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

Gustilo and Anderson classification (Open Fracture) Gustilo and Anderson. (JBJS 1976) Gustilo, Mendoza and Williams. (J.Trauma 1984)

Oestern and Tscherne classification (Close Fracture) Grade C0 : Little or no soft-tissue injury Grade CI : Superficial abrasion Grade CII : Deep, contaminated abrasion with local contusional damage to skin or muscle Grade CIII: Extensive skin contusion or crushing or muscle destruction (compartment syndrome) Tscherne HG : Fractures Associated with Soft Tissue In-juries. 1984 JAAOS, 2003, vol. 11 no. 6 431-438

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

Proximal and distal tibia fractures ( Plating vs Nailing ) Proximal tibia fractures Nailing : Apex anterior mal-reduction (2x) plating : Hardware removal (3X) a lower rate of infection and a higher incidence of malunion in nail group Distal tibia fractures Nailing : nonunion(12%) and malunion plating : wound breakdown, prominent hardware

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)

Timing of surgical debridement Debated ?? Early débridement within 6 hours (??) Routine primary closure (X) Serial débridements after 48 to 72 hrs Antibiotic-impregnated beads Negative pressure wound therapy (NPWT)

Open Tibia Fractures Conversion to nailing : < 2 weeks 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

Acceleration of Fracture Healing recombinant human bone morphogenetic protein-2 (rhBMP-2) and rhBMP-7 (level I) (FDA)–approved rhBMP-2 : open tibia fractures (within 14 days) rhBMP-7 : tibial nonunions

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 nutrition Underlying metabolic or endocrine disorders Surgeon factors : Distraction of the fracture Excessive soft-tissue stripping Excessive reaming

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

Complication – Nonunion

An infected nonunion, A staged exchange nailing (interval débridement, external fixator, and antibiotic therapy)

Tibial Plafond Fractures (Pilon fractures)

Tibial Plafond Fractures Higher energy with axial load Significant articular damage More compromised soft-tissue envelopes High complication rate

X At Emergency Room The timing of CT : after external fixation 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 III Type I Type II Ruedi and Allgöwer system

Articular Surface Fracture Primary fracture lines A : anterolateral or Chaput fragment M : medial malleolar fragment P : posterior malleolar or Volkmann fragment ※ Additional articular pieces are created via secondary fracture lines J Bone Joint Surg 2005;87:692-697

Immediate ORIF External Fixation Staged ORIF 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 ) Related to 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 !!)

Outcome Patient-specific variables Preexisting medical comorbidities Male sex Work-related injuries Lower income and education level Fracture-specific variables Severity of the injury Quality of the reduction

Outcome High incidence of posttraumatic ankle arthritis (> Gr. 2 : more than 60%) Inability to run : the most common complaint (27/31 patients) Few require secondary reconstructive procedures (5/40) Symptoms decrease with a long time (an average of 2.4 years) J Bone Joint Surg Am2003;85(2):287-295

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 !!