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Introduction
  • Proximal third-tibia fractures 
  • Epidemiology
    • most common long bone fx
    • account for 4% of all fx seen in the Medicare population
  • Mechanism
    • low energy fx pattern
      • result of torsional injury
      • indirect trauma results in spiral fx
      • fibula fx at different level
      • Tscherne grade 0 / I soft tissue injury
    • high energy fx pattern
      • direct forces often result in wedge or short oblique fx and sometimes significant comminution
      • fibula fx at same level
      • severe soft tissue injury
        • Tscherne II / III
        • open fx
  • Associated conditions
    • soft tissue injury (open wounds)
      • critical to outcome
    • compartment syndrome
    • bone loss
    • ipsilateral skeletal injury
      • extension to the tibial plateau or plafond
      • posterior malleolar fracture
        • most commonly associated with spiral distal third tibia fracture
Classification
 
Oestern and Tscherne Classification of Closed Fractuer Soft Tissue Injury
Grade 0 Injuries from indirect forces with negligible soft-tissue damage
Grade I Superficial contusion/abrasion, simple fractures
Grade II
Deep abrasions, muscle/skin contusion, direct trauma, impending compartment syndrome
Grade III
Excessive skin contusion, crushed skin or destruction of muscle, subcutaneous degloving, acute compartment syndrome, and rupture of major blood vessel or nerve
 

Gustilo-Anderson Classification of Open Tibia Fractures
Type I Limited periosteal stripping, clean wound < 1 cm
Type II Mild to moderate periosteal stripping, wound >1 cm in length

Type IIIA Significant soft tissue injury (often evidenced by a segmental fracture or comminution), significant periosteal stripping, wound usually >5cm in length, no flap required 

Type IIIB Significant periosteal stripping and soft tissue injury, flap required due to inadequate soft tissue coverage (STSG doesn't count). Treat proximal 1/3 fxs with gastrocnemius rotation flap, middle 1/3 fxs with soleus rotation flap, distal 1/3 fxs with free flap.
Type IIIC Significant soft tissue injury (often evidenced by a segmental fracture or comminution), vascular injury requiring repair to maintain limb viability
 For prognostic reasons, severely comminuted, contaminated barnyard injuries, close range shotgun/high velocity gunshot injuries, and open fractures presenting over 24 hours from injury have all been later included in the grade III group.
 
Presentation
  • Symptoms
    • pain, inability to bear weight, deformity
  • Physical exam
    • inspection and palpation
      • deformity / angulation / malrotation
      • contusions
      • blisters
      • open wounds
      • compartments
        • palpation
        • pain
        • passive motion of toes
        • intracompartmental pressure measurement if indicated (i.e., sedated or intubated)
    • neurologic
      • deep peroneal n.
      • superficial peroneal n.
      • sural n.
      • tibial n.
      • saphenous n.
    • pulse
      • dorsalis pedis
      • posterior tibial
        • be sure to check contralateral side
Imaging
  • Radiographs
    • recommended views
      • full length AP and lateral views of affected tibia
      • AP, lateral and oblique views of ipsilateral knee and ankle
  • CT
    • indications
      • intra-articular fracture extension or suspicion of joint involvement
      • CT ankle for spiral distal third tibia fracture  
        • to exclude posterior malleolar fracture
Treatment of Closed Tibia Fractures
  • Nonoperative
    • closed reduction / cast immobilization 
      • indications
        • closed low energy fxs with acceptable alignment
          • < 5 degrees varus-valgus angulation
          • < 10 degrees anterior/posterior angulation
          • > 50% cortical apposition
          • < 1 cm shortening
          • < 10 degrees rotational malalignment
          • if displaced perform closed reduction under general anesthesia
        • certain patients who may be non-ambulatory (ie. paralyzed), or those unfit for surgery 
      • technique
        • place in long leg cast and convert to functional (patellar tendon bearing) brace at 4 weeks
      • outcomes
        • high success rate if acceptable alignment maintained
        • risk of shortening with oblique fracture patterns 
          • mean shortening is 4 mm
        • risk of varus malunion with midshaft tibia fractures and an intact fibula 
        • non-union occurs in 1.1% of patients treated with closed reduction
  • Operative
    • external fixation
      • indications
        • can be useful for proximal or distal metaphyseal fxs
      • complications 
        • pin tract infections common
      • outcomes
        • higher incidence of malalignment compared to IM nailing
    • IM Nailing
      • indications
        • unacceptable alignment with closed reduction and casting
        • soft tissue injury that will not tolerate casting
        • segmental fx
        • comminuted fx
        • ipsilateral limb injury (i.e., floating knee)
        • polytrauma
        • bilateral tibia fx
        • morbid obesity
      • contraindications
        • pre-existing tibial shaft deformity that may preclude passage of IM nail
        • previous TKA or tibial plateau ORIF (not strict contraindication)
      • outcomes
        • IM nailing leads to (versus external fixation) 
          • decreased malalignment
        • IM nailing leads to (versus closed treatment) 
          • decrease time to union
          • decreased time to weight bearing
        • reamed vs. unreamed nails 
          • reamed possibly superior to unreamed nails for treatment of closed tibia fxs for decrease in future bone grafting or implant exchange (SPRINT trial)
          • recent studies show no adverse effects of reaming (infection, nonunion)
          • reaming with use of a tourniquet is NOT associated with thermal necrosis of the tibial shaft 
    • percutaneous locking plate 
      • indications
        • proximal tibia fractures with inadequate proximal fixation from IM nailing
        • distal tibia fractures with inadequate distal fixation from IM nail
      • complications
        • non-union and delayed union 
        • wound infection and dehiscence
        • long plates may place superficial peroneal nerve at risk q q
      • Percutaneous plate shown to have (versus infrapatellar IMN) q
        • Equivalent time to union
        • Greater radiation exposure
        • Longer surgical duration
        • Lower postoperative pain scores
        • More difficulty in hardware removal
Treatment of Open Tibia Fractures
  • Operative
    • antibiotics, I&D
      • indications
        • all open fractures require an emergent I&D
      • timing of I&D
        • surgical debridement 6-8 hours after time of injury is preferred 
        • grossly contaminated wounds are irrigated in emergency department
      • antibiotics
        • standard abx for open fractures (institution dependent)
          • cephalosporin given for 24-48 hours in Grade I,II, and IIIA open fractures
          • aminoglycoside added in Grade IIIB injuries 
            • minimal data to support this
          • penicillin administered in farm injuries
            • minimal data to support this
        • tetanus prophylaxis
      • outcomes
        • early antibiotic administration is the most important factor in reducing infection 
        • emergent and thorough surgical debridement is also an important factor 
        • must remove all devitalized tissue including cortical bone
    • external fixation
      • indications
        • provisional external fixation an option for open fractures with staged IM nailing or plating
        • falling out of favor in last decade
        • indicated in children with open physis
    • IM Nailing 
      • indications
        • most open fx can be treated with IM nail within 24 hours
        • contraindicated in children with open physis (use flexible nail, plate, or external fixation instead)
      • outcomes for open fxs
        • IM nailing vs. external fixation
          • no difference with respect to
            • infection rate
            • union rate
            • time to union
          • IM nailing superior with respect to
            • decreased malalignment
            • decreased secondary surgeries
            • shorter time to weight bearing
        • reamed nails vs. unreamed nails
          • reaming does not negatively affect union, infection, or need for additional surgeries in open tibia fractures     
          • gapping at the fracture site is greatest risk for non-union 
            • transverse fx pattern and open fractures also at increased risk for non-union
        • rhBMP-2 
          • prior studies have shown use in open tibial shaft fractures    
            • accelerate early fracture healing
            • decrease rate of hardware failure
            • decrease need for subsequent autologous bone-grafting
            • decrease need for secondary invasive procedures
            • decrease infection rate
          • recent studies have not fully supported the above findings and rhBMP-2 remains highly controversial
    • amputation
      • indications
        • no current scoring system to determine if an amputation should be performed
        • relative indications for amputation include
          • significant soft tissue trauma
          • warm ischemia > 6 hrs
          • severe ipsilateral foot trauma
      • outcomes
        • LEAP study
          • most important predictor of eventual amputation is the severity of ipsilateral extremity soft tissue injury 
          • most important predictor of infection other than early antibiotic administration is transfer to definitive trauma center 
          • study shows no significant difference in functional outcomes between amputation and salvage
          • loss of plantar sensation is not an absolute indication for amputation 
Technique
  • IM nailing of shaft fractures
    • preparation
      • anesthesia
        • general anesthesia recommended
      • positioning
        • patient positioned supine on radiolucent table
        • bring fluoro in from opposite, non-injured, side
        • bump placed under ipsilateral hip
        • leave full access to foot and ankle to help judge intraoperative length, rotation, and alignment of extremity
      • tourniquet
        • tourniquet placed on proximal thigh
        • not typically inflated
        • use in patients with vascular injury or significant bleeding associated with extensive soft tissue injuries
        • deflate during reaming or nail insertion (weak data to support this)
    • approach
      • options include
        • medial parapatellar
          • most common starting point
          • can lead to valgus malalignment when used to treat proximal fractures
        • lateral parapatellar
          • helps maintain reduction when nailing proximal 1/3 fractures
          • requires mobile patella
        • patellar tendon splitting
          • gives direct access to start point
          • can damage patellar tendon or lead to patella baja (minimal data to support this)
        • semiextended medial or lateral parapatellar
          • used for proximal and distal tibial fractures
        • suprapatellar (transquadriceps tendon)
          • requires special instruments
          • can damage patellofemoral joint 
      • starting point
        • medial parapatellar tendon approach with knee flexed
          • incision from inferior pole of patella to just above tibial tubercle
          • identify medial edge of patellar tendon, incise
          • peel fat pad off back of patellar tendon
          • starting guidewire is placed in line with medial aspect of lateral tibial spine on AP radiograph, just below articular margin on lateral view   
          • insert starting guide wire, ream
        • semiextended lateral or medial parapatellar approach
          • skin incision made along medial or lateral border of patella from superior pole of patella to upper 1/3 of patellar tendon
          • knee should be in 5-30 degrees of flexion
          • choice to go medial or lateral is based of mobility of patella in either direction
          • open retinaculum and joint capsule to level of synovium
          • free retropatellar fat pad from posterior surface of patellar tendon
          • identify starting point as mentioned previously
    • fracture reduction techniques
      • spanning external fixation (ie. traveling traction)
      • clamps
      • femoral distractor
      • small fragment plates/screws
      • intra-cortical screws
    • reaming
      • reamed nails superior to unreamed nails in closed fractures 
      • be sure tourniquet is released
      • advance reamers slowly at high speed
      • overream by 1.0-1.5mm to facilitate nail insertion
      • confirm guide wire is appropriately placed prior to reaming
    • nail insertion
      • insert nail in slight external rotation to move distal interlocking screws anteriorly decreasing risk of NVS injury
      • if nail does not pass, remove and ream 0.5-1.0mm more
    • locking screws
      • statically lock proximal and distally for rotational stability
        • no indication for dynamic locking acutely
      • number of interlocking screws is controversial
        • two proximal and two distal screws in presence of <50% cortical contact
        • consider 3 interlock screws in short segment of distal or proximal shaft fracture
Complications
  • Knee pain
    • >50% anterior knee pain with IM nailing 
      • occurs with patellar tendon splitting and paratendon approach 
      • pain relief unpredictable with nail removal
    • lateral radiograph is best radiographic views to make sure nail is not too proud proximally 
  • Malunion 
    • high incidence of valgus and procurvatum (apex anterior) malalignment in proximal third fractures  
    • varus malunion leads to ipsilateral ankle pain and stiffness 
    • chronic angular deformity is defined by the proximal and distal anatomical/mechanical axis of each segment
      • center of rotation of angulation is intersection of proximal and distal axes
  • Nonunion
    • definition
      • delayed union if union at 6-9 mos.
      • nonunion if no healing after 9 mos.
    • treatment
      • nail dynamization if axially stable
      • exchange nailing if not axially stable 
        • reamed exchange nailing most appropriate for aseptic, diaphyseal tibial nonunions with less than 30% cortical bone loss.    
        • consider revision with plating in metaphyseal nonunions
      • posterolateral bone grafting if significant bone loss
      • non-invasive techniques (electrical stimulation, US)
      • BMP-7 (OP-1) has been shown equivalent to autograft 
        • often used in cases of recalcitrant non-unions
      • compression plating has been shown to have 92-96% union rate after open tibial fractures initially treated with external fixation
      • fibular osteotomy of tibio-fibular length discrepancy associated with healed or intact fibula 
  • Malrotation 
    • most commonly occurs after IM nailing of distal 1/3 fractures 
    • can assess tibial rotation by obtaining perfect lateral fluoroscopic image of knee, then rotating c-arm 105-110 degrees to obtain mortise view of ipsilateral ankle
    • reduced risk with adjunctive fibular plating   
  • Compartment syndrome
    • incidence 1-9%
      • can occur in both closed and open tibia shaft fxs
    • diagnosis
      • high index of clinical suspicion
      • pain out of proportion
      • pain with passive stretch
      • compartment pressure within 30mm Hg of diastolic BP is most sensitive diagnostic test
    • treatment
      • emergent four compartment fasciotomy
    • outcome
      • failure to recognize and treat compartment syndrome is most common reason for successful malpractice litigation against orthopaedic surgeons
    • prevention
      • increased compartment pressure found with
        • traction (calcaneal
        • leg positioning
  • Nerve injury
    • LISS plate application without opening for distal screw fixation near plate holes 11-13 put superficial peroneal nerve at risk of injury due to close proximity 
    • saphenous nerve can be injured during placement of locking screws
    • transient peroneal nerve palsy can be seen after closed nailing 
      • EHL weakness and 1st dorsal webspace decreased sensation
      • treated nonoperatively; variable recovery is expected
 

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