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  • 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
      • 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
      • 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
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