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Introduction
  • Fractures of the proximal tibial shaft that are associated with
    • high rates of malunion
      • valgus
      • apex anterior (procurvatum)
    • soft tissue compromise
  • Epidemiology
    • incidence
      • 5-11% of all tibial shaft fractures
  • Pathophysiology
    • mechanism
      • low energy
        • result of torsional injury
        • indirect trauma
      • high energy
        • direct trauma
  • Associated conditions
    • compartment syndrome
    • soft tissue injury
      • critical to outcome
Anatomy
  • Osteology
    • proximal tibia
      • triangular
      • wide metaphyseal region
      • narrow distally
  • Muscles
    • deforming forces
      • patellar tendon
        • proximal fragment into extension
        • fracture into apex anterior, or procurvatum
      • gastrocnemius 
        • distal fragment into flexion
      • pes anserinus
        • proximal fragment into varus
        • valgus deforming force of the fracture
      • anterior compartment musculature
        • valgus deforming force of the fracture
Classification 
 
AO Classification - 42
Type A
 Simple fracture pattern
Type B

 Wedge fracture pattern

Type C
 Comminuted fracture pattern
 
Presentation
  • Symptoms
    • pain, inability to bear weight
  • Physical exam
    • inspection and palpation
      • contusions
      • blisters
      • open wounds
      • compartments
        • palpation
        • passive motion of toes
        • intracompartmental pressure measurement if indicated
    • 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 and lateral views of ipsilateral knee
      • AP and lateral views of ipsilateral ankle
  • CT
    • indications
      • question of intra-articular fracture extension
Treatment of Closed Tibia Fractures
  • 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 alignment
      • technique
        • place in long leg cast and convert to functional brace at 4 weeks
        • cast in 10 to 20 degrees of flexion
      • outcomes
        • rotational control is difficult to achieve by closed methods
  • Operative
    • external fixation
      • indications
        • fractures with extensive soft-tissue compromise
        • polytrauma
      • technique
        • bi-planar and multiplanar pin fixators are useful
    • intramedullary nailing
      • indications
        • enough proximal bone to accept two locking screws (5-6 cm)
      • outcomes
        • high rates of malunion with improper technique
          • most common malunion
            • valgus
            • apex anterior (procurvatum)
    • percutaneous locking plate
      • indications
        • inadequate proximal fixation for IM nailing
        • best suited for transverse or oblique fractures
        • minimal soft-tissue compromise
      • technique
        • may be used medially or laterally
        • better soft tissue coverage laterally makes lateral plating safer
      • outcomes
        • lateral plating with medial comminution can lead to varus collapse
        • long plates may place superficial peroneal nerve at risk
Surgical Technique
  • Intramedullary nailing
    • approach
      • lateral parapatellar
        • helps maintain reduction for proximal 1/3 fractures
        • requires mobile patella
        • medial parapatellar approach may lead to valgus deformity
      • suprapatellar
        • facilitates nailing in semiextended position
    • starting point 
      • proximal to the anterior edge of the articular margin
      • just medial to the lateral tibial spine
      • use of a more lateral starting point may decrease valgus deformity
        • use of a medial starting point may create valgus deformity
    • fracture reduction techniques
      • blocking (Poller) screws     
        • coronal blocking screw
          • prevents apex anterior (procurvatum) deformity
          • place in posterior half of proximal fragment
        • sagittal blocking screw
          • prevents valgus deformity
          • place on lateral concave side of proximal fragment
        • enhance construct stability if not removed
      • unicortical plating   
        • short one-third tubular plate placed anteriorly, anteromedially, or posteromedially across fracture
        • secure both proximally and distally with 2 unicortical screws
      • universal distractor
        • Schanz pins inserted from medial side, parallel to joint
        • pin may additionally be used as blocking screws
    • nail insertion
      • options
        • standard insertion with knee in flexion
        • nail insertion in semiextended position  
          • may help to prevent apex anterior (procurvatum) deformity
            • neutralizes deforming forces of extensor mechanism
    • locking screws
      • statically lock proximally and distally for rotational stability
        • no indication for dynamic locking acutely
      • must use at least two proximal locking screws
Complications
  • Malunion   
    • incidence
      • 20-60% rate of malunion following intramedullary nailing (valgus/procurvatum)
    • treatment
      • revision intramedullary nailing
      • osteotomy if fracture has healed
    • prevention
      • blocking screws
      • temporary plating
      • universal distractors
      • nailing in semiextended position
 

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