Fractures of the tibial diaphysis Published: September 2013 Malcom Smith AOT Basic Principles Course

Learning outcomes Outline the assessment of closed tibial fractures Describe nonoperative and operative treatment options Discuss how closed soft-tissue injuries should be managed Teaching points: Concentrate on closed fractures, but briefly refer to open fractures.

Tibial diaphyseal fractures Problem 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 nonunions/year

Clinical assessment Patient assessment History and energy of injury Other associated injuries Advanced Trauma Life Support (ATLS)

Clinical assessment Soft-tissue assessment Open/closed Compartment syndrome Nerve and vascular examination

Clinical assessment Bony assessment Fracture site, severity, and stability Classification and position

Specific assessment X-rays: A/P and lateral Special investigations Pressure monitoring Angiography CAT scan (rare for diaphyseal fractures)

Clinical management General trauma patient management Initial reduction and splintage Soft-tissue protection Preparation for definitive management

Soft-tissue injury Complications and prognosis are directly related to the degree of soft-tissue injury

Tibial diaphyseal fracture classification

Tibial diaphyseal fracture classification

Tibial diaphyseal fracture classification

Tibial diaphyseal fracture classification

Tibial diaphyseal fracture classification

Nonoperative treatment Nonoperative treatment does NOT mean no treatment Closed reduction and plaster of Paris application can achieve good results Nonoperative treatment requires close monitoring

Nonoperative treatment Good casts can prevent lateral shift Good casts can prevent angulation Good casts can control rotation No cast can prevent shortening

“A fracture in plaster of Paris will not displace more than its previous maximal displacement” Augusto Sarmiento

Nonoperative treatment of tibial shaft fractures Relative stability leads to healing by callus

Nonoperative treatment Children Undisplaced fractures “Stable” reduced fractures Contraindication for surgery: Patient Health care team

Operative treatment—nailing Indirect reduction that preserves soft-tissue attachments Allows movement at fracture site which results in early union with callus formation Anatomical reduction is rare but restoration of length, axis, and rotation is common

Nailing—mechanics Nails function as internal splints Nails can withstand heavy loads Nails can be mobilized with early weight bearing

Intramedullary (IM) nailing Indications Closed diaphyseal fractures Open diaphyseal fractures Segmental fractures Floating knee Nonunions Treatment of choice for the vast majority of fractures

Insertion principles Starting point Proximal Central Anterior

Locking principles In the vast majority of cases static locking is carried out Locking None Static Dynamic Indications Length Rotation Alignment

Problems nailing proximal and distal fractures Malalignment Instability Failure Malunion Nonunion To avoid this, fractures must be reduced and held during nail insertion!

Reamed or unreamed nails?—closed tibial fractures Union 15.4 weeks 22.8 weeks Nonunion 0% 20% Malunion 16% Screw breakage 4% 52% Nail breakage Reference: Court-Brown CM, Will E, Christie J, et al (1996) Reamed or unreamed nailing for closed tibial fractures. A prospective study in Tscherne C1 fractures. J Bone Joint Surg Br; 78(4):580–583. This study showed a very marked advantage for reamed nails over unreamed nails. “Reamed nails mechanically and biologically superior.” Court-Brown CM, et al

Reamed and unreamed IM nailing Randomized controlled trial of 1,226 adult tibial shaft fractures followed for 1 year 57 (4.6%) nonunions 105 reamed versus 114 unreamed nailing group experienced “problem event” Possible benefit for reamed nailing in closed fractures No benefit of reaming with open fractures Delaying reoperation for nonunion for at least 6 months may substantially decrease the need for reoperation This metaanalysis did show a slight advantage for reamed over unreamed nails in closed tibial fractures. The study did not confirm the dramatic findings of CM Court-Brown, et al. References: Bhandari M, Guyatt G, Tornetta P 3rd, et al. Randomized trial of reamed and unreamed intramedullary nailing of tibial shaft fractures. J Bone Joint Surg Am. 2008 Dec;90(12):2567-78.

Anterior knee pain—complication of nailing Incidence varies from series to series 0–40% Related to surgical approach—may be more common in patella tendon splitting approaches Centre of tibial head is just medial to patellar tendon

Operative treatment—compression plating 18 months Direct reduction can destroy soft-tissue attachments Needs maximal periosteal preservation Rigid fixation will result in slow union without callus formation Anatomical reduction Technique needs to be perfect

Compression plating—indications Simple metaphyseal fractures Corrective osteotomy for malunion Plating for hypertrophic nonunion Often done percutaneously (MIPO)

Operative treatment—external fixator Useful in severe soft- tissue damage Rarely used as definitive treatment

Compartment syndrome Devastating complication Incidence: 1–7% Occurs in both reamed and unreamed nailing High index of suspicion will lead to diagnosis Presents with pain Clinical suspicion important Beware of patients with reduced sensation Definitive diagnosis: compartment pressure < 30 mm below diastolic = compartment syndrome References: McQueen MM, Gaston P, Court-Brown CM. Acute compartment syndrome. Who is at risk? J Bone Joint Surg Br. 2000 Mar;82(2):200-3.

Take-home messages Assessment of the injury Nonoperative and operative options Choice of implants—their advantages and disadvantages Surgical technique Importance of the closed soft-tissue injury