Closed Fractures of the Tibial Diaphysis. Much emphasis to High Energy fractures In Fact: 76.5% are...
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Transcript of Closed Fractures of the Tibial Diaphysis. Much emphasis to High Energy fractures In Fact: 76.5% are...
![Page 1: Closed Fractures of the Tibial Diaphysis. Much emphasis to High Energy fractures In Fact: 76.5% are closed 53.5% have mild soft tissue damage.](https://reader030.fdocuments.us/reader030/viewer/2022032702/56649ce35503460f949afaa0/html5/thumbnails/1.jpg)
Closed Fractures of the Tibial Diaphysis
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• Much emphasis to High Energy fractures• In Fact: 76.5% are closed
53.5% have mild soft tissue damage
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Tibial Fractures
• Most common long bone fracture
• 492,000 fractures yearly• Average 7.4 day hospital
stay• 100,000 nonunions per
year
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History & Physical
• Pain, inability to bear weight, and deformity
• Local swelling and edema variable
• Careful inspection of soft tissue envelope, including compartment swelling
• Thorough neurovascular assessment including motor/sensory exam and distal pulses
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Physical Exam
• Soft tissue injury with high-energy crush mechanism may take several days to fully declare itself
• Repeated exam to follow compartment swelling
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Radiographic Evaluation
• AP and Lateral views of entire tibia from knee to ankle
• Oblique views can be helpful in follow-up to assess healing
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Associated Injuries• Up to 30% of patients
with tibial fractures have multiple injuries
• Ipsilateral fibula fracture common
• Ligamentous injury of knee with high energy tibia fractures
Browner and Jupiter, Skeletal Trauma, 3rd Ed
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Associated Injuries
• Ipsilateral femur fx, “floating knee”
• Neuro/vascular injury less common than in proximal tibia fx or knee dislocation
• Foot and ankle injury
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Classification
• Numerous classification systems
• Important variablesPattern of fracture
location of fracture
comminution
associated fibula fracture
degree of soft tissue injury
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OTA Classification• Follows Johner &
Wruh system
• Relationship between fracture pattern and mechanism
• Comminution is prognostic for time
to union Johner and Wruhs, Clin Orthop 1983
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Henley’s Classification
• Applies Winquist & Hansen grading of femur 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
• 5-15%• HISTORY
Hi-Energy
Crush
• 4 leg compartments
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Nerve is the Tissue most Sensitive to Ischemia
• PAIN first Symptom
• PAIN with Passive Stretch first Sign
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Each Compartmenthas Specific Innervation
• Ant Comp - Deep Peroneal N.• Lateral - Sup Peroneal N.• Deep Post. - Tibial N.• Sup Post. - Sural N.
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Anterior Compartment
• Dorsiflexes ankle
• Tib ant, EDL, EHL, and peroneus tertius muscles
• Anterior tibial a./v.• deep peroneal n.
1st webspace sensation
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Lateral Compartment
• Everts the foot
• Peroneus brevis and longus muscles
• Superficial peroneal n.dorsal foot
sensation
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Superficial Posterior Compartment
• Plantarflexes ankle
• Gastrocnemius, soleus, popliteus, and plantaris muscles
• Sural nerveLateral heel sensation
• Greater and lesser saphenous veins
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Deep Posterior Compartment
• Plantarflexion and inversion of foot
• FDL, FHL, Tib post muscles
• Post tibial vessels, peroneal a.
• tibial nervePlantar foot sensation
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Compartment Syndrome is a Clinical Diagnosis
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Pressure Measurements are Helpful
• Various Thresholds
P = 30
P = 45
∆ P < 30= Diastolic BP - Compartment Pressure
McQueen, JBJS-B, 1990
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Pressures Not Uniform
• Highest at Fracture Site
• Highest Pressures in Posterior & Anterior Compartments
•Heckman JBJS 76
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Clinical Monitoring
• Need Close Observation
• Repetitive Exams• Some instances
repetitive Pressure measurements
• Indwelling Monitors?
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Goals of Fasciotomy
• Decompress The Compartment
• Do Not Strip Muscle From The Bone
• Single vs. Two incisions
• Plan for fracture fixation
• Plan for wound closure
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Closed Tibial Shaft Fractures
• Broad Spectrum of Injures w/ many treatments
• Nonsurgical management
• Intramedullary nails• Plates• External Fixation
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Nonoperative Treatment Indications
• Minimal soft tissue damage
• Stable fracture pattern• < 5° varus/valgus• < 10° pro/recurvatum• < 1 cm shortening
• Ability to bear weight in cast or fx brace
• Frequent follow-up
Schmidt, et.al., ICL 52, 2003
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Fracture Brace
• Closed Functional Treatment
1,000 Tibial Fractures
60% Lost to F/u
• All < 1.5cm shortening• Only 5% more than 8° varus
• Average 3.7wks in long leg cast, then
Functional fracture brace
Sarmiento, JBJS 1984
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Sarmiento
• Union 98.5%• Time 18.1 Wks.• Short >20mm
1.4%
Initial shortening = final shortening
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Ankle Motion after tibia fractures
• 25% patients with 25% loss of ankle-ROM
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Natural History
• Long-term angular deformities may be well tolerated without associated knee or ankle arthrosis
• Kristensen F/U: 20-29 yrAll patients >10 degree deformity
• Merchant & Dietz F/U: 29 yrs. Outcome not associated with ang., site, immob.
(37/108 patients)
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Surgical Indications
• High energy fracture
• Moderate soft tissue injury
• Unstable fracture patternInability to maintain reduction
• Open fracture
• Compartment syndrome
• Ipsilateral femur fracture
• Pt cannot tolerate long-leg cast
Schmidt, et.al., ICL 52, 2003
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Surgical Options
• Intramedullary nail
• ORIF with plate
• External Fixation
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Advantages of IM Nail
• Less malunion and shortening
• Earlier weight bearing• Early ankle and knee
motion• Possibly cheaper than
casting if time off work included
Tovainen, Ann Chir Gynaecol, 2000
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IM Nails – Hooper, et.al.
• In a prospective study if displacement >50% angulation >10°
• Nails superior to cast treatment
Hooper, JBJS-B, 1991
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IM Nails – Bone, et.al.
Retrospective review 99 patients
Cast Nail
Time to union 26wks 18wks
SF-36 74 85
Knee score 89 96
Ankle score 84 97 Bone, et.al. JBJS, 1997
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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, et.al. Injury Mar 2005Bhandari, et.al., JOT 2000
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Blachut JBJS 79A
Reamed Non-Reamed
# pts. 73 63
Nonunion 4% 11%
Malunion 4% 3%
Broken Bolts3% 16%
Reamed vs. Nonreamed Nails
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IM Nails – Interlocking Bolts
• Loss of alignment w/out interlocking
• Spiral 7/22
• Transverse 0/27
• Metaphyseal 7/28
•Templeman CORR 1997
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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 1996
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IM Nail Removal – Knee Pain
• Pain resolved 27%
• Marked improvement 69%
• Pain worse 3%
• No difference in knee pain based on tendon sparing approach
Court-Brown, JOT 1996
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Iaquinto, Am J. Orth 1997
Neurological Complications
63 patients reviewedCompared type of anesthesia
4.1 X greater risk of Neurologic injury w/ epidural
Need to monitor exam postop
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Disadvantages of IM Nail
*Court-Brown et al. JOT 96
• Anterior knee pain (up to 56.2%)
• Risk of infection• Increased hardware
failure with unreamed nails
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Expanded Indications
• Proximal 1/3 fractures• Beware Valgus and Procurvatum
• Distal 1/3 fractures• Beware Varus or valgus
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Proximal Tibia Fracture
• Entry site is critical
• Reference is Lateral Tibial Spine
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Just Right
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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 – sublux patella laterally
• Use handheld awls to gently ream through the trochlear groove
Tornetta, CORR Jul 1996
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Hyperextended position
• Pulls patella proximally to allow straight starting angle.
• Universal distractor
Beuhler & Duwelius, JOT 1997
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Blocking (Poller) Screws
• Functionally narrows IM canal
• Increases strength and rigidity of fixation
• 21 patients
• All healed within 3-12 months• Mean alignment 1 degree valgus, procurvatum 2 degrees.
Krettek C, et al. JBJS 81B: 963, 1999
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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• Joy Stick• Calcaneal Traction
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Universal Distractor Reduction
Beuhler & Duwelius, JOT 1997
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Plate Fibula
Egol, et.al. JOT Feb 2006
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Distal Tibia 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 Feb. 2004.
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Plating of Tibial Fractures
• Narrow 4.5mm DCP plate can be used for shaft fractures
• Newer periarticular plates available for metaphyseal fractures
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AO Technique of Tibia Plating
• Anterior longitudinal incision• 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
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Subcutaneous Tibial Plating
• Newer alternative is use of limited incisions and subcutaneous plating- requires indirect reduction of fracture
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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
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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
Johner and Wruhs, Clin Orthop 1983
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External Fixation
• Generally reserved for open tibia fractures or periarticular fractures
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Technique of External Fixation
• Unilateral frame with half pins • 5mm half pins (‘near-near and
far-far’)• 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
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Outcomes of External Fixation
Anderson et al. Clin Orthop 1974Edge and Denham JBJS[Br] 1981
• 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 fxs. can be treated in a cast.
• Unstable fxs. often best treated by intramedullary nail