Summary Diaphyseal tibial fractures are the most common long bone fracture. Diagnosis is confirmed by plain radiographs of the tibia and adjacent joints. Treatment is generally operative with intramedullary nailing. In rare cases, external fixation or ORIF is more appropriate depending on the location and orientation of the fracture. Epidemiology Incidence most common long bone fx make up about 17% of all lower extremity fractures account for 4% of all fractures seen in the Medicare population Demographics M > F age bracket bimodal distribution young patients - high energy mechanisms older patients - falls, lower energy mechanisms Anatomic location proximal 1/3 tibia fractures account for 5-10% of tibial shaft fractures Etiology Pathophysiology mechanism of injury low energy (fall from standing, twisting, etc) result of indirect, torsional injury leads to spiral fracture pattern with fibula fracture at a different level high association of posterior malleolus fractures with spiral distal tibia fractures more likely to be associated with a lower degree of soft tissue injury high energy fx (MVA, fall from height, athletics, etc) result of direct force leads to wedge or short oblique fracture that may have significant comminution with fibula fracture at same level more likely to be associated with severe soft tissue injury Oestern and Tscherne II / III open fractures pathoanatomy proximal third tibia fractures must rule out extension into tibial plateau on plain films or CT scan high risk for valgus/procurvatum deformity with IM nailing distal third tibia fracture higher rates of ankle injury seen with distal 1/3 tibia fracture and spiral fracture pattern posterior malleolus most common associated ankle injury which, in some cases, may affect syndesmotic stability extension into or adjacent to tibial plafond may require separate/additional fixation and are managed differently than tibial shaft fractures associated conditions soft tissue injury severity of muscle injury has highest impact on eventual need for amputation compartment syndrome more common in diaphyseal tibial shaft fractures than proximal or distal tibia fractures 8.1% risk in diaphyseal fractures, compared to proximal (1.6%) and distal (1.4%) fractures can occur even in the setting of an open fracture all four compartments must be examined. If patient is unable to participate in examination and concern is high clinically, intracompartmental compartment measurements should be performed bone loss ipsilateral skeletal injury tibial plateau fractures tibial plafond fractures femoral shaft fractures floating knee is an indication for antegrade tibial nailing and retrograde femoral nailing posterior malleolar fracture distal 1/3 and spiral tibial shaft fractures Anatomy Osteology tibial shaft is triangular in cross-section proximal medullary canal is centered laterally important for start point with IM nailing anteromedial tibial crest is composed of dense, cortical bone and rests in a subcutaneous position, making it useful as a landmark tibial tubercle sits anterolaterally, approximately 3 cm distal to joint line attachment of patellar tendon gerdy's tubercle lies laterally on proximal tibia attachment of iliotibial band pes anserinus lies medially on proximal tibia attachment of sartorius, semitendinosus, and gracilis Muscles anterior compartment tibialis anterior extensor digitorum longus (EDL) extensor hallicus longus (EHL) lateral compartment peroneus longus peroneus brevis superficial posterior compartment gastrocnemius (medial/lateral heads) soleus plantaris deep posterior compartment popliteus tibialis posterior flexor digitorum longus (FDL) flexor hallicus longus (FHL) Ligaments superficial medial collateral ligament (MCL) attaches approximately 5-7 cm distal to joint line deep to the pes anserinus adjacent fibula supports attachments for the lateral collateral ligament complex and long head of biceps femoris Blood Supply anterior tibial a. peroneal a. posterior tibial a. medial sural a. lateral sural a. Nervous System superficial peroneal n. deep peroneal n. tibial n. sural n. Biomechanics proximal tibiofibular joint gliding synovial joint tibia is responsible for about 80-85% of lower extremity weight-bearing interosseous membrane fibrous structure interconnecting tibia/fibula which provides axial stability tibiofibular syndesmosis fibula rests in distal tibial incisura and is stabilized by syndesmotic ligaments anterior inferior tibiofibular ligament (AITFL) posterior inferior tibiofibular ligament (PITFL) inferior transverse tibiofibular ligament (ITL) interosseous ligament (IOL) - continuation of interosseus membrane syndesmotic stability can be affected by distal, spiral tibial shaft fractures Classification Fracture classification is primarily descriptive based on pattern and location OTA Classification 42A Simple fracture patterns 42B Wedge patterns 42C Complex/comminuted patterns Oestern and Tscherne Classification of Closed Fracture 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 Minimal periosteal stripping, wound >1 cm in length without extensive soft-tissue injury damage 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 included in the grade III group. Presentation Symptoms severe leg pain inability to bear weight deformity Physical exam inspection deformity / angulation / malrotation contusions blisters open wounds palpation check firmness of each compartment to evaluate for compartment syndrome motion fracture crepitus noted neurovascular peripheral nerve exam deep peroneal n. superficial peroneal n. sural n. tibial n. saphenous n. dorsalis pedis and posterior tibial pulses - compare to contralateral side doppler if necessary CT angiography indicated if pulses not dopplerable Imaging Radiographs recommended views full-length AP and lateral views of the affected tibia AP, lateral and oblique views of ipsilateral knee and ankle repeat radiographs recommended after splinting or fracture manipulation CT indications intra-articular fracture extension or suspicion of plateau/plafond involvement distal 1/3 or spiral tibia fracture used to exclude posterior malleolar fracture also used to identify nonunion findings high variation in reported incidence of posterior malleolus fracture with distal 1/3 spiral tibia fractures (25-60%) Treatment Nonoperative closed reduction / cast immobilization indications closed, low energy fractures with acceptable alignment < 5 degrees varus-valgus angulation < 10 degrees anterior/posterior angulation > 50% cortical apposition < 1 cm shortening < 10 degrees rotational malalignment certain patients who may be non-ambulatory (ie. paralyzed), or those unfit for surgery outcomes angulation and rotational alignment are well maintained with casting, however, shortening is hard to control risk of shortening higher with oblique and comminuted fracture patterns mean shortening is 4 mm risk of varus malunion with midshaft tibia fractures and an intact fibula high success rate if acceptable alignment maintained non-union occurs in approximately 1% of patients treated with closed reduction Operative I&D + antibiotics indications all open tibia fractures require an emergent I&D surgical debridement within 12-24 hours of injury wounds should be irrigated and dressed with saline-soaked gauze in the emergency department before splinting all open tibia fractures require immediate antibiotics should be administered within 3 hours of injury standard abx for open fractures (institution dependent) cephalosporin given continuously for 24 hours after definitive surgery 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 theoretically covers Clostridium tetanus vaccination status should be confirmed and appropriate prophylaxis should be administered if necessary 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 damage control for polytrauma patients open fractures with soft tissue defects/contamination proximal or distal metaphyseal fractures techniques uniplanar, circular, hybrid external fixators all available should be converted to intramedullary nail within 7-21 days, ideally less than 7 days outcomes longer time to union and worse functional outcomes with definitive external fixation compared to IM nailing in type III open tibia fractures higher incidence of malalignment compared to IM nailing high rate of pin tract infections; avoid intra-articular placement given risk for septic arthritis 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 techniques reamed vs. unreamed nailing reamed nailing allows for larger diameter nail suprapatellar vs. infrapatellar nailing provisional reduction techniques (blocking screws, plating, etc) particularly useful for proximal 1/3 tibial shaft fractures outcomes union rates >80% for closed tibia fractures treated with nailing risks for nonunion: gapping at fracture site, open fracture and transverse fracture pattern shorter immobilization time, earlier time to weight-bearing, and decreased time to union compared to casting decreased malalignment compared to external fixation suprapatellar vs. infrapatellar nailing improved fracture alignment with suprapatellar nailing reamed vs. unreamed nails reamed may have higher union rates and lower time to union than unreamed nails in closed fractures (controversial) reamed nails are safe for use with open fractures, with no evidence of decreased nonunion rates in open fractures recent studies show no adverse effects of reaming (infection, embolism, nonunion) reaming with the use of a tourniquet is not associated with thermal necrosis of the tibial shaft, despite prior studies suggesting otherwise higher rate of locking screw breakage with unreamed nailing open reduction and internal fixation indications proximal tibia fractures with inadequate proximal fixation from IM nailing distal tibia fractures with inadequate distal fixation from IM nail tibia fractures in the setting of adjacent implant/hardware (i.e. prior total knee arthroplasty) outcomes compared to IM nailing of tibia fractures: larger incision increased risk of wound complications and hardware irritation similar rates of union in closed fractures more difficult hardware removal greater radiation exposure intraoperatively possibly less angular deformity risk of damage to the superficial peroneal nerve during percutaneous screw insertion holes 11,12, and 13 (proximally) of a 13 hole plate place nerve at risk augmentation with rhBMP-2 indications prior studies have demonstrated some use in open tibial shaft fractures outcomes (controversial, as recent studies have not fully supported these findings) 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 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 METALS study military patients who undergo amputation appear to have better functional outcomes than those who undergo limb salvage Technique Closed reduction/cast immobilization technique long leg casting initially may convert to functional (patellar tendon bearing) brace at around 4 weeks close follow-up with repeat radiographs to ensure no displacement can wedge cast to correct slight deformity monitor for skin irritation Irrigation and debridement timing within 24 hours of initial injury to decrease risk of infection technique sharp debridement of nonviable soft tissue & bone thorough irrigation of contaminated wound may require multiple debridements immediate closure of open wounds is acceptable if minimal contamination is present and is performed without excessive skin tension if skin cannot be closed, vac-assisted closure should be considered in short-term. External fixation technique bypass fracture, likely adjacent joint (i.e. open 1/3 tibial shaft fracture with placement of proximal 1/3 tibia and calcaneus/metatarsal pins to span fracture) construct stiffness increased with larger pin diameter, number of pins on each side of fracture, rods closer to bone, and a multiplanar construct complications pin site infections common Intramedullary nailing approach infrapatellar nailing medial parapatellar most common starting point incision from inferior pole of patella to just above tibial tubercle identify medial edge of patellar tendon, incise insert guidewire as detailed below and ream can lead to valgus malalignment in proximal 1/3 tibial 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 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 identify starting point and ream as detailed below suprapatellar nailing (transquadriceps tendon) requires special instruments can damage patellofemoral joint easier positioning if additional instrumentation needed more advantageous for proximal or distal 1/3 tibia fractures technique starting point starting guidewire is placed in line with medial aspect of lateral tibial spine on AP radiograph, just below articular margin on lateral view in proximal 1/3 tibia fractures starting point should cheat laterally to avoid classic valgus/procurvatum deformity ensure guidewire is aligned with tibia in coronal and sagittal planes as you insert opening reamer is placed over guidewire and ball-tipped guidewire can then be passed fracture reduction spanning external fixation (ie. traveling traction) clamps femoral distractor small fragment unicortical plates/screws blocking (poller) screws placed in metaphyseal segment at the concavity of the deformity in proximal 1/3 tibia fractures, posteriorly placed blocking screw in proximal fragment and laterally placed blocking screw in the metaphyseal fragment help direct the nail more centrally, avoiding valgus/procurvatum deformities increase biomechanical stability of bone/implant construct by 25% unicortical provisional plate not associated with increased infections, wound complications, and nonunion compared to closed-nailing techniques reaming reamed nails superior to unreamed nails in closed fractures ensure fracture is reduced before reaming overream by 1.0-1.5mm to facilitate nail insertion confirm guide wire is appropriately placed prior to reaming should be "center-center" in the coronal and sagittal planes distally at the physeal scar nail insertion anterior aspect of nail should be lined up with axis of tibia when inserting nail - typically should line up with 2nd metatarsal in absence of tibial deformity 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 prefer multiplanar screw fixation in these short segments Open reduction and internal fixation approach lateral vs. medial lateral may have more soft tissue interference but may be preferred in setting of soft tissue/wound issues technique generally, minimally invasive plating is used to preserve soft tissues plate attached to external jig to allow for percutaneous insertion of screws must ensure appropriate contour of plate to avoid malreduction complications higher risk for wound issues, particularly in open fractures neurovascular risk superficial peroneal nerve (SPN) commonly at risk laterally Amputation approach below knee amputation (BKA) vs. above knee amputation (AKA) based on degree of soft tissue damage technique standard BKA vs. ertl/bone block technique complications infection hematoma phantom pain Complications Anterior knee pain incidence >30-50% with IM nailing risk factors infrapatellar nailing with patellar tendon splitting and paratendon approach suprapatellar nailing may have lower rate of anterior knee pain more common if nail left proud proximally lateral radiograph is best radiographic views to evaluate proximal nail position treatment removal of nail pain relief unpredictable with nail removal Malunion incidence all tibial shaft fractures - between 8-10% higher in proximal 1/3 tibia fractures - up to 50% valgus/procurvatum deformity patellar tendon pulls proximal fragment into extension, while hamstring tendons and gastrocnemius pull the distal fragment into flexion (procurvatum) distal 1/3 fractures have a higher rate of valgus malunion with IM nailing compared to plating risk factors definitive management with casting or external fixation most common deformity is varus with nonsurgical management varus malunion may place patient at risk for ipsilateral ankle pain and stiffness starting point too medial with IM nailing poor reduction intraoperatively treatment prevention is most important adequate reduction, proper start point when nailing if malalignment is noted immediately after surgery, return to operating room is appropriate with removal of nail, reduction and nail reinsertion if malunion is appreciated at later followup, eventual nail removal and tibial osteotomy can be considered Nonunion (no healing at 9 months) incidence estimated between 2-10% risk factors open fracture cortical contact <50% transverse fracture pattern treatment rule out infection nail dynamization if axially stable exchange nailing if not axially stable reamed exchange nailing most appropriate for aseptic, diaphyseal tibial nonunions oblique tibial shaft fractures have the highest rate of union when treated with exchange nailing consider revision with plating in metaphyseal nonunions posterolateral bone grafting if significant bone loss 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 a 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 incidence highest after IM nailing of distal 1/3 tibia fractures increases risk of adjacent ankle arthrosis treatment should always assess rotation in operating room obtain perfect lateral fluoroscopic image of knee, then rotate c-arm 105-110 degrees to obtain mortise view of ipsilateral ankle may have reduced risk with adjunctive fibular plating Compartment syndrome incidence estimated between 1-9% can occur in both closed and open tibia shaft fractures risk factors high energy injuries significant soft tissue injuries treatment emergent four-compartment fasciotomy Nerve injury incidence true incidence unknown believed to be a rare complication risk factors 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 deep peroneal nerve can be injured with overpenetration of posterolaterally-directed proximal external fixator pins treatment usually nonoperatively with variable recovery expected may need AFO if foot drop present Infection incidence approximately 5% risk factors open fracture severe soft tissue injury with contamination longer time to definitive soft tissue coverage treatment may require I&D or eventual removal of hardware use of wound vacuum-assisted closure does not decrease risk of infection