Updated: 5/27/2021

Proximal Third Tibia Fracture

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  • 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
Technique Guides (1)
Questions (29)
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(OBQ13.149) Figures A through E are paired diagrams depicting the anteroposterior and lateral profiles of the proximal tibia. Which of the following figures has arrows that correspond to the ideal entry point for intramedullary nailing of a proximal third diaphyseal tibial fracture?

QID: 4784
FIGURES:
1

Figure A

15%

(714/4673)

2

Figure B

70%

(3253/4673)

3

Figure C

10%

(461/4673)

4

Figure D

3%

(136/4673)

5

Figure E

2%

(102/4673)

L 3 B

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(SBQ12TR.22) A 34-year-old male presents with a closed left leg injury after falling off a 20ft ladder. His injury radiographs are shown in Figure A. He is taken for intramedullary nail (IMN) fixation. Which of the following correctly combines techniques used to decrease the incidence of the most common deformities associated with this fracture pattern?

QID: 3937
FIGURES:
1

Starting point in Figure B with blocking screw in Figure D

3%

(38/1324)

2

Starting point in Figure B with blocking screw in Figure E

10%

(138/1324)

3

Starting point in Figure C with blocking screw in Figure D

8%

(102/1324)

4

Starting point in Figure C with blocking screw in Figure E

75%

(989/1324)

5

Starting point in Figure C with blocking screw in Figure F

4%

(48/1324)

L 2 A

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(SBQ12TR.17) A 34-year-old man is involved in a motorcycle accident and sustains a closed tibia fracture and multiple rib fractures. A radiograph is provided in Figure A. During surgical treatment of this fracture, which of the following techniques will help facilitate a successful reduction and intramedullary fixation?

QID: 3932
FIGURES:
1

Hyperflexion to help prevent apex anterior angulation

3%

(61/1925)

2

A medial parapatellar incision to help prevent valgus angulation

1%

(26/1925)

3

Starting point just lateral to the medial tibial eminence to help prevent valgus angulation

12%

(234/1925)

4

A medially placed blocking screw to help prevent valgus angulation

10%

(195/1925)

5

Suprapatellar nailing technique to help prevent apex anterior angulation

72%

(1394/1925)

L 3 B

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(OBQ12.6) A 75-year-old-male presents after being struck by a vehicle while crossing the street. He complains of right leg pain, and physical exam reveals no evidence of an open fracture. Initial radiographs are shown in Figures A and B, and intramedullary nailing of the fracture is planned. What is the proper blocking screw technique to prevent apex anterior and valgus deformity of the fracture?

QID: 4366
FIGURES:
1

Insertion of blocking screws lateral and posterior to the nail

63%

(3639/5746)

2

Insertion of blocking screws medial and posterior to the nail

14%

(801/5746)

3

Insertion of blocking screws lateral and anterior to the nail

10%

(596/5746)

4

Insertion of blocking screws medial and anterior to the nail

10%

(571/5746)

5

Insertion of blocking screws medial, lateral, and posterior to the nail

1%

(77/5746)

L 3 A

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(OBQ11.161) A 28-year-old female is struck by a motor vehicle while crossing the street and suffers the injury seen in Figure A. What technical adjunct could have prevented the operative complication seen in Figure B?

QID: 3584
FIGURES:
1

Nail of a lesser radius of curvature

3%

(121/3685)

2

Nail with a more distal Herzog curve

7%

(244/3685)

3

Application of an anterior unicortical plate

77%

(2851/3685)

4

Nailing while in a hyperflexed position

6%

(230/3685)

5

A more distal and medial nail entry site

6%

(222/3685)

L 1 C

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(OBQ11.193) A 45-year-old male sustains a proximal third tibia fracture as an isolated injury and elects to undergo operative treatment with intramedullary nailing. Post-operative radiographs show excessive procurvatum deformity. Which of the following operative techniques would have helped to best avoid the procurvatum deformity?

QID: 3616
1

Tibial nailing with increased knee flexion

2%

(39/2419)

2

Lateral blocking screw in the proximal fragment

1%

(27/2419)

3

Medial blocking screw in the proximal fragment

1%

(19/2419)

4

Anterior blocking screw in the proximal fragment

14%

(330/2419)

5

Posterior blocking screw in the proximal fragment

83%

(1997/2419)

L 2 A

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(OBQ11.264) A 34-year-old female sustains a proximal third tibia fracture as an isolated injury and elects to undergo operative treatment with intramedullary nailing. Which of the following operative techniques would help to best avoid a procurvatum deformity of the tibia?

QID: 3687
1

Semiextended position during nailing

76%

(2798/3698)

2

Lateral blocking screws in proximal tibia fragment

4%

(133/3698)

3

Use of a radiolucent triangle to flex the knee

5%

(168/3698)

4

Anterior blocking screw in the proximal tibia fragment

15%

(556/3698)

5

Medial parapatellar arthrotomy avoiding the patellar tendon

1%

(26/3698)

L 2 B

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(OBQ10.140) Which of the following techniques has not been shown to prevent valgus angulation during intramedullary nailing of proximal one-third tibia fractures?

QID: 3228
1

Use of a blocking screw lateral to midline in the proximal segment

12%

(318/2596)

2

Use of femoral distractor

46%

(1184/2596)

3

Use of a lateral tibial nail starting point

8%

(208/2596)

4

Use of supplementary plate and screw fixation

2%

(54/2596)

5

Use of a suprapatellar nailing portal

32%

(819/2596)

L 5 A

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(OBQ09.176) A 38-year-old male sustains the closed injury shown in Figures A and B. When treating this injury with an intramedullary nail, addition of blocking screws into which of the following positions can prevent the characteristic malunion deformity?

QID: 2989
FIGURES:
1

Anterior to the nail in the proximal segment; medial to the nail in the proximal segment

7%

(114/1634)

2

Anterior to the nail in the proximal segment; lateral to the nail in the proximal segment

11%

(178/1634)

3

Posterior to the nail in the proximal segment; lateral to the nail in the proximal segment

74%

(1203/1634)

4

Anterior to the nail in the distal segment; lateral to the nail in the distal segment

3%

(42/1634)

5

Posterior to the nail in the distal segment; medial to the nail in the proximal segment

5%

(84/1634)

L 2 A

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(OBQ09.189) A 37-year-old male sustains the closed injury seen in figure A. What technique can be utilized to avoid the characteristic deformity seen in this fracture pattern if an intramedullary nail is used for treatment?

QID: 3002
FIGURES:
1

Medial starting point

10%

(199/2055)

2

Lateral starting point

64%

(1318/2055)

3

Aiming the nail posteriorly in the proximal segment

2%

(39/2055)

4

Anterior blocking screw in the proximal segment

7%

(152/2055)

5

Medial blocking screw in the proximal segment

17%

(340/2055)

L 2 B

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(OBQ06.269) All of the following techniques can help to prevent apex-anterior angulation during intramedullary nailing of proximal one-third tibia fractures EXCEPT:

QID: 280
1

Posterior blocking screw in the proximal segment

13%

(89/682)

2

Posterior starting hole

4%

(25/682)

3

Interlocking the nail in a semi-extended knee position

3%

(18/682)

4

Anteriorly directing the nail

5%

(33/682)

5

Anterior blocking screw in the proximal segment

75%

(511/682)

L 2 C

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(OBQ06.201) A 25-year-old man sustains a left leg injury during a motorcycle accident. A radiograph is provided in Figure A. The fracture is treated in a minimally invasive manner with a lateral locking plate and percutaneous screw fixation. A post-operative radiograph is provided in Figure B. Which of the following complications has been associated with this fixation construct?

QID: 212
FIGURES:
1

Compartment syndrome

14%

(89/624)

2

Common peroneal nerve injury

16%

(99/624)

3

Superficial peroneal nerve injury

58%

(362/624)

4

Deep peroneal nerve injury

11%

(69/624)

5

Popliteal artery injury

1%

(4/624)

L 3 B

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(OBQ06.275) Which of the following is an advantage of using blocking screws for tibial nailing?

QID: 286
1

Decrease risk of nail breakage

16%

(192/1226)

2

Eliminate use of interlocking screws

1%

(10/1226)

3

Allow for larger nail use

8%

(101/1226)

4

Enhance construct stiffness

70%

(853/1226)

5

Decrease torsional rigidity

5%

(66/1226)

L 3 B

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(OBQ05.255) A 22-year-old female is struck by a truck and sustains the injury seen in figure A. What deformities are most commonly seen in treating this injury with an intramedullary nail?

QID: 1141
FIGURES:
1

Apex anterior and varus

10%

(208/2039)

2

Apex anterior and valgus

81%

(1651/2039)

3

Apex posterior and varus

2%

(31/2039)

4

Apex posterior and valgus

4%

(87/2039)

5

Rotational

3%

(57/2039)

L 2 B

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