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A 25-year-old male pedestrian sustained a Type II open tibia fracture after being struck by a car at 10:00PM. He was transported to a Level I trauma hospital where he was given intravenous antibiotics and tetanus at 10:45PM. He underwent irrigation and debridement of the wound with 9L of saline solution and was treated with reamed intramedullary nail fixation at 11:45PM. A vacuum assisted dressing was placed over a 5x3cm skin deficit. What part of his overall treatment has shown to reduce the risk of infection THE MOST at the site of injury?
Early tetanus administration
Early intravenous antibiotic administration
Reamed intramedullary nail fixation
Irrigation and debridement of the open fracture with 9L of solution
Vacuum assisted dressings over skin deficit
Select Answer to see Preferred Response
The most important factor shown to reduce the risk of infection at the site of an open fracture is early intravenous antibiotic administration.
Infection risk after Gustilo Type II open fractures ranges from 10-20% in large studies. Antibiotic treatment initiated within 3 hours from the time of injury has shown to significantly reduce the rate of infection. Antibiotic coverage for Type II open fractures should cover gram positive bacteria. Soil-contaminated wounds should include anaerobic coverage. The dose of antibiotic given must be within a therapeutic range and titrated to the patient's weight (e.g. Ancef 2 g IV for >70 kg). Duration of antibiotic therapy has been suggested to be between 1 and 3 days, although there is no agreement on a firm end point.
Pollak et al. reviewed a large cohort of open fractures treated at Level I trauma centers. They demonstrated a significant decrease in infection rate with either early direct admission (<2 hours) or transfer (<11 hours) for ONLY type III open tibia fractures. They did not not discuss timing of antibiotic treatment because this was not prospectively collected. Although they did not collect data on antibiotic treatment, the authors theorize that early transfer potentially resulted in earlier administration of antibiotics.
Patzakis et al. examined a series of 1104 open fractures to determine the factors contributing to infection. They showed the most important factor in reducing the infection rate was the early administration of antibiotics.
Illustration A is table showing the Gustilo classification of open fractures.
Answers 1,4: These responses have been shown to reduce the risk of infection in open fractures, however, the most important factor has been shown to be early antibiotic therapy.
Answer 3: Reamed intramedullary nailing has not been shown to decrease infection risk in open tibia fractures, however, skeletal stability will prevent ongoing soft tissue damage
Answer 5: Vacuum-assisted wound dressings (or negative pressure wound therapy) are controversial as to whether they provide any protective effect against infection.
Pollak AN, Jones AL, Castillo RC, Bosse MJ, MacKenzie EJ.
J Bone Joint Surg Am. 2010 Jan;92(1):7-15. PMID: 20048090 (Link to Abstract)
Pollak, JBJS 2010
Patzakis MJ, Wilkins J.
Clin Orthop Relat Res. 1989 Jun;(243):36-40. PMID: 2721073 (Link to Abstract)
Patzakis, CORR 1989
Title: Distal Tibial Plating Presenter: David Lowenberg, MDColumbia University O...
Please rate question.
Average 4.0 of 8 Ratings
A 35-year-old male patient sustains a twisting injury to his leg while playing soccer. Radiographs are seen in Figures A and B. You decide to treat this fracture with intramedullary nailing. In order to prevent a missed injury that should be addressed during the same surgery, you order the following test
MRI of the ipsilateral knee
MRI of the ipsilateral hip
CT scan of the ipsilateral knee
Radiographs of the ipsilateral ankle
Axial radiograph of the ipsilateral calcaneus
This patient has spiral distal tibia and proximal fibula fractures. Dedicated imaging of the ankle should be performed to exclude a posterior malleolus fracture. Imaging options include either dedicated ankle radiographs or CT scans.
Tibial shaft fractures arise from high- or low-energy injuries. Low-energy injuries are characterized by (1) torsional mechanism of injury, (2) spiral pattern, (3) fibula fracture at a different level. Surgical options for closed shaft fractures include IM nailing and plate fixation. Concomitant ankle fractures should be treated during the same surgery to improve outcome.
Boraiah et al. examined the association of posterior malleolus fractures with spiral distal tibial fractures. They found that 39% had posterior malleolus fractures. In simple fractures (92%), none of the posterior malleolar fracture lines were contiguous with the diaphyseal fracture lines. In comminuted fractures (8%), an occult fracture line extended into the posterior tibial lip. Diagnosis was missed in 5% before CT scanning was initiated, and 0% after.
Stuermer et al. examined tibial fractures with associated ankle injury. Of spiral tibial fractures, 37% extended into the ankle, 5% involved the medial malleolus, 26% involved distal fibula, 8% had syndesmotic disruption, and 16% had posterior malleolar fracture. They recommend ankle radiographs for rotational trauma, spiral distal third fractures, Maisonneuve fractures, and fractures associated with an intact fibula.
Figures A and B are AP and lateral radiographs showing a spiral distal tibial fracture with a proximal fibula fracture. Illustration A is an axial CT scan showing the posterior malleolar fracture not seen on plain radiographs. Illustration B shows a missed posterior malleolar fragment in a fracture treated with IM nailing that subsequently displaced.
Answers 1, 2, 3, 5: There is no association between spiral distal tibial fractures and injuries of the hip, knee or calcaneus.
Boraiah S, Gardner MJ, Helfet DL, Lorich DG.
Clin Orthop Relat Res. 2008 Jul;466(7):1692-8. Epub 2008 Mar 18. PMID: 18347885 (Link to Abstract)
Boraiah, CORR 2008
Stuermer EK, Stuermer KM.
J Orthop Trauma. 2008 Feb;22(2):107-12. PMID: 18349778 (Link to Abstract)
Stuermer, JOT 2008
Title: Distal Tibia Fractures Nail vs. Plate Presenter: Andrew Schmidt,MDColumbi...
Average 3.0 of 12 Ratings
A 67-year-old male is involved in a motor vehicle accident and presents with the closed orthopedic injuries shown in Figures A and B. He is also noted to have a grade 1 splenic laceration and lung contusion. He is cleared by the trauma team, and undergoes early total care with reamed femoral and tibial nailing. A tourniquet is used for the tibial nailing portion of the case, and the tibial isthmus is over reamed to accept a larger nail. The use of a tourniquet in this case has been most clearly shown to be associated with which of the following?
Tibia shaft necrosis post-operatively
Increased pulmonary morbidity post-operatively
Increased cortical bone temperature during reaming
Increased nonunion rates
Decreased pain post-operatively
In patients with multitrauma, combining reamed femoral nailing with fracture fixation (ie. tibial shaft) under tourniquet control has been shown to increase pulmonary morbidity.
Limb reperfusion after tourniquet ischemia causes pulmonary microvascular injury. Similarly, microembolization, like that associated with reamed femoral nailing, can induce pulmonary microvascular injury. Both processes result in increased pulmonary capillary membrane permeability and edema, and ultimately increased pulmonary morbidity.
Karunakar et al showed in a canine model that there is no significant difference in the heat generated during reaming with and without a tourniquet. The factor that made the most difference was related to the size of the reamer used compared with the diameter of the isthmus. They concluded that the risk of thermal necrosis appears to be related more to the process of intramedullary reaming than to the tourniquet.
Giannoudis and associates performed a prospective randomized trial on 34 patients to measure the rise of temperature during reaming of the tibia before intramedullary nailing with and without the use of a tourniquet. The factor that generated the most heat was using large reamers (11 mm to 12 mm) in a patient with a small isthmus (8 mm to 9 mm). Use of a tourniquet, steroid use, and knee flexion during reaming were not shown to be associated with diaphyseal necrosis after reamed tibial nailing.
Pollak et al evaluated the association between femoral nailing followed by tourniquet ischemia and clinical lung injury. They reviewed 72 patients with femoral shaft fractures and tibial or ankle fractures requiring internal fixation over a six year period. All femoral shaft fractures were treated with reamed intramedullary nails, and the patients were divided into groups, based on whether the tibial or ankle injury was managed surgically with or without a tourniquet. They noted increased pulmonary morbidity in the group where a tourniquet was used.
Figure A shows a femoral shaft fracture at the junction of the middle and proximal one-third of the femoral shaft. Figure B shows a contralateral tibial shaft fracture.
1-Tourniquet use has not been shown to lead to thermal necrosis of the bone during reaming of the tibial shaft.
3-The cortical temperature does not increase to a greater degree with tourniquet use versus non-tourniquet use during reaming.
4-There is no evidence that use of a tourniquet affects tibial shaft union rates after reaming and intramedullary nailing.
5-Tourniquet use has been associated with increased pain post-operatively.
Giannoudis PV, Snowden S, Matthews SJ, Smye SW, Smith RM.
J Bone Joint Surg Br. 2002 May;84(4):492-6. PMID: 12043766 (Link to Abstract)
Giannoudis, BJJ 2002
Karunakar MA, Frankenburg EP, Le TT, Hall J.
J Orthop Trauma. 2004 Nov-Dec;18(10):674-9. PMID: 15507820 (Link to Abstract)
Karunakar, JOT 2004
Pollak AN, Battistella F, Pettey J, Olson SA, Chapman MW.
Clin Orthop Relat Res. 1997 Jun;(339):41-6. PMID: 9186199 (Link to Abstract)
Pollak, CORR 1997
Average 2.0 of 15 Ratings
Which of the following fracture patterns is classically associated with varus malunion if treated with closed reduction and casting?
Figure B shows a midshaft tibia fracture with an intact fibula, which places the fracture at increased risk of varus malalignment during healing.
Nonsurgically treated tibial shaft fractures with an intact fibula have an increased risk of varus malunion when treated nonsurgically. The fibula acts as a strut, preventing valgus collapse, but predisposing to varus angulation. Limb-length discrepancies can also occur.
Teitz et al. found that 26 percent of patients over the ago of 20 years old with isolated tibial shaft fractures treated nonsurgically went on to varus malunion. They also found that when the fibula remains intact, a tibiofibular length discrepancy can develop and cause altered strain patterns in the tibia and fibula leading to later ipsilateral joint sequeale.
Bonnevialle et al performed a retrospective study to assess the outcome after reamed nailing of tibial fractures with an intact fibula. Thirty-eight fractures were evaluated at a minimum of one year from surgery. Healing was achieved after the first intention treatment in 30 patients, after dynamization in 6. A non-union in 2 patients was also successfully managed with new nailing and dynamization. The authors concluded that nailing is a reliable technique for the treatment of tibial fractures with an intact fibula.
Sarmiento et al reviewed 1,000 consecutive closed diaphyseal tibial fractures, treated with prefabricated functional below-knee braces, to determine factors predictive of final fracture outcome. They found that final angulatory deformity in any plane was < or = 6 degrees in 90% of patients. They also noted that the presence of an intact fibula was a relative contraindication for functional fracture bracing because angulatory deformity was more likely to develop.
Figure B shows a midshaft tibial shaft fracture with an intact fibula.
Answer 1: Figure A shows a distal tibia and fibula fracture which are not specifically prone to varus malunion. Rather, if treated with IM nailing, fracture alignment is dictated by placement of the guide-wire and path of reaming which must be center-center distally.
Answer 3: Figure C shows a midshaft fibula and tibia fracture at the same level. The fibula, in this case, would not predispose the fracture specifically to varus malalignment.
Answer 4: Figure D shows a proximal tibial shaft and associated fibula fracture. This fracture pattern is predisposed to valgus and procurvatum.
Answer 5: Figure E shows a segmental tibial shaft fracture which are prone to shortening, translational, and rotational malalignment.
Teitz CC, Carter DR, Frankel VH.
J Bone Joint Surg Am. 1980 Jul;62(5):770-6. PMID: 7391100 (Link to Abstract)
Teitz, JBJS 1980
Bonnevialle P, Bellumore Y, Foucras L, Hézard L, Mansat M.
Rev Chir Orthop Reparatrice Appar Mot. 2000 Feb;86(1):29-37. PMID: 10669822 (Link to Abstract)
Average 4.0 of 14 Ratings
Which of the following is true regarding the center of rotation of angulation (CORA) as it refers to tibial diaphyseal angular deformity?
It is the point at which the proximal mechanical axis and distal mechanical axis meet
It is the point at which the proximal anatomical axis and proximal mechanical axis meet
It is always the point on the cortex at the most concave portion of the deformity
It is the point at which the distal anatomical axis and distal mechanical axis meet
It is always the point on the cortex at the most convex portion of the deformity
The center of rotation of angulation(CORA) in diaphyseal tibial deformity is defined as the intersection of the proximal mechanical(PMA) or anatomical axis(PAA), and the distal mechanical(DMA) or anatomical axis(DAA).
Angular deformity of the femur or tibia involves angulation not only of the bone but also of its axes. When a bone is divided and angulated, the mechanical and anatomic axis of the bone are also divided into proximal and distal segments. The pairs of proximal and distal axis lines intersect to form an angle. The point at which the proximal and distal axis lines intersect is called the CORA.
The axis line of the proximal bone segment is called the PMA or PAA, and axis line of the distal segment is called the DMA or DAA. In the tibia, because the mechanical and anatomical axes are almost the same, the PMA and PAA lines overlap, as do the DMA and DAA lines.
Illustration A shows the CORA as it relates to the axes of an angulated tibia.
2-5:These do not describe the CORA or any other specific anatomical points as they related to long bone deformity.
Average 2.0 of 30 Ratings
A 21-year-old male undergoes intramedullary nailing of the closed tibial shaft fracture shown in Figure A. At his 6-week follow-up, he is noted to have peroneal nerve deficits that were not present preoperatively. Which of the following findings is most consistent with a diagnosis of transient peroneal nerve neurapraxia as the result of his intramedullary nailing?
Decreased lateral hindfoot sensation
Decreased Achilles reflex
Decreased peroneus longus strength
Decreased extensor hallucis longus strength
Decreased plantar forefoot sensation
Decreased extensor hallucis longus strength is the physical exam finding most consistent with transient peroneal nerve neurapraxia.
Transient peroneal nerve neuropraxia has been noted in up to 5% of patients undergoing closed nailing of tibial shaft fractures. This is of unknown etiology, although injury to the peroneal nerve branches can be from placement of the interlocking screws into the nail. In this syndrome, extensor hallucis longus weakness is noted and decreased sensation is seen in the 1st dorsal webspace (deep peroneal nerve distribution). These symptoms generally begin improving by 3 months and have variable rates of recovery.
Robinson et al. reported on 'dropped hallux' syndrome, with weakness of extensor hallucis longus and numbness in the first web space, without clinical involvement of extensor digitorum longus or tibialis anterior. They found this in 5% of their patients after tibial nailing of closed tibia fractures, and all recovered either partially or completely by 4 months.
Lawrence et al. performed an anatomic study that reported the deep peroneal nerve was located superficial to the anterior tibial artery between the tibialis anterior and extensor hallucis longus muscles in the distal one third of the leg. They also found that the deep peroneal nerve crossed deep to the extensor hallucis longus tendon to enter the interval between the extensor hallucis longus and extensor digitorum longus at an average distance of 12.5 mm proximal to the ankle.
Figure A shows a tibial shaft fracture with mild displacement.
Answer 1: Lateral hindfoot sensation is generally via the sural nerve.
Answer 2: Achilles reflex is via S1 roots.
Answer 3: The peroneus longus is innervated by the superficial peroneal nerve.
Answer 5: Plantar forefoot sensation is via the tibial nerve along with the medial and lateral plantar branches.
Robinson CM, O'Donnell J, Will E, Keating JF.
J Bone Joint Surg Br. 1999 May;81(3):481-4. PMID: 10872371 (Link to Abstract)
Robinson, BJJ 1999
Lawrence SJ, Botte MJ.
Foot Ankle Int. 1995 Nov;16(11):724-8. PMID: 8589813 (Link to Abstract)
Lawrence, FAI 1995
Average 3.0 of 26 Ratings
A 35-year-old male suffers the injury seen in Figures A and B following a motor vehicle collision. He is initially taken to a local hospital. The treating surgeon, concerned that his hospital does not have a plastic surgeon available for soft-tissue coverage, arranges for transfer of the patient to a nearby level I trauma center for definitive care. Upon arrival at the definitive treatment center, the patient is taken for formal debridement and external fixator application. Which of the following options has the greatest effect on this patient's risk of infection?
External fixator application
Operative debridement within 6 hours
TIme to transfer to definitive trauma center
Soft-tissue coverage within 48 hours
Figures A and B demonstrate an open, segmental tibia shaft fracture with extensive soft-tissue injury. Recent evidence has demonstrated that time to transfer to a definitive trauma center has a significant effect on the incidence of infection for high-energy, open lower extremity fractures.
Pollak et. al analyzed a subgroup of 315 patients with high-energy, open lower extremity fractures from the Lower Extremity Assessment Project (LEAP study). Time to admission to a definitive trauma center for treatment was a significant, independent predictor of infection, with patients transferred 11-24 hours following injury having a significantly increased risk of major infection as compared with patients transferred within 3 hours of injury.
Werner et. al reviewed the existing literature surrounding the urgency of surgical debridement for open fractures, specifically relating to the "6 hour rule". The authors found limited evidence in the current literature to support emergent debridement within 6 hours of injury, and recommend urgent debridement (within 24 hours) once the patient is physiologically stable, life threatening emergencies have been addressed, and adequate surgical staff and resources are available.
1. External fixator application, although important for limb stability and ongoing assessment of the soft-tissue envelope, has not been shown to affect the rate of infection for open fractures
2. Tetanus prophylaxis is only effective against one infectious organism
3. Time to debridement was not shown to affect the rate of infection in the referenced articles
4. Time to soft-tissue coverage was not shown to have a statistically significant difference on the rate of infection in the level II study by Pollak et. al
Werner CM, Pierpont Y, Pollak AN.
J Am Acad Orthop Surg. 2008 Jul;16(7):369-75. PMID: 18611994 (Link to Abstract)
Werner, JAAOS 2008
Average 2.0 of 55 Ratings
A 54-year-old female sustains a communited tibial shaft fracture from an accident at work. She undergoes simultaneous external fixation and ORIF using minimally invasive plate osteosynthesis. Following surgery, she complains of numbness along the dorsum of her medial and lateral foot. In which location (labeled A - E) on Figure A did percutaneous placement without careful dissection of a pin/screw likely cause her nerve injury?
The above clinical scenario describes a post-op superficial peroneal nerve (SPN) deficit following ORIF of a tibial fracture using both external fixation and minimally invasive plate osteosynthesis (MIPO). The less invasive stabilization system (LISS) plate by Synthes is a system which utlizes the MIPO technique. This minimally invasive technique can increase the risk of damage to the SPN without careful identification of the nerve distally due to its close proximity to LISS plate holes 11-13.
Deangelis et al studied the anatomy of the superficial peroneal nerve in relation to fixation of tibia fractures with the LISS plate using cadaveric dissections. They found that the superficial peroneal nerve is at significant risk during percutaneous screw placement in holes 11 through 13 of the 13-hole proximal tibia LISS plates. They recommended using an incision and careful dissection down to the plate in this region of distal locking screws to minimize the risk of damage to the nerve.
Roberts et al also studied neurovascular anatomy of the leg in relation to screw placement, but did it in relation to locking screws used in intramedullary nailing. They concluded that intramedullary nail locking screws placed from a lateral-to-medial direction minimized the risk of injuries to the SPN and tibial neurovascular bundle. A disadvantage of lateral-to-medial locking screw placement was less resistance to nail bending forces.
Deangelis JP, Deangelis NA, Anderson R
J Orthop Trauma. 2004 Sep;18(8):536-9. PMID: 15475849 (Link to Abstract)
Deangelis, JOT 2004
Roberts CS, King D, Wang M, Seligson D, Voor MJ.
J Orthop Trauma. 1999 Jan;13(1):27-32. PMID: 9892122 (Link to Abstract)
Roberts, JOT 1999
Average 3.0 of 18 Ratings
Isolated exchange reamed interlocking nailing is most likely indicated as the next step in treatment for which of the following clinical scenarios:
Tibial shaft nonunion with a 4cm bone defect
Infected tibial shaft nonunion
Hypertrophic diaphyseal tibial nonunion
Atrophic tibial shaft nonunion
Hypertrophic metadiaphyseal distal tibia nonunion
If a hypertrophic nonunion is present, it is most likley a mechanical issue. Tibial diaphyseal hypertrophic nonunions (Illustration A) have approximately an 85-90% incidence of union with exchange reamed nailing. A nonunion that has bone loss or appears atrophic (Illustration B) will usually require improved mechanical stability as well as biological stimulation in the form of either autograft or an osteoinductive substance like BMP. A bone defect of up to 5-6cm in length can usually achieve union with bone grafting. In the presence of an infected nonunion, the infectious process needs to be addressed prior to the introduction of any revision hardware. If a patient does not show radiographic signs of tibial fracture union for 9 months and does not have progression toward healing for 3 consecutive months, then revision surgery would be indicated.
Tempelman et al looked at 71 tibial shaft fractures treated with nonlocked or dynamically locked IM nails and found a loss of alignment in 11% of the fractures that were not transverse in nature. They concluded that these nailing techniques should not be used in the treatment of spiral or oblique tibial shaft fractures.
1-A 4cm bone defect could not be corrected with exchanged nailing alone, and would either need extensive grafting or bone transport
2-An infected tibial shaft nonunion would require infection clearance prior to exchanged nailing
4-Atrophic nonunions typically need biologic stimulation in the form of acute grafting or insertion of a BMP type substance
5-Hypertrophic metadiaphyseal distal tibial nonunions can be treated with isolated exchanged nailing, however this does not have the same success as diaphyseal injuries. It is difficult to acheive appropriate stability to allow for fracture healing in the metadiaphyseal region, and other modalities such as plating need to be considered.
Templeman D, Larson C, Varecka T, Kyle RF.
Clin Orthop Relat Res. 1997 Jun;(339):65-70. PMID: 9186202 (Link to Abstract)
Templeman, CORR 1997
Average 3.0 of 25 Ratings
A 27-year-old female sustains a twisting injury to her leg while rollerblading. Radiographs of the tibia and fibula are provide in Figures A and B. A closed reduction is performed and the patient is placed in a long leg cast. Radiographs following cast placement are provided in Figures C and D. The decision is made to proceed with closed treatment instead of operative. Which of the following is most likely to occur with nonoperative management?
Malunion due to unacceptable coronal alignment
Malunion due to unacceptable sagittal alignment
Fracture displacement due to the mechanism of injury
Fracture displacement due to the age of the patient
Shortening due to the oblique nature of the tibia fracture
The radiographs demonstrate a distal third spiral tibia shaft with a proximal fibula fracture. The coronal and sagittal alignments are within acceptable limits. The oblique fracture is at risk of shortening, especially with a concomitant fibular fracture.
Acceptable alignment for non-operative treatment of tibia fractures is defined as:
<5 degrees varus-valgus angulation,
<10 degrees anterior/posterior angulation
>50% cortical apposition
<1 cm shortening
< 10 degrees rotational alignment
Sarmiento et al. reviews fracture bracing for the treatment of long bones. With reference to tibial fractures, bracing is best for transverse fractures. Shortening is difficult to control in oblique fractures. However, shortening is usually less than 15 mm and does not result in functional limitations. He reports union in 97% of tibial fractures treated with bracing.
One year follow-up radiographs are provided in Illustrations A and B. The patient presented in this question went on to functional healing.
Sarmiento A, Latta LL.
J Am Acad Orthop Surg. 1999 Jan;7(1):66-75. PMID: 9916190 (Link to Abstract)
Sarmiento, JAAOS 1999
Average 3.0 of 48 Ratings
A 45-year-old female pedestrian is hit by an automobile. A clinical photo and radiograph are shown in Figure A and B. What is the most important factor in a surgeon's decision of determining between limb salvage and amputation?
Level of education
Lack of plantar sensation
Contralateral lower extremity open fracture(s)
Severity of soft tissue injury
Amount of tibial bone loss
The clinical photo and radiograph are consistent with a Grade III open tibia fracture.
The referenced study by the LEAP group reviews 527 patients with severe lower extremity fractures and found that the most important factor in determining the ability to salvage the extremity remains the severity of the soft tissue injury of that extremity. Bone loss has been shown to have no effect on the eventual outcome (amputation versus salvage). Similarly, plantar sensation at presentation has no bearing on final outcome, and in the LEAP study, often either partially or fully returned.
MacKenzie EJ, Bosse MJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, Sanders R, Jones AL, McAndrew MP, Patterson B, McCarthy ML, Rohde CA.
J Trauma. 2002 Apr;52(4):641-9. PMID: 11956376 (Link to Abstract)
MacKenzie, JTACS 2002
Average 4.0 of 29 Ratings
Which of the following nonunions is appropriately treated with exchange reamed nailing without bone graft augmentation?
Infected tibial shaft nonunion 6 months status post intramedullary nail fixation
Oligotrophic humeral shaft nonunion 7 months status post non-operative management
Hypertrophic tibial shaft nonunion 7 months status post intramedullary nail fixation
Comminuted open tibial shaft nonunion with segmental bone loss 8 months status post intramedullary nail fixation
Supracondylar femoral shaft nonunion 6 months status post intramedullary nail fixation with 4 distal locking screws
Exchange nailing is indicated for nonunions of diaphyseal femoral and tibia fractures in the absence of infection, comminution, or segmental bone loss. Hypertrophic nonunions need better stability (increased nail diameter) to achieve union. Where as atrophic nonunions often need better biology (bone graft, flap coverage, etc.)
The referenced article by Brinker et al reviews the indications for exchange nailing. They argue, on the basis of the available literature, that exchange nailing is an excellent choice for aseptic nonunions of noncomminuted diaphyseal femoral and tibia fractures.
Zelle et al. demonstrated 95% success with reamed exchange nailing for the treatment of aseptic tibial shaft nonunions that were initially treated with nonreamed intramedullary nailing.
Brinker MR, O'Connor DP.
J Bone Joint Surg Am. 2007 Jan;89(1):177-88. PMID: 17200326 (Link to Abstract)
Brinker, JBJS 2007
Zelle BA, Gruen GS, Klatt B, Haemmerle MJ, Rosenblum WJ, Prayson MJ.
J Trauma. 2004 Nov;57(5):1053-9. PMID: 15580032 (Link to Abstract)
Zelle, JTACS 2004
Average 4.0 of 20 Ratings
A 21-year-old male sustains the open injury shown in Figure A, which is associated with a 12 centimeter laceration over the fracture site. This laceration is able to be closed during initial surgery. What adjunct treatment has been shown to improve outcomes when using an intramedullary nail?
Adjunctive fracture plating
Antibiotic impregnated cement beads
rhBMP-2 has been shown in two randomized controlled studies to have improved clinical outcomes in grade III open tibial fractures.
Swiontkowski et al and Govender et al have shown in two separate clinical studies that use of this product has: significantly fewer invasive interventions (e.g., bone-grafting and nail exchange), significantly faster fracture-healing than did the control patients, increased healing (union) rates, fewer hardware failures, fewer infections, and faster wound-healing (83% compared with 65% had wound-healing at six weeks).
Swiontkowski MF, Aro HT, Donell S, Esterhai JL, Goulet J, Jones A, Kregor PJ, Nordsletten L, Paiement G, Patel A.
J Bone Joint Surg Am. 2006 Jun;88(6):1258-65. PMID: 16757759 (Link to Abstract)
Swiontkowski, JBJS 2006
Govender S, Csimma C, Genant HK, Valentin-Opran A, Amit Y, Arbel R, Aro H, Atar D, Bishay M, Börner MG, Chiron P, Choong P, Cinats J, Courtenay B, Feibel R, Geulette B, Gravel C, Haas N, Raschke M, Hammacher E, van der Velde D, Hardy P, Holt M, Josten C, Ketterl RL, Lindeque B, Lob G, Mathevon H, McCoy G, Marsh D, Miller R, Munting E, Oevre S, Nordsletten L, Patel A, Pohl A, Rennie W, Reynders P, Rommens PM, Rondia J, Rossouw WC, Daneel PJ, Ruff S, Rüter A, Santavirta S, Schildhauer TA, Gekle C, Schnettler R, Segal D, Seiler H, Snowdowne RB, Stapert J, Taglang G, Verdonk R, Vogels L, Weckbach A, Wentzensen A, Wisniewski T.
J Bone Joint Surg Am. 2002 Dec;84-A(12):2123-34. PMID: 12473698 (Link to Abstract)
Govender, JBJS 2002
Percutaneous placement of a lateral proximal tibial locking plate that extends down to the distal third of the leg is associated with postoperative decreased sensation of which of the following distributions?
First dorsal webspace
Placement of long lateral tibial plates have been shown to have a risk of iatrogenic injury to the superficial peroneal nerve, which has a sensory distribution to the dorsal foot. This risk is seen especially with percutaneous approaches, such as those used with the LISS plate.
The first reference by Deangelis et al found a risk of superficial peroneal injury with percutaneous screw placement of holes 11-13 in the LISS plate.
The second referenced article by Roberts et al noted a slightly increased distance to the neurovascular bundle when interlocking tibial nails in a lateral to medial direction (compared to medial to lateral locking) and slightly increased biomechanical strength when locking in a medial to lateral direction.
The third referenced article by Wolinsky et al notes a risk of iatrogenic injury to the deep peroneal nerve and anterior tibial artery with an anterolateral approach to the distal tibia, but notes the superficial peroneal nerve is safe with an appropriate exposure.
Wolinsky P, Lee M
J Orthop Trauma. 2008 Jul;22(6):404-7. PMID: 18594305 (Link to Abstract)
Wolinsky, JOT 2008
Average 4.0 of 23 Ratings
Which of the following types of nonunions is most likely to achieve union following a reamed exchange intramedullary nailing only?
Distal femoral nonunion with less than 10% bone loss
Infected nonunion of the femoral shaft
Mid-diaphyseal humeral nonunion with less than 10% bone width loss
Proximal humeral shaft nonunion with less than 10% bone width loss
Diaphyseal tibial shaft nonunion with less than 30% cortical width bone loss
Reamed exchange intramedullary nailing of diaphyseal tibial shaft fractures in which there is less than 30% of cortical bone loss can achieve union rates ranging between 76%-96%.
In a review article, Brinker et al discusses the indications and limitations of exchange nailing of ununited fractures. Biological as well as mechanical factors contribute to the healing of nonunions. Anatomically, multiple studies cited in this review article demonstrate that distal femoral nonunions do not readily achieve union following exchange nailing. Humerus nonunions, both diaphyseal and proximal locations, more readily achieve union with plate fixation and bone grafting according to articles cited in this review as well.
Banaszkiewicz et al also discusses the difficulties with exchange nailing of femoral nonunions with a large percentage of patients requiring additional surgeries to achieve union.
Templeman et al discusses the successful results of reamed exchange intramedullary nailing of delayed union and nonunion of the tibial shaft. The authors recommend the use of bone graft only when there is substantial bone loss, usually exceeding 30% of the cortical diameter.
Banaszkiewicz PA, Sabboubeh A, McLeod I, Maffulli N.
Injury. 2003 May;34(5):349-56. PMID: 12719163 (Link to Abstract)
Banaszkiewicz, INJURY 2003
Templeman D, Thomas M, Varecka T, Kyle R.
Clin Orthop Relat Res. 1995 Jun;(315):169-75. PMID: 7634665 (Link to Abstract)
Templeman, CORR 1995
Average 2.0 of 36 Ratings
A 32-year-old male sustains the injury shown in Figure A and undergoes treatment as shown in Figure B. Following placement of this implant, what is the best technique to confirm it is not too proud proximally?
Lateral radiograph of the knee
AP radiograph of the knee
Oblique radiographs of the knee
Merchant radiograph of the knee
Internally rotated 45 degree view of the knee
The safe zone for tibial nail placement as seen on radiographs is just medial to the lateral tibial spine on the anteroposterior radiograph and immediately adjacent and anterior to the articular surface as visualized on the lateral radiograph.
Tornetta et al specifically located the safe zone for nail entry in a study using fresh frozen cadaver knees. The authors found that the safe zone for nail placement is located 9.1+/-5 millimeters lateral to the midline of the plateau and three millimeters lateral to the center of the tibial tubercle. The width of the safe zone averaged 22.9 millimeters and was as narrow as 12.6 millimeters.
The starting point of the of the nail can be best viewed on the lateral knee radiograph, an example of which is shown in Illustration A. Illustration B shows the "sweet spot" for nail insertion as defined by Tornetta.
Tornetta P 3rd, Riina J, Geller J, Purban W.
J Orthop Trauma. 1999 May;13(4):247-51. PMID: 10342349 (Link to Abstract)
Tornetta, JOT 1999
Average 3.0 of 24 Ratings
Which of the following factors has been shown in a clinical trial to be equivalent to autologous bone graft for treatment of tibial nonunions that were treated with intramedullary nailing?
Demineralized bone matrix
Cancellous bone allograft chips
Osteogenic Protein-1 (OP-1), which is also known as BMP-7, has been evaluated in a randomized, prospective, multi-institution study of tibial nonunions.
Between 5% to 10% of tibial shaft fractures progress to nonunion, causing substantial disability. Bone autografts, along with internal fixation, are the usual treatment for these failures, but the morbidity associated with autogenous tissues remains problematic. Bone morphogenetic proteins are currently available for clinical use and preclinical models, and an increasing number of patients treated with these molecules demonstrate their safety and efficacy.
Friedlaender et al studied BMP-7 (Osteogenic Protein-1 or OP-1) in a randomized, prospective, multi-institution study of tibial nonunions. Clinical and radiographic outcomes were statistically indistinguishable at 9 months following treatment and OP-1 avoided donor site morbidity.
Swiontkowski et al performed a level I study of patients with acute open tibial fractures randomized to treatment with or without rhBMP-2. Interestingly, in their subgroup analysis the authors found no significant difference between the two groups when patients were treated with reamed intramedullary nailing.
It should be noted, however, that there is more recent evidence supporting the use of BMP-2 in the treatment of tibial nonunions and this may change the focus of boards and OITE questions in the future.
Friedlaender GE, Perry CR, Cole JD, Cook SD, Cierny G, Muschler GF, Zych GA, Calhoun JH, LaForte AJ, Yin S.
J Bone Joint Surg Am. 2001;83-A Suppl 1(Pt 2):S151-8. PMID: 11314793 (Link to Abstract)
Friedlaender, JBJS 2001
A 45-year-old male presents with the fracture seen in Figures A and B after a motor vehicle collision. After debridement and external fixation, he is taken to the operating room for definitive soft tissue flap coverage and intramedullary nailing. Administration of recombinant human Bone Morphogenetic Protein-2 (rhBMP-2) at the time of fracture fixation will lead to which of the following?
Decreased risk of subsequent bone grafting procedures
Shorter hospital stay
Increased blood loss
Decreased risk of angular deformity at final union
Increased risk of deep vein thrombosis
Administration of rhBMP-2 at the time of definitive fixation has been shown to decrease the need for subsequent bone grafting procedures in Gustilo-Anderson type IIIA and IIIB open tibia fractures.
Swiontkowski et al performed a subgroup analysis of two prospective randomized control studies regarding the use of rhBMP-2 in open tibia fractures. The authors found a significant risk reduction in the need for secondary procedures, including bone grafting, with the addition of rhBMP-2 for type IIIA and IIIB open tibia fractures.
Govender et al performed a randomized prospective RCT of 450 patients with open tibia fractures allocated to tibia nailing or nailing with one of 2 different dosages of rhBMP-2. They found a 44% reduction in the need for secondary intervention as a result of delayed union, better wound healing, and decreased infection in the higher dose rhBMP-2 group compared to controls.
Figure A demonstrates a severe soft tissue injury associated with an open tibia fracture. Figure B demonstrates a segmental tibial shaft fracture with an associated fibula fracture.
Average 4.0 of 19 Ratings
A 30-year-old man presents with a distal third tibia fracture that has healed in 25 degrees of varus alignment. The patient is at greatest risk of developing which of the following conditions as a result of this malunion?
Degenerative lumbar spine changes
Ipsilateral ankle pain and stiffness
Ipsilateral hip joint degenerative changes
Contralateral hip joint degenerative changes
Ipsilateral medial knee degenerative changes
A significant malunion of the distal tibia has important consequences for patient outcome, including pain, gait changes, and cosmesis.
The first referenced article by Milner et al looked at long-term outcomes of tibial malunions and noted that varus malunion led to increased ankle/subtalar stiffness and pain regardless of the amount of radiographic degenerative changes.
The second referenced article by Puno et al reinforced the concept of decreased functional outcomes of the ankle with tibial malunions, and noted that other lower extremity joints (ipsilateral and contralateral) do not have increased rates of degeneration from such a malunion.
Puno RM, Vaughan JJ, Stetten ML, Johnson JR.
J Orthop Trauma. 1991;5(3):247-54. PMID: 1941305 (Link to Abstract)
Puno, JOT 1991
Milner SA, Davis TR, Muir KR, Greenwood DC, Doherty M.
J Bone Joint Surg Am. 2002 Jun;84-A(6):971-80. PMID: 12063331 (Link to Abstract)
Milner, JBJS 2002
A 25-year-old man is struck by car while crossing the street. His injuries include the closed left tibial shaft fracture shown in Figure A. He is a smoker, but is otherwise healthy. Intramedullary nailing is performed without initial complications. Which of the following puts this patient at greatest risk for tibial nonunion?
Use of anti-inflammatories post-operatively
Post-operative gapping at the fracture site
Presence of an associated fibular fracture
History of smoking
Mechanism of injury
Post-operative gapping at the fracture site significantly increased the risk of reoperation due to nonunion or malunion.
Bhandari et al performed a retrospective study to identify which prognostic factors were associated with an increased risk of reoperation for nonunion in surgically treated tibial shaft fractures. They examined over 200 fractures, and found the presence of an open fracture wound (RR 4.32), lack of cortical continuity between the fracture ends following fixation (RR 8.33), and the presence of a transverse fracture (RR 20.0) were the three variables most predicitive of reoperation.
Audige et al analyzed 416 patients with operatively treated tibial shaft fractures who were followed for at least 6 months. They found that the greatest risk for delayed healing or nonunion was the presence of an open injury, fractures of the distal 1/3 of the tibia, and postoperative gapping at the fracture site (The risk of healing problems was doubled for fractures of the distal shaft and for fractures showing a postoperative diastasis).
Audigé L, Griffin D, Bhandari M, Kellam J, Rüedi TP.
Clin Orthop Relat Res. 2005 Sep;438:221-32. PMID: 16131895 (Link to Abstract)
Audigé, CORR 2005
Bhandari M, Tornetta P 3rd, Sprague S, Najibi S, Petrisor B, Griffith L, Guyatt GH.
J Orthop Trauma. 2003 May;17(5):353-61. PMID: 12759640 (Link to Abstract)
Bhandari, JOT 2003
A 25-year-old male is a driver in a motor vehicle accident and sustains the isolated closed injury seen in Figures A and B. He is treated with an intramedullary nail, and postoperative radiographs are shown in Figures C and D. Which of the statements concerning reaming and nails is true?
Unreamed tibias have the highest amount of mineral apposition rates
Reamed tibias result in the highest amount of new bone formation
Unreamed nails result in the lowest porosity of bone
Reamed and unreamed tibias have similar mineral apposition rates
Tight nails results in higher cortical reperfusion than loose nails
The patient in the scenario has a closed distal one-third tibia fracture. Canal reaming increases the biologic environment for fracture healing but can potentially disrupt cortical blood flow. As such, many recommend canal reaming 1-2mm greater than the canal width followed by insertion of a nail that matches the native canal width. Reamed and unreamed tibias have similar mineral apposition rates.
In 1998, Hupel et al studied the effect of loose and tight unreamed, locked nails on cortical blood flow and strength of union in a canine model. They found that loose nails allowed higher cortical reperfusion at the time of insertion and at eleven weeks.
In a later study by the same group in 2001, they studied the effect of non-reamed, limited reamed and standard reamed nails on porosity, new bone formation and mineral apposition. They found the lowest porosity in the limited reaming group but found new bone formation and mineral apposition rates similar at eleven weeks across the three groups. They concluded that limited reaming is preferred in patients with vascular compromise to the tibia.
Hupel TM, Aksenov SA, Schemitsch EH.
J Orthop Trauma. 1998 Feb;12(2):127-35. PMID: 9503303 (Link to Abstract)
Hupel, JOT 1998
Hupel TM, Weinberg JA, Aksenov SA, Schemitsch EH.
J Orthop Trauma. 2001 Jan;15(1):18-27. PMID: 11147683 (Link to Abstract)
Hupel, JOT 2001
Average 1.0 of 70 Ratings
What percentage of patients will complain of knee pain at the time of union of a tibial shaft fracture treated with a reamed intramedullary nail?
Anterior knee pain is the most common complication after intramedullary nailing of the tibia. Dissection of the patellar tendon and its sheath during transtendinous nailing was thought to be a contributing cause of chronic anterior knee pain.
The referenced paper by Toivanen et al. compared two different nail-insertion techniques in 50 patients who were randomized to treatment with paratendinous or transtendinous nailing. Sixty-seven percent of the transtendinous and seventy-one percent of the paratendinous approaches resulted in patients with postoperative anterior knee pain. The same authors published an 8 year follow-up which showed that the percentage dropped down to 29%, but there was still no advantage of paratendinous over the transtendinous approach.
In the more recent study by Lefaivre with an average patient follow up of 14 years, knee pain was present in greater than 70% of the respondents.
Toivanen JA, Väistö O, Kannus P, Latvala K, Honkonen SE, Järvinen MJ.
J Bone Joint Surg Am. 2002 Apr;84-A(4):580-5. PMID: 11940618 (Link to Abstract)
Toivanen, JBJS 2002
Väistö O, Toivanen J, Kannus P, Järvinen M.
J Trauma. 2008 Jun;64(6):1511-6. PMID: 18545115 (Link to Abstract)
Väistö, JTACS 2008
Lefaivre KA, Guy P, Chan H, Blachut PA.
J Orthop Trauma. 2008 Sep;22(8):525-9. PMID: 18758282 (Link to Abstract)
Lefaivre, JOT 2008
Average 2.0 of 58 Ratings
A 36-year-old male is brought to the trauma center following a motor vehicle accident. Physical exam shows a deformed left lower extremity with a 1-cm open wound over the anterolateral aspect of his leg. Radiographs are provided in Figures A and B. Which of the following interventions has been shown in the literature to decrease the occurrence of infection at the fracture site?
Operative debridement within 6 hours of injury
Immediate prophylactic antibiotic administration
Immediate stabilization with internal fixation after debridement
Irrigating with a saline solution that is mixed with an antibiotic
Irrigating with high pressure pulsatile lavage following surgical debridement
The clinical scenario and radiographs are consistent with a Gustilo and Anderson type 3A open tibia fracture.
Melvin et al review the evidenced-based literature and make recommendations for the initial evaluation and management of open tibial shaft fractures. The time elapsed before antibiotic administration and adequate surgical debridement of all contamination are the only factors definitively shown to reduce infection and improve outcome. Traditional recommendations have suggested surgical debridement of open fractures occur within 6 hours of injury. However, there is no literature to support this time window. Certainly, open fractures should be addressed with urgency, but there is no evidence reporting a definitive time window. There is insufficient data to recommend gram negative coverage with gentamicin for all open fractures although this is a common practice. The addition of antibiotics to the irrigation solution has been shown to decrease bacterial load, but it has also demonstrated host tissue necrosis and delayed wound healing. There is not sufficient data to support its use over a castile soap solution or normal saline. Similarly, high pressure pulsatile lavage decreases bacterial load, but also seeds bacteria deeper within the soft tissues and harms host tissues. There is no evidence to support pulsatile lavage over gravity flow.
Melvin JS, Dombroski DG, Torbert JT, Kovach SJ, Esterhai JL, Mehta S
J Am Acad Orthop Surg. 2010 Jan;18(1):10-9. PMID: 20044487 (Link to Abstract)
Melvin, JAAOS 2010
When discussing treatment options with a 35-year-old healthy male with an isolated, closed tibial shaft fracture, the surgeon should inform him that in comparison to closed treatment, the advantages of intramedullary nail fixation include all of the following EXCEPT?
Quicker time to union
Decreased risk of malunion
Decreased risk of compartment syndrome
Decreased risk of shortening
Quicker return to work
All of the answer choices are correct except #3. Intramedullary nailing can increase the risk of compartment syndrome.
In a study of 94 tibial fractures, Finkemeier reported 10 (11%) had compartment syndromes. Three of the 10 patients developed the compartment syndrome postoperatively.
In comparing IM nailing to non-op, Bone et al showed that IM nailing had a shorter time to union (mean, 18 vs 26 weeks; p = 0.02), lower non-union rate (2% vs 10%), decreased incidence of shortening (2% vs 27%), and quicker return to work (mean, 4 vs 6.5 months), but no difference in compartment syndrome (0% in both groups).
The classic article cited by Sarmiento el al. reported that closed treatment with use of a prefabricated functional below-the-knee brace was effective in a study of 1000 closed diaphyseal fractures of the tibia with an incidence of nonunion of only 1.1%. However, those authors had very strict criteria for use of the fracture-brace (exclusion criteria included intact fibula and tibial shortening >2cm).
Bone LB, Sucato D, Stegemann PM, Rohrbacher BJ.
J Bone Joint Surg Am. 1997 Sep;79(9):1336-41. PMID: 9314395 (Link to Abstract)
Bone, JBJS 1997
Sarmiento A, Sharpe FE, Ebramzadeh E, Normand P, Shankwiler J.
Clin Orthop Relat Res. 1995 Jun;(315):8-24. PMID: 7634690 (Link to Abstract)
Sarmiento, CORR 1995
Finkemeier CG, Schmidt AH, Kyle RF, Templeman DC, Varecka TF
J Orthop Trauma. 2000 Mar-Apr;14(3):187-93. PMID: 10791670 (Link to Abstract)
Finkemeier, JOT 2000
Average 3.0 of 21 Ratings
A 30-year-old patient sustains a comminuted tibia fracture and is treated with minimally invasive plating, shown in Figure A. The patient returns to the office 2 weeks after the surgery and reports persistent numbness over most of the dorsum of the foot, but motor exam is normal. What is the most likely explanation?
unrecognized compartment syndrome
common peroneal nerve injury
superficial peroneal nerve injury
sural nerve injury
tibial nerve injury
Superficial peroneal nerve (SPN) injury is a known complication of percutaneous plating of proximal tibial fractures with the LISS system as seen in Figure A.
The Less Invasive Stabilization System (LISS) is a minimally invasive implant that uses indirect fracture reduction techniques. When using the LISS system, percutaneous screw placement increases the risk of injury to nearby structures because they are not necessarily visualized. The superficial peroneal nerve exits the superficial fascia of the leg approximately 8 cm above the tip of the lateral malleolus. The nerve then travels from posterior to anterior in the vicinity of the distal aspect of the 13-hole proximal tibia LISS plate (near holes 11-13). In a patient of shorter stature, the nerve could cross the distal portion of a 9-hole plate.
Deangelis et al. performed a cadaveric study using Less Invasive Stabilization System (LISS) plates and found that the average distance from the SPN to the center of holes 11, 12, and 13 was 10.0 mm, 6.8 mm, and 2.7 mm respectively. They recommended using a larger incision and careful dissection down to the plate in this region to minimize the risk of damage to the nerve.
Cole et al. retrospectively reviewed 77 tibia fractures treated with LISS and found that 91% healed without complication. In their cohort, there were no superficial peroneal nerve palsies and one deep peroneal nerve palsy.
Figure A demonstrates AP and lateral x-rays of a tibial shaft fracture treated with a LISS plate.
A: compartment syndrome would have demonstrated pain out of proportion which the patient never complains of
B, D, and E are all less likely to be injured with LISS plate application than the superficial peroneal nerve.
Cole PA, Zlowodzki M, Kregor PJ.
J Orthop Trauma. 2004 Sep;18(8):528-35. PMID: 15475848 (Link to Abstract)
Cole, JOT 2004
Average 3.0 of 16 Ratings
Intramedullary nailing of proximal tibial shaft fractures are technically demanding, and use of an extended medial parapatellar incision with a semiextended technique can prevent what common deformity at the fracture site?
Valgus and flexion is the most common deformity seen after intramedullary nailing of proximal tibia fractures. The semi-extended nailing position helps overcome the procurvatum or flexion deformity of the fracture.
Lang et al. reported in their study of 32 proximal third tibia fractures that 56% of the fractures had 5 degrees or more valgus angulation and 28% had 10 degrees or more valgus angulation. Angulation in the AP plane ranged from 0 degrees to 20 degrees, all of which was apex anterior. Nineteen (59%) fractures demonstrated 5 degrees or more angulation, and 7 (22%) fractures demonstrated 10 degrees of more angulation.
Tornetta advocates use of extended medial parapatellar incision with the leg in a semiextended position to allow for a more proximal and lateral starting point. This modified starting point forces the nail to overcome the tendency of the fracture to flex (apex anterior) and go into valgus.
Lang GJ, Cohen BE, Bosse MJ, Kellam JF.
Clin Orthop Relat Res. 1995 Jun;(315):64-74. PMID: 7634688 (Link to Abstract)
Lang, CORR 1995
Tornetta P 3rd, Collins E.
Clin Orthop Relat Res. 1996 Jul;(328):185-9. PMID: 8653954 (Link to Abstract)
Tornetta, CORR 1996
A 35-year-old male has a closed mid-shaft tibia fracture following a skiing accident. You have recommended intramedullary nailing of the tibia. What is the most common complication he must be advised about?
anterior knee pain
Chronic anterior knee pain at the insertion site is the most common frequently reported complication of closed nailing of a tibial shaft fracture. A high incidence of knee pain has been associated with IM nailing. The etiology of anterior knee pain remains unclear. It had been previously thought that the incidence of pain is higher when the nail was inserted by a patellar tendon-spliting approach versus a paratendon approach. According to the Keating paper, insertion of the nail through the patella tendon was associated with a higher incidence of knee pain compared to the paratendon site of nail insertion (77% and 50% respectively). Toivanen et al. investigated this question when the group randomized fifty patients with a tibial shaft fracture requiring intramedullary nailing equally to treatment with paratendinous or transtendinous nailing. Fourteen (67%) of the twenty-one patients treated with transtendinous nailing reported anterior knee pain at the final evaluation. Of these fourteen patients, thirteen were mildly to severely impaired by the pain. Fifteen (71%) of the twenty-one patients treated with paratendinous nailing reported anterior knee pain, and ten of the fifteen were impaired by the pain. The Lysholm, Tegner, and Iowa knee scoring systems; muscle-strength measurements; and functional tests showed no significant differences between the two groups. Compared with a transpatellar tendon approach, a paratendinous approach for nail insertion does not reduce the prevalence of chronic anterior knee pain or functional impairment by a clinically relevant amount after intramedullary nailing of a tibial shaft fracture.
Keating JF, Orfaly R, O'Brien PJ.
J Orthop Trauma. 1997 Jan;11(1):10-3. PMID: 8990026 (Link to Abstract)
Keating, JOT 1997
Average 4.0 of 17 Ratings
A 40-year-old woman is involved in motorcycle accident 2 hours ago and sustains an isolated right leg injury shown in Figure A. She has dopplerable posterior tibial and dorsalis pedis artery signals with less than 2 second capillary refill as shown in Figure B. Sensation is intact in the distribution of the tibial nerve but decreased in the distribution of the peroneal nerve. She is cleared by the general surgery trauma team to go to the operating room for treatment of her leg. What is the most appropriate Gustilo classification and initial treatment for her injury?
Gustilo 3A with spanning external fixation and delayed definitive fixation with soft tissue coverage
Gustilo 3A with immediate medial and lateral plating followed by delayed soft tissue coverage
Gustilo 3B with spanning external fixation and delayed definitive fixation with soft tissue coverage
Gustilo 3B with immediate medial and lateral plating followed by delayed soft tissue coverage
Gustilo 3C with spanning external fixation and delayed definitive fixation with soft tissue coverage
The injury described above is a Type IIIB injury as per the Gustilo and Anderson classification. Type I injuries are low energy and have small soft-tissue wounds (usually <1 cm in length) with minimal contamination. Type II injures have a wound >1 cm in length, but do not have extensive soft-tissue damage, flaps, or avulsions. Type IIIA injuries are associated with soft-tissue damage secondary to high-energy trauma but have adequate soft-tissue coverage. Type IIIB injures exhibit severe periosteal stripping and bone exposure, often associated with massive contamination. These often require treatment with soft-tissue coverage procedures. Type IIIC fractures require vascular repair. The risk for infection in this scenario is as high as 44%, so placing definitive plate fixation is contraindicated when future debridement and soft tissue coverage procedures will be needed. External fixation provides excellent stability, provisional skeletal alignment, and minimal additional soft tissue injury.
Average 4.0 of 21 Ratings
A 56-year-old male sustains a Type IIIB open, comminuted tibial shaft fracture distal to a well-fixed total knee arthroplasty that is definitively treated with a free flap and external fixation. Nine months after fixator removal, he presents with a painful oligotrophic nonunion. Laboratory workup for infection is negative. Passive knee range of motion is limited to 15 degrees. What is the most appropriate treatment for his nonunion?
Knee manipulation under anesthesia
Cast immobilization and use of a bone stimulator
Unilateral external fixation
At 9 months, observation is no longer an option, as the fracture is not healing and is adjacent to a arthrofibrotic joint. Plate osteosynthesis has been shown to be an effective method of treatment for patients who have had an open fracture of the tibia that has failed to unite after external fixation and/or immobilization in a cast.
Wiss et al reported a series of fifty tibial non-unions with a similar clinical scenario. He reported that, with compression plating, 92% of the nonunions healed without further intervention. In their study, 39/50 patients, had autogenous bone grafting in addition to compression plating.
Wiss DA, Johnson DL, Miao M.
J Bone Joint Surg Am. 1992 Oct;74(9):1279-85. PMID: 1429783 (Link to Abstract)
Wiss, JBJS 1992
Average 3.0 of 22 Ratings
A 32-year-old male sustains the closed injury shown in Figure A. He undergoes reamed intramedullary nailing 4 hours after his injury. Postoperative images are shown in Figures B and C. Compared to unreamed nailing, reamed nailing of this injury has been associated with which of the following?
Decreased infection rate
Increased need for additional surgeries to obtain union
Increased infection rates
Decreased time to union
Increased compartment syndrome rate
Reamed nailing of closed tibial shaft fractures has been shown to lead to an earlier time to union without an increased rate of complications when compared to unreamed nailing.
The referenced study by Finkenmeier et al is a randomized controlled study of reamed vs. unreamed nails in open and closed tibia fractures (excluding Grades IIIB and IIIC). They found that the use of reamed insertion of IM nails for the treatment of closed tibia fractures lead to an earlier time to union without increased complications. The authors reported no differences in infection rate, compartment syndrome rate, or percent needing additional surgeries to obtain union. More secondary procedures were needed with unreamed nails in closed fractures only. Increased rates of interlocking screw failure were seen if smaller screws were needed for smaller, unreamed nails.
The referenced study by Keating et al reported that reaming for open tibia fractures is safe, with time to union and nonunion rate increasing with increased soft tissue injury as classified by the Gustilo-Anderson classification.
Bhandari et al conducted a multicenter, blinded randomized trial of 1319 adults in whom a tibial shaft fracture was treated with either reamed or unreamed intramedullary nailing. When comparing outcomes in open and closed injuries at twelve months, they found a benefit for reamed intramedullary nailing in patients with closed fractures, but found no difference between approaches in patients with open fractures.
Figure A shows a tibial shaft fracture, with intramedullary fixation shown in Figures B and C.
Keating JF, O'Brien PI, Blachut PA, Meek RN, Broekhuyse HM.
Clin Orthop Relat Res. 1997 May;(338):182-91. PMID: 9170379 (Link to Abstract)
Keating, CORR 1997
Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures Investigators, Bhandari M, Guyatt G, Tornetta P 3rd, Schemitsch EH, Swiontkowski M, Sanders D, Walter SD.
J Bone Joint Surg Am. 2008 Dec;90(12):2567-78. PMID: 19047701 (Link to Abstract)
Study, JBJS 2008
Average 2.0 of 48 Ratings
Which of the following tibial injuries is most commonly treated with staged open reduction and internal fixation with free flap soft tissue reconstruction?
Type IIIB intra-articular distal tibia fracture
Type IIIB segmental midshaft tibia fracture
Type IIIB transverse midshaft tibia fracture
Type IIIB Schatzker I proximal tibia fracture
Type IIIC Schatzker IV proximal tibia fracture
By definition, with Type IIIB injuries, there is exposed bone after debridement which will require a local or a free flap for coverage. Distal third IIIB tibial shaft fracture are unique in that they usually require a free flap or reverse sural rotational flap to obtain adequate coverage. As stated in Skeletal Trauma, "As local donor muscles in the distal third of the tibia are almost non-existent, closure of an open plafond fracture, or any extensive Type IIIB injury in this area will usually require free tissue transfer. The primary options are latissimus dorsi or rectus abdominus for large defects, and gracilis for smaller wounds." In addition to the flaps mentioned here, others, including fasciocutaneous flaps and radial forearm flaps, are also utilized with success in this area.
Typically, treatment of Type IIIB tibial shaft fractures should be staged. Initially tetanus prophylaxis, antibiotics with gram negative and positive coverage, and application of an external fixator with repeat I&D’s are employed for immediate fracture care. Plating is usually required in the presence of significant intra-articular fracture involvement.
Incorrect Answers: Typically, proximal third tibia fractures requiring soft tissue coverage can be treated with a gastrocnemius rotation flap and middle third tibia fractures with soft tissue defects can be reliably covered with a soleus rotation flap. Therefore, a free flap is less commonly indicated in the proximal and middle tibia.
Average 4.0 of 41 Ratings
A 42-year-old male sustains a left leg injury as the result of a high-speed motor vehicle collision. Physical exam reveals a grossly deformed left leg with a 1 centimeter open wound over the anterolateral aspect of his tibia; no gross neurovascular deficits are noted. Injury radiographs are shown in Figures A and B. He undergoes immediate tibial nailing with debridement and primary closure of his traumatic wound. Which of the following is the Gustilo-Anderson classification for his fracture?
Figures A and B show a significantly comminuted, segmental tibial fracture. In this scenario, the fracture is appropriately classified as a Grade III because there is a highly comminuted, segmental fracture which is always associated with significant periosteal stripping. The patient's leg was able to be closed primarily, which means that it should be classified as a IIIA.
Gustilo et al reviews 18 years of open fracture treatment and outcomes. They reported that débridement and copious irrigation, with primary closure for type I and II fractures and secondary closure for type III fractures resulted in a 5% infection rate (9% for type III fractures). Initial wound cultures were positive in 70.3% despite an infection rate of that patient group of only 2.5%.
Answer 1: Gustilo Type I wounds have a clean skin lesion that are < 1 cm, and a simple fracture with minimal comminution.
Answer 2: Gustilo Type II wounds have a skin lesion > 1 cm, no extensive soft tissue damage, minimal crushing, and moderate comminution and contamination.
Answer 4: Gustilo Type IIIB are defined as wounds that require a flap for salvage.
Answer 5: Gustilo Type IIIC have an exposed fracture with arterial damage that requires repair.
Gustilo RB, Anderson JT
J Bone Joint Surg Am. 1976 Jun;58(4):453-8. PMID: 773941 (Link to Abstract)
Gustilo, JBJS 1976
Average 3.0 of 53 Ratings
HPI - 20 male patient presents following a segmented tibial fracture, sustained in a motorcycle accident 1 year ago.
The fracture was treated with ORIF with plate and screws at another institution (XRays shown).
The patient had skin problems with exposed plate at approximately 8 months post-op
I removed the plates on the tibia and one fibula plate for dynamization and I used a monolateral external fixator.
Now, the skin and bone look like this after 2 months due to surgery.
How would you suggest managing this patient?
HPI - Pain in the upper leg for the past 10 days, severe pain which increases with activity, not relieved by rest.
History of fracture 2.5 years ago for which surgery was done (at an outside hospital) and recovery was quite uneventful.
Patient now has suddenly developed this problem.
What is the next best step in management?
HPI - Road traffic accident.
Isolated leg trauma.
What is best treatment option for this patient?
HPI - Fall whilst intoxicated
Underwent ORIF fibula by another surgeon on day on injury in attempt to get the limb out to length - complexity of fibula fracture resulted in approx. 1.5cm shortening and malrotation.
Would you plan to re-reduce and fix the fibula as part of your definitive management?
HPI - Injury to left leg with a grinder wheel.
What is the best treatment for this patient?
HPI - 54 yo non-smoker, relatively healthy host who is 2 years out from open distal tibia fracture treated IMN with five months of “wound vac” for open wound by private doc in town. After her insurance ran out he stopped seeing her despite having a vac on. She came to us and plastics performed a rotational fasciocutaneous flap which allowed her wound to heal. At two years she had continued pain and broken nail hardware distally with CT proven nonunion with negative laboratory workup for infection (ESR, CRP, WBC). Her wound was healed and has had no drainage after the plastics flap. See X-rays and representative CT scan below.
Surgical plan for this patient's nonunion?
HPI - 24 year old female presents to ER following a motor vehicle accident. She is unable to move her leg or bear weight secondary to pain.
In addition to immediate I&D, how would you manage this patient?
HPI - 03/2016 Patient underwent osteosynthesis of a tibial shaft fracture with intramedullary (IM) nail. The was complicated by post-operative compartment syndrome with fasciotomy, negative pressure wound therapy.
The patient developed a post-operative peroneal nerve palsy and required intensive rehabilitation.
Present condition good with full range of motion, without subjective problems, minimal pain, full restoration of nerve function.
Present X-ray and CT imaging with signs of pseudarthrosis of the fracture. CT and X-ray are shown. progressive osteoporosis !!!!
How would you treat this pseudarthrosis?
HPI - 43M presents to our hospital after being involved in a road traffic accident 3 days ago.
He has an isolated right leg injury with a small opening in the skin (1 cm) on the anteromedial aspect of the middle third of the leg.
What would be your initial management of this patient?
HPI - rotational injury
What is the accepted malrotation and angulation in distal tibial fracture managed by nail?
HPI - o Sudden onset of moderate-to-severe pain the right leg following a mechanical fall from standing
o Presented to the emergency room with isolated pain and deformity in the right leg
o Specifically denied numbness or tingling or pain out of proportion
o Denies pain in other extremities
o Denies loss of consciousness, chest pain or dizziness prior to falll
On initial presentation, would you get any further preop imaging?
HPI - 2 days history of hit by bike . Closed injury
How would you treat this injury?
HPI - Motor vehicular accident 2 months and 10 days ago. Grade I open injury
How would you like to manage this case upon the first visit (before surgery in this instance)?
HPI - MOTORCYCLE ACCIDENT
How would you treat this fracture?
HPI - ski injury
HPI - 1.5 year back RTA. open Fracture tibia fibula ( gustilo information not available) managed by ex fix at some hospital . Later developed osteomyelitis with multiple discharging sinuses.
What further radiologic work-up would you perform?
HPI - 2 wheeler rider - head on collision with a bus - presented to us 8 hours after injury with compound femur fracture and compound tibia fractures on the right side.
Would you approach this patient with a staged approach (provisional fixation with definitive fixation at a later date)?
HPI - started with fever and dicharge of pus from healed suture line for 1 week
Based on the images provided and assuming this is an infected nonunion, how would you treat this patient?
HPI - fall 3days ago from a ladder
HPI - Patient had previous distal tibia fracture treated with a DCP.
Now presented with tibia shaft fracture at proximal end of the plate.
HPI - H/o of RTA on4/4/2014',pt admitted to hospital c/o inability to walk .x ray shows f/x upper tibia.f/x treated with T plate.
What would you do for this patient at the current time with the imaging available?
HPI - 29 yo male wants hardware removed. Minimal to no symptoms, is afraid to participate in sports with plate in.
HPI - Sustained comp grade 3 fracture both bone right leg 3months back.Extetnal fixator was applied flap coverage was done.External fixator was removed 2weeks back
How would you treat this patient at this point?
HPI - Mentally challenged. Came from rehabilitation center with history of epileptic Fitts, followed by fall and sustained trauma to right leg.
HPI - Patient sustained fracture distal 3rd right tibia 1week back.C/R and A/K pop cast was applied.patient developed swelling and blisters and cast had to be removed.blister over the fracture site has almost dried
HPI - The patient sustained a comminuted open gustilo III fracture of the left tibia due to a motorbike accident two and a half months ago. He was operated on an emergency basis. Thorough debridement of the trauma was performed followed by osteosynthesis with a ring external fixation .
What is the best treatment option for this patient?
HPI - 90 y/o unassisted community ambulating female involved in a MVC who presents with isolated, closed tibia fracture.
HPI - case of MVA 2 months ago.sustained a degloving injury with rt tibia fibula fracture.treated in another hospital with external fixator and skin grafting.skin grafting coverage from knee to ankle
HPI - open tibia fx with bone loss 1 year ago treated with ex fix removed after 9 mo (patient didnt refer for f/u)
do you agree with treatmebt?
unfortunately appropriate sized nail was not available
HPI - fall of heavy object on rt leg open wound over the tibia.he was treated by my collegue with external fixator and primary closure of wound after wound debridment.planned a tibial nailing.
How would you treat this tibia fracture?
HPI - RSA 1year back. Type IIIA open segmental tibia fracture with intra-articular extension.. Treated by debridement and external fixator application. Fixator was removed and pop cast was applied. Now patient presented with nonunion and deformity at fracture site.
How would you treat this patient?
HPI - Psychiatric, tried to suicide. Fell down from 3 meters.
HPI - Patient sustained compound grade 3 Segmental fracture right tibia 4 months back.Treated with external fixator and rotational flap.fixator removed about 1 month back.
How would you treat this patient considering the poor soft tissue condition over fracture sight
HPI - 20 yo male s/p 3 close range shotgun blasts. Massive soft tissue loss medially at level of defect. STAT angiogram revealed peroneal artery is only vessel intact to foot. Underwent I&D, bead placement, partial closure and exfix. Patient with good family support, but he is currently unemployed and not college educated. He appears to have poor coping skills.
What would be your next step in treatment?
HPI - Closed tibial fracture with moderate swelling deep ecchymosis
HPI - Motor vehicle accident(3 weeks ago) resulting:
- comminuted proximal tibial fracture with diaphyseal component, transarticular external fixation.
- vascular compromise with popliteal artery injury, Vascular Surgery performed saphenous vein grafting successfully with Plastic Surgery grafting on the medial aspect of the tibia.
How would you definitely treat this injury?
HPI - She has been treated conservatively during 6 months
What is the best treatment?
HPI - h/o inabilty to weight bear on left leg after a twisting injury
operative or casting
HPI - 14 year old 6'2" male presented with a closed tibial shaft fracture on 9/12/13 and no other injuries. Of note his father is 6'1".
HPI - falling from hight ....operated since 5 mounth ....partial wieght bearing with pain
How would you manage this tibia nonunion?
HPI - Fall from standing height 3 months ago
What is the treatment?
HPI - RTA
What method would you use to remove this bone fragment?
HPI - pain inabilty to stand after fall.
operative or conservative