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 login to view 2 more bullets high energy login to view 1 more bullet 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 login to view 2 more bullets gastrocnemius login to view 1 more bullet pes anserinus login to view 2 more bullets anterior compartment musculature login to view 1 more bullet 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 login to view 3 more bullets 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 login to view 2 more bullets distal fragment flexed login to view 1 more bullet 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 login to view 6 more bullets outcomes login to view 3 more bullets Operative external fixation indications login to view 2 more bullets outcomes login to view 1 more bullet intramedullary nailing indications login to view 1 more bullet outcomes login to view 4 more bullets percutaneous locking plate indications login to view 4 more bullets outcomes login to view 3 more bullets 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 login to view 3 more bullets suprapatellar login to view 1 more bullet technique starting point login to view 4 more bullets fracture reduction techniques login to view 14 more bullets nail insertion login to view 5 more bullets locking screws login to view 3 more bullets complications malunion login to view 1 more bullet Pecutaneous locking plate approach anterolateral login to view 1 more bullet 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 login to view 3 more bullets 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