1. Tibial Shaft Fractures
台中榮民總醫院 骨科部
王舜平 醫師

2. 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

3. Trauma Mechanism Direct or indirect trauma Low-energy trauma:
Simple falls, twisting injuries
Sports injuries
High-energy trauma :
motor vehicle or motorcycle crashes

4. Classification Fracture classification :
AO/OTA fracture classification

5. AO/OTA fracture classification

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

7. 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

8. 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 !!

9. 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 Aug;23(7):514-8

10. 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

11. 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)

12. Concomitant Ipsilateral fractures of the left tibial plateau and left tibial pilon

13. 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)

14. 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

15. Surgical Treatment - External Fixation
Minimally invasive
Relative stability
Easier wound care
Temporary usage
Damage control techniques
Definitive usage
soft-tissue injury
bone loss

16. 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

17. 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

18. 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

19. 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%)

20. Proximal and distal tibia fractures
Malunion (84%) of proximal tibial fracture
Lower (58%) in distal tibial fractures
Improved reduction :
blocking or Pöller screws

21. 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

22. Open Tibia Fractures Urgent management Early antibiotic
Wound coverage - sterile
Tetanus prophylaxis
Surgical débridement
Fracture stabilization

23. 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)

24. 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)

25. 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

26. 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

27. 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

28. 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

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

30. Complication – Nonunion

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

32. Tibial Plafond Fractures (Pilon fractures)

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

34. 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

35. 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

36. 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:

37. Immediate ORIF External Fixation Staged ORIF
Surgical Treatment
Immediate ORIF
External Fixation
Staged ORIF

38. 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

39. 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 !!

40. 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 “

41. 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

42. 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

43. 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):

44. Complications Wound-healing and deep infections
Malunions and nonunions
Postoperative scarring and stiffness
Hardware prominence
Posttraumatic arthritis

45. 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 !!)

46. 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

47. 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):

48. 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 !!)

49. Thanks for your attentions !!