Summary Proximal third tibia fractures are relatively common fractures of the proximal tibial shaft that are associated with high rates of soft tissue compromise and malunion (valgus and procurvatum). Diagnosis is made with orthogonal radiographs of the tibia with CT scan often required to assess for intra-articular extension. Treatment generally consists of surgical open reduction and internal fixation (ORIF) versus intramedullary nail fixation. Epidemiology Incidence common 5-11% of all tibial shaft fractures Etiology Pathophysiology mechanism low energy result of torsional injury (spiral oblique fracture) indirect trauma high energy direct trauma Associated conditions compartment syndrome soft tissue injury critical to outcome severity of muscle injury has the greatest impact on need for amputation 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 varus 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 contusions blisters open wounds compartments palpation passive motion of toes intracompartmental pressure measurement if indicated neurovascular deep peroneal n. superficial peroneal n. sural n. tibial n. saphenous n. dorsalis pedis posterior tibial Imaging Radiographs recommended views AP lateral ipsilateral knee, tibia, and ankle findings proximal fracture extended, apex anterior, varus apex extended due to patellar tendon varus due to pes anserinus + anterior compartment distal fragment flexed flexed due to gastrocnemius CT indications question of intra-articular fracture extension Differential Tibial shaft fx Knee dislocation Tibial plateau fx Diagnosis Radiographic diagnosis confirmed by clinical presentation and radiographs 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 alignment outcomes shortening is most difficult to control with nonoperative management angulation and rotational control are difficult to achieve by closed methods extent of shortening and translation on injury radiographs should be expected at time of union Operative external fixation indications fractures with extensive soft-tissue compromise polytrauma outcomes higher incidence of malalignment than IMN 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 extreme proximal fractures inadequate proximal fixation for IM nailing best suited for transverse or oblique fractures minimal soft-tissue compromise outcomes lateral plating with medial comminution can lead to varus collapse long plates may place superficial peroneal nerve at risk higher infection rate that IMN for open fractures Techniques Closed reduction / cast immobilizxation technique place in long leg cast and convert to functional brace at 4 weeks cast in 10 to 20 degrees of flexion External fixation technique bi-planar and multiplanar pin fixators are useful circular frames indicated for very proximal fractures can be safely converted to IMN within 7-21 days 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 technique 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 valgus and apex anterior (procurvatum) Pecutaneous locking plate approach anterolateral straight or hockey stick incision anterolaterally from just proximal to joint line (if intra-articular extenion) to just lateral to the tibial tubercle and extend distally as needed technique may be used medially or laterally better soft tissue coverage laterally makes lateral plating safer complications superficial peroneal nerve injuy with use of a longer plate varus collapse if lateral only plate used with medial comminution Complications Anterior knee pain incidence occurs in more than 30% of cases treated with IMN resolves with removal of IMN in 50% of cases Nonunion infection must be ruled out dynamization if axially stable Malunion Most common is valgus and apex anterior (procurvatum) increases long-term risk of arthrosis incidence 20-60% rate of malunion following intramedullary nailing (valgus/procurvatum) prevention laterally based starting point and anterior insertion angle entry of IMN should be in line with the medial border of the lateral tibial eminence blocking screws placed in metaphyseal segment on the concave side of the deformity place laterally to prevent valgus and posterior to prevent procurvatum in proximal fragment this narrows the available space for the IMN direct the nail toward a more centralized position use of provisional unicortical plate semiextended position for nailing universal distractors treatment revision intramedullary nailing osteotomy if fracture has healed Prognosis High rate of malunion following intramedullary nailing