain 2/3, improve w/in year
• Risk of infection Increased hardware
failure with unreamed nails
Thermal Necrosis Medial HW
prominence
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IM Nails
PRCT 62 pts
– If displacement >50% angulation >10°
– Nails superior to cast treatment
Hooper JBJS-B ‘91
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IM Nails – Bone et.al.
Retrospective review 99 patients
Cast Nail
Time to union 26 wks 18 wks
SF-36 74 85
Knee score 89 96
Ankle score 84 97 Bone JBJS ‘97
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Reamed vs. Nonreamed Nails
Reamings (osteogenic)
Larger Nails (& locking bolts)– Hardware failure rare w/ newer nail
designs
Damage to endosteal blood supply?– Clinically proven safe even in open fx
Forster Injury ‘05Bhandari JOT ‘00
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Blachut JBJS ‘97
Reamed Non-Reamed
# pts. 73 63
Nonunion 4% 11%
Malunion 4% 3%
Broken Bolts 3% 16%
Time to Union 16.7 wks 25.7 wksLarsen JOT ‘04
Reamed vs. Nonreamed Nails
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IM Nails – Interlocking Bolts
Loss of alignment w/o interlocking
Spiral 7/22Transverse 0/27Metaphyseal 7/28
Templeman CORR ‘97
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Complications
Infection 1-5% Union >90% Knee Pain 56%
– w/ kneeling 90%– w/ running 56%– at rest 33%
Court-Brown JOT ‘96
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Knee Pain after IMN
Incidence– Varied in lit. 10-86%
Attributed to:– Skin Incision– Approach– Insertion Site– Quad weakness– Nail Prominence
Removal– 27% resolved– 69% marked
improvement– 3% worse Court-Brown JOT ‘96
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Neurologic Complications
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Expanded Indications
Proximal 1/3 fractures Beware Valgus and Procurvatum
Distal 1/3 fractures Beware Varus or valgus Beware of intraarticular extension
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Proximal Tibia Fracture
Entry site is critical
Reference– Lateral Tibial
Spine
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Too Low! Too Medial!Procurvatum Valgus
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Semiextended Position
Neutralize quadriceps pull on proximal fragment
Medial parapatellar approach – subluxate patella laterally
Use handheld awls to gently ream through the trochlear groove
Tornetta CORR ‘96
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Hyperextended position
Pulls patella proximally to allow straight starting angle
Universal distractor
Beuhler JOT ‘97
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Blocking (Poller) Screws
Functionally narrows IM canal– Increases strength and rigidity of fixation– Place on concave side of deformity
21 patients– All healed within 3-12 months– Mean alignment 1° valgus, 2° procurvatum
Krettek JBJS ‘99
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Technique
Screws placed on concave side of deformity
Proximal or distal fractures
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Distal Tibial Fractures
Reduction before reaming
Distractor Fibula plate/nail Joy Stick Calcaneal Traction
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Universal Distractor Reduction
Beuhler JOT ‘97
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Plate Fibula
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Distal Tibial Joystick
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Outcomes of IM Nailing
• 859 closed tibia fractures• 92.5% union rate• 18.5 weeks to union• 1.9% infection rate• 4.4% aseptic nonunion
• “Reamed intramedullary nailing will probably continue to be the best method of treating tibial diaphyseal fractures.”
Court-Brown JOT ‘04
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Plating of Tibial Fractures
• 3.5 mm or Narrow 4.5mm DCP plate can be used for shaft fractures
• Newer periarticular plates available for metaphyseal fractures
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Subcutaneous Tibial Plating
• Newer alternative is use of limited incisions and subcutaneous plating- requires indirect reduction of fracture and hybrid screw fixation options
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Advantages of Plating
Anatomic reduction usually obtained
In low energy fractures– 97% G/E results
reported• Ruedi Injury
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Disadvantages of Plating
• Increased risk of infection and soft tissue problems, especially in high energy fractures
• Higher rate hardware failure than IM nail
• Delayed WB (load bearing) Johner CORR ‘83
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External Fixation
• Generally reserved for open tibia fractures or periarticular fractures
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AO Technique of Tibia Plating• Anterior longitudinal incision
• 1 cm lateral to tibial crest• Maintain AT paratenon and periosteum
• Plate on medial border of tibia
• 3.5 mm or 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
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Technique of External Fixation
• Unilateral frame with half pins
• 5mm half pins• near-near and far-far• Stay out of zone of injury
• Pre-drilling of pins recommended
• Fracture held reduced while clamps and connecting bar applied
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Advantages of External Fixator
• Can be applied quickly in polytrauma patient
• Allows easy monitoring of soft tissues and compartments
• Modifiable• No long term deep HW
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Outcomes of External Fixation
Anderson CORR ‘74Edge JBJS ‘81
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
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Conclusions
Common fracture w/ several treatment options
Closed stable fx can be treated in a cast
Unstable fx often best treated by intramedullary nail
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Acknowledgments
1st Edition lecture R. Cantu M.D.Cases Courtesy R. Winquist M.D.
E. Kubiak M.D.
Return to Lower Extremity
Index
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Questions/Comments
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