Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling...
-
Upload
nguyenkhuong -
Category
Documents
-
view
222 -
download
3
Transcript of Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling...
![Page 1: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/1.jpg)
Tibial Shaft FracturesMr Krishna Vemulapalli
Consultant Orthopaedics Surgeon
Queens & King George Hospitals
29/03/2018 Vemulapalli
![Page 2: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/2.jpg)
Queens Hospital14/03/2018 Google Maps
https://www.google.co.uk/maps/@51.5689712,-0.2549157,10z 1/1
Map data ©2018 Google 10 km
29/03/2018 Vemulapalli
![Page 3: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/3.jpg)
Orthopaedics Department
• Covers > 800000- 1M population
• 12 Trauma & Orthopaedics Consultants
• 2 Trauma Consultants
• One of the Busy Trauma department
• 24 Trauma lists per week
• 600-700 Hip fractures per year
29/03/2018 Vemulapalli
![Page 4: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/4.jpg)
29/03/2018
Paediatric
Orthopaedics
FOOT AND ANKLE
Vemulapalli
![Page 5: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/5.jpg)
Services
• Ponseti Treatment- Club foot/ Talipes
• DDH
• Diabetic Foot Service
29/03/2018 Vemulapalli
![Page 6: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/6.jpg)
Courses
• Queens Ponseti Course
• Queens FRCS(orth) Clinical course-www.queensfrcscourse.com
• Queens Orthopaedics for Emergency staff (A&E)
• Queens Foot & Ankle Course
29/03/2018 Vemulapalli
![Page 7: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/7.jpg)
29/03/2018 Vemulapalli
![Page 8: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/8.jpg)
29/03/2018 Vemulapalli
![Page 9: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/9.jpg)
Tibial shaft fractures
• Surgical anatomy
• Epidemiology
• Investigations
• Classification
• Treatment• Plaster cast- non operative
• Operative treatment
• Open Fractures
• Compartment syndrome
29/03/2018 Vemulapalli
![Page 10: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/10.jpg)
Anatomy- structure & function
• Tibia- Latin word- means Flute
• 2nd largest bone in body
• Articulates with Femur above and talus below
• Carries 5 times the body weight
• Tibia is subcutaneous for much of its course- prone for direct trauma
29/03/2018 Vemulapalli
![Page 11: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/11.jpg)
Surgical Anatomy
Strong, Noncompliant fascia completely surrounds the muscle accompanying the tibia
29/03/2018 Vemulapalli
![Page 12: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/12.jpg)
Epidemiology
• Most common long bone fracture
• Incidence-26/100000
• Most fractures are found in young males
• Male-41/100000. Average Age 31
• Female-12.3/100000. Average Age 54yrs
• Second peak in elderly patients.
29/03/2018 Vemulapalli
![Page 13: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/13.jpg)
Why is it important?
• Most common Long bone fracture-492,000 fractures/year
• Most common Open Fracture
• Significant cost• 569,000 hospital days• Major cause of disability
• Significant complications• 50,000 non unions /year
29/03/2018 Vemulapalli
![Page 14: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/14.jpg)
Mechanism of injury & Presentation
• Direct trauma- sports
• RTA
• Unable to weight bear
• Pain; swelling and deformity of the leg
• ? Bleeding from open wound
29/03/2018 Vemulapalli
![Page 15: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/15.jpg)
Diagnosis
• Fracture-Very Obvious
• Soft tissue assesment
• Open or closed
• Compartment syndrome
29/03/2018 Vemulapalli
![Page 16: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/16.jpg)
Investigations
• X-ray- AP/Lat• Knee and Ankle to be included
29/03/2018 Vemulapalli
![Page 17: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/17.jpg)
Investigations……
• CT scan• Planning the operation
• For assessing the # extension into the joints
29/03/2018 Vemulapalli
![Page 18: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/18.jpg)
Radiographs
1. The location and morphology of the fracture
2. Presence of secondary fracture lines
3. Presence of Comminution, signifying a high energy injury
4. Bone defects/missing bone
5. Fracture lines extending into the knee or ankle
29/03/2018 Vemulapalli
![Page 19: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/19.jpg)
AO Classification
29/03/2018 Vemulapalli
![Page 20: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/20.jpg)
Treatment Goals
1. Establishing Bone union
2. Establishing and Maintaining normal length, alignment and rotation
3. Establishing and maintaining the normal anatomical relationship between the knees and ankles for weightbearing, motion and Propulsion
29/03/2018 Vemulapalli
![Page 21: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/21.jpg)
Treatment Options
• Non operative• Cast or Braces
• Operative• IM Nailing
• Plating
• External fixator• Mono or Circular
29/03/2018 Vemulapalli
![Page 22: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/22.jpg)
Non-operative Treatment
29/03/2018 Vemulapalli
![Page 23: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/23.jpg)
Nonoperative treatment
• Non operative treatment does NOT mean no treatment
• Closed reduction and plaster of Paris application achieve
good results
• Non operative treatment is difficult and demanding
29/03/2018 Vemulapalli
![Page 24: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/24.jpg)
Cast Treatment-Indications
• Low- energy
• Stable
• Un displaced or Minimally Displaced
• Isolated Tibial shaft Fractures
29/03/2018 Vemulapalli
![Page 25: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/25.jpg)
Cast Treatment-Contraindications
• High Energy
• Unstable
• Segmental
• Off-ended
• Excessive shortened ( >1 cm)
• Neuro vascular damage
• Compartment syndrome
• Macerated/damaged Skin
• Polytrauma
29/03/2018 Vemulapalli
![Page 26: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/26.jpg)
Advantages of Cast
• No infection
• No need of sophisticated equipment
• Can be readily performed under most Spartan conditions
• Cast failure is easier to correct than implant failure
• It does not make subsequent operative treatment impossible
29/03/2018 Vemulapalli
![Page 27: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/27.jpg)
Disadvantages of Cast
• Requires a compliant patient
• Patient must accept some deformity- Malunion; Delayed union
• Accept the possibility of prolong treatment
• Ankle & Subtalar Stiffness
29/03/2018 Vemulapalli
![Page 28: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/28.jpg)
Non operative treatment
• Plaster can prevent lateral shift
• Plaster can prevent angulation
• Plaster can control rotation
• Plaster can NOT prevent shortening
29/03/2018 Vemulapalli
![Page 29: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/29.jpg)
Cast Treatment
• Weight bearing Long Cast application with 5-10 degrees flexion of knee for 4 weeks
• Patellar tendon-bearing cast / brace for 4-6 weeks
• Weekly X-rays for the first 3 -4 weeks
• Continue brace until osseous union demonstrated on X-rays
29/03/2018 Vemulapalli
![Page 30: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/30.jpg)
Cast Application- Treatment
• Under Analgesia or Spinal or General
• Leg Hanging of table with knee flexed ( Relax Gastrocs and allows traction by Gravity)
• Fracture reduced
• Padding starting from toes with extra padding over the heel, malleoli, fibula neck
• Plaster applied from toes to just above the Tibial tubercle
29/03/2018 Vemulapalli
![Page 31: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/31.jpg)
Cast application….
• Molding with palms done over medial tibia, behind both malleoli, over the arch of the foot
• No molding over the fibular head or Tibial tubercle
• Plaster extended proximally 2 finger breadths below the greater trochanter
• Knee flexed 5-10 degrees
29/03/2018 Vemulapalli
![Page 32: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/32.jpg)
Following cast
• Xray to confirm the position
• For Angular deformity corrections <10 degrees-Wedging
29/03/2018 Vemulapalli
![Page 33: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/33.jpg)
Cast wedging
• Can be Open or Close Wedging
• Open wedging- Minor risk of distraction of fracture
• Close wedging- Pinch or compress the skin-Necrosis
• Can be at site of fracture-Watson or junction of long axis of 2 fragments
29/03/2018 Vemulapalli
![Page 34: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/34.jpg)
Stop Casting Operative Rx
• Malposition of >100
• Shortening of > 1 cm
• Repeated wedging
• Wedging more than 100
29/03/2018 Vemulapalli
![Page 35: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/35.jpg)
Operative Treatment
• Internal fixation
• IM Nails
• Reamed or Un reamed
• Plates
• Classic or MIPO
• External fixation
• Unilateral
• Circular
• Hybrid
29/03/2018 Vemulapalli
![Page 36: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/36.jpg)
Indications of internal fixation
• Failed Closed treatment
• Unstable tibial fractures
• Ipsilateral tibial & femoral fractures
• Fractures with intra articular extension
• Segmental fractures
• Bilateral tibial fractures
• Open fractures
• Pathological fractures
• Fractures with vascular complications & compartment syndrome
29/03/2018 Vemulapalli
![Page 37: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/37.jpg)
Internal Fixation- IM nailing
• Work Horse
• Indicated in most of the shaft fractures
• Fracture Zone should be 5 cm below Knee and 5 cm Above Ankle
• Reamed Vs Unreamed
• Locking Vs Unlocking
29/03/2018 Vemulapalli
![Page 38: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/38.jpg)
Operative treatment-Nailing- Advantages
• Indirect reduction which preserves soft-tissue attachments
• Allows movement at fracture site which results in early union with callus formation
• Anatomical reduction rare but restoration of length, axis and rotation is usual
29/03/2018 Vemulapalli
![Page 39: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/39.jpg)
Nailing-Advantages
• Nails function as internal splints
• Nails can withstand heavy loads
• Nails can be mobilized with early weight bearing
29/03/2018 Vemulapalli
![Page 40: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/40.jpg)
Complications of IM nail
• Anterior knee pain
• Thermal necrosis
• Destroys endosteal circulation
• Iatrogenic fracture
• Compartmental syndrome
29/03/2018 Vemulapalli
![Page 41: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/41.jpg)
Plate & Screws
29/03/2018 Vemulapalli
![Page 42: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/42.jpg)
Internal fixation-Plates & Screws-Indications• Metaphyseal fractures
• Fractures extending into Knee or Ankle joint
• Malunions
• Nonunions
29/03/2018 Vemulapalli
![Page 43: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/43.jpg)
Internal fixation- compression plate- facts
• Destroys periosteal circulation
• Direct reduction will destroy soft tissue attachments
• Rigid fixation will result in slow union without callus formation
• Anatomical reduction
• Plates cannot withstand weight-bearing forces
• Plates will not permit early weight bearing
29/03/2018 Vemulapalli
![Page 44: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/44.jpg)
Internal fixation- Plates & Screws
• Disadvantage• Skin Necrosis*• Wound Dehiscence• Infection• Restricted weight bearing• Non union• Re fracture (After plate removal)
• *avoid tourniquets ( <20%)
29/03/2018 Vemulapalli
![Page 45: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/45.jpg)
Ex-fix
29/03/2018 Vemulapalli
![Page 46: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/46.jpg)
Ex-Fix
• Mainly used in
• Sick patient
• Sick limb
29/03/2018 Vemulapalli
![Page 47: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/47.jpg)
External fixation-Indications
• Open fractures• Fractures with bone loss• Nonunion• Malunion• Infected nonunion• Closed fractures
complicated by• Compartment
syndrome• Vascular injury• Head injury• Burns• Impaired sensation
29/03/2018 Vemulapalli
![Page 48: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/48.jpg)
Types of Ex fix
• Mono
• Circular
• Hybrid
29/03/2018 Vemulapalli
![Page 49: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/49.jpg)
Disadvantages
• Pin track infections
• High rate malunion
• High Reoperation rate
• Requires frequent adjustments
• Visual reminder of the disability (social & psychological effect)
• Fractures through pin sites
29/03/2018 Vemulapalli
![Page 50: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/50.jpg)
Summary of Fixation devices
29/03/2018 Vemulapalli
![Page 51: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/51.jpg)
Tibial Fixation Options
• Plate• Ex Fix• IM nail
29/03/2018 Vemulapalli
![Page 52: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/52.jpg)
Complications of Tibial Shaft Fractures
• Delayed / Non Union
• Infections
• Malunion & Shortening
• Vascular injuries
• Compartmental syndrome
• Joint Stiffness & Ankylosis
• Traumatic arthritis
• RSD
• Fat embolism
29/03/2018 Vemulapalli
![Page 53: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/53.jpg)
Open fractures
29/03/2018 Vemulapalli
![Page 54: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/54.jpg)
Open fractures
• An open fracture is one in which a break in the skin and underlying soft tissue directly communicates with the fracture and its hematoma
29/03/2018 Vemulapalli
![Page 55: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/55.jpg)
Gustilo And Anderson ClassificationType Wound Level of
ContaminationSoft Tissue Injury Bone Injury
I <1 cm long Clean Minimal Simple, Minimal comminution
II >1 cm long Moderate Moderate, Some muscle damage
Moderate Comminution
III
A >10 cm High Severe with Crushing Usually Comminuted; Soft-tissue Coverage of bone possible
B >10 cm High Very Severe loss of coverage
Bone Coverage poor; usually requires soft-tissue reconstructive surgery
C >10 cm High Very severe loss of coverage plus vascular injury requiring repair
Bone coverage poor Usually requires soft-tissue reconstructive surgery
29/03/2018 Vemulapalli
![Page 56: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/56.jpg)
Tschern classification of soft tissuesGrade-0 Minimum soft tissue injury
Simple # pattern
Grade-1 Superficial AbrasionMild to moderate # pattern
Grade-2 Deep AbrasionImpending compartment syndromeSevere # pattern
Grade-3 Extensive crushSevere # pattern +/- Vascular injuryCompartmental syndrome29/03/2018 Vemulapalli
![Page 57: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/57.jpg)
Complications and Prognosis are directly related to degree of soft tissue injury
29/03/2018 Vemulapalli
![Page 58: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/58.jpg)
Compartment syndrome
29/03/2018 Vemulapalli
![Page 59: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/59.jpg)
Compartment syndrome
• Pain• Excessive to fracture
• Pain• Passive stretching of toes
• Pain• Uncontrollable with normal
analgesia
29/03/2018 Vemulapalli
![Page 60: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/60.jpg)
Compartmental syndrome
• Anterior compartment very common
• Deep Posterior second commonest
• Lateral compartment always associated with ant of post compartment syndrome
29/03/2018 Vemulapalli
![Page 61: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/61.jpg)
Diagnosis
• High Index of suspicion
• Clinical Hx & Examination
Vemulapalli29/03/2018
![Page 62: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/62.jpg)
Compartment syndrome- Diagnosis
• High Index of Suspicion
• Pain; Pain; Pain
• Tight/ Tense Compartments
• Nerve paresthesia
• Compartmental pressure monitors
29/03/2018 Vemulapalli
![Page 63: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/63.jpg)
Treatment
Fasciotomy
29/03/2018 Vemulapalli
![Page 64: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/64.jpg)
Summary
• Tibial fractures are very common
• Young people fracture
• Can be treated non-op or operatively
• Open fractures are common
• High index of suspicion for diagnosing compartmental syndrome
29/03/2018 Vemulapalli
![Page 65: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/65.jpg)
Vemulapalli
THANKYOU
29/03/2018
![Page 66: Tibial Shaft Fractures - benecaremedical.com · •RTA •Unable to weight bear •Pain; swelling and deformity of the leg •? Bleeding from open wound ... •Polytrauma 29/03/2018](https://reader033.fdocuments.in/reader033/viewer/2022051509/5af9b85e7f8b9a5f588e6fb9/html5/thumbnails/66.jpg)
• “A fracture in plaster of Paris will not displace more than its previous maximal displacement”
Sarmiento,York 1998
29/03/2018 Vemulapalli