1. Closed Fractures of the Tibial Diaphysis

2. Much emphasis to High Energy fractures In Fact: 76.5% are closed 53.5% have mild soft tissue damage

3. Tibial Fractures Most common long bone fracture 492,000 fractures yearly Average 7.4 day hospital stay 100,000 nonunions per year

4. 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

5. Physical Exam Soft tissue injury with high-energy crush mechanism may take several days to fully declare itself Repeated exam to follow compartment swelling

6. Radiographic Evaluation AP and Lateral views of entire tibia from knee to ankle Oblique views can be helpful in follow-up to assess healing

7. 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, 3r d Ed

8. Associated Injuries Ipsilateral femur fx, “floating knee” Neuro/vascular injury less common than in proximal tibia fx or knee dislocation Foot and ankle injury

9. Classification Numerous classification systems Important variables Pattern of fracture location of fracture comminution associated fibula fracture degree of soft tissue injury

10. 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

11. Henley’s Classification Applies Winquist & Hansen grading of femur to fractures of the tibia

12. 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

13. Compartment Syndrome 5-15% HISTORY Hi-Energy Crush 4 leg compartments

14. Nerve is the Tissue most Sensitive to Ischemia PAIN first Symptom PAIN with Passive Stretch first Sign

15. Each Compartment has Specific Innervation Ant Comp - Deep Peroneal N. Lateral - Sup Peroneal N. Deep Post. - Tibial N. Sup Post. - Sural N.

16. Anterior Compartment Dorsiflexes ankle Tib ant, EDL, EHL, and peroneus tertius muscles Anterior tibial a./v. deep peroneal n. 1 st webspace sensation

17. Lateral Compartment Everts the foot Peroneus brevis and longus muscles Superficial peroneal n. dorsal foot sensation

18. Superficial Posterior Compartment Plantarflexes ankle Gastrocnemius, soleus, popliteus, and plantaris muscles Sural nerve Lateral heel sensation Greater and lesser saphenous veins

19. Deep Posterior Compartment Plantarflexion and inversion of foot FDL, FHL, Tib post muscles Post tibial vessels, peroneal a. tibial nerve Plantar foot sensation

20. Compartment Syndrome is a Clinical Diagnosis

21. Pressure Measurements are Helpful Various Thresholds P = 30 P = 45 ∆ P < 30 = Diastolic BP - Compartment Pressure McQueen, JBJS-B, 1990

22. Pressures Not Uniform Highest at Fracture Site Highest Pressures in Posterior & Anterior Compartments Heckman JBJS 76

23. Clinical Monitoring Need Close Observation Repetitive Exams Some instances repetitive Pressure measurements Indwelling Monitors?

24. 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

25. Closed Tibial Shaft Fractures Broad Spectrum of Injures w/ many treatments Nonsurgical management Intramedullary nails Plates External Fixation

26. 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

27. 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

28. Sarmiento Union 98.5% Time 18.1 Wks. Short >20mm 1.4% Initial shortening = final shortening

29. Ankle Motion after tibia fractures 25% patients with 25% loss of ankle- ROM

30. Natural History Long-term angular deformities may be well tolerated without associated knee or ankle arthrosis Kristensen F/U: 20-29 yr All patients >10 degree deformity Merchant & Dietz F/U: 29 yrs. Outcome not associated with ang., site, immob. (37/108 patients)

31. Surgical Indications High energy fracture Moderate soft tissue injury Unstable fracture pattern Inability to maintain reduction Open fracture Compartment syndrome Ipsilateral femur fracture Pt cannot tolerate long-leg cast Schmidt, et.al., ICL 52, 2003

32. Surgical Options Intramedullary nail ORIF with plate External Fixation

33. 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

34. IM Nails – Hooper, et.al. In a prospective study if displacement >50% angulation >10° Nails superior to cast treatment Hooper, JBJS-B, 1991

35. IM Nails – Bone, et.al. Retrospective review 99 patients Cast Nail Time to union26wks18wks SF-36 74 85 Knee score 89 96 Ankle score 84 97 Bone, et.al. JBJS, 1997

36. 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 2005 Bhandari, et.al., JOT 2000

37. Blachut JBJS 79A Reamed Non-Reamed # pts. 73 63 Nonunion 4% 11% Malunion4% 3% Broken Bolts3% 16% Reamed vs. Nonreamed Nails

38. IM Nails – Interlocking Bolts Loss of alignment w/out interlocking Spiral 7/22 Transverse 0/27 Metaphyseal 7/28 Templeman CORR 1997

39. Complications Infection 1-5% Union >90% Knee Pain 56% w/ kneeling 90% w/ running 56% at rest 33% Court-Brown, JOT 1996

40. 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

41. Iaquinto, Am J. Orth 1997 Neurological Complications 63 patients reviewed Compared type of anesthesia 4.1 X greater risk of Neurologic injury w/ epidural Need to monitor exam postop

42. 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

43. Expanded Indications Proximal 1/3 fractures Beware Valgus and Procurvatum Distal 1/3 fractures Beware Varus or valgus

44. Proximal Tibia Fracture Entry site is critical Reference is Lateral Tibial Spine

45. Just Right

46. Too Low!Too Medial! Procurvatum Valgus

47. 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

48. Hyperextended position Pulls patella proximally to allow straight starting angle. Universal distractor Beuhler & Duwelius, JOT 1997

49. 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

50. Technique Screws placed on concave side of deformity. Proximal or distal fractures

52. Distal Tibial Fractures Reduction before reaming Distractor Fibula plate Joy Stick Calcaneal Traction

53. Universal Distractor Reduction Beuhler & Duwelius, JOT 1997

54. Plate Fibula Egol, et.al. JOT Feb 2006

55. Distal Tibia Joystick

56. 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.

57. Plating of Tibial Fractures Narrow 4.5mm DCP plate can be used for shaft fractures Newer periarticular plates available for metaphyseal fractures

58. 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

59. Subcutaneous Tibial Plating Newer alternative is use of limited incisions and subcutaneous plating- requires indirect reduction of fracture

60. 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

61. 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

62. External Fixation Generally reserved for open tibia fractures or periarticular fractures

63. 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

64. Advantages of External Fixator Can be applied quickly in polytrauma patient Allows easy monitoring of soft tissues and compartments

65. Outcomes of External Fixation Anderson et al. Clin Orthop 1974 Edge 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

66. Conclusions Common fracture w/ several treatment options. Closed stable fxs. can be treated in a cast. Unstable fxs. often best treated by intramedullary nail