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https://upload.orthobullets.com/topic/1062/images/tibia.jpg
https://upload.orthobullets.com/topic/1062/images/patellar_tendon.jpg
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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
      • 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 hamstrings 
  • 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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Questions (24)
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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? Review Topic

QID: 2989
FIGURES:
1

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

8%

(93/1239)

2

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

12%

(143/1239)

3

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

72%

(886/1239)

4

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

3%

(37/1239)

5

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

6%

(71/1239)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

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

QID: 280
1

Posterior blocking screw

13%

(41/321)

2

Posterior starting hole

4%

(12/321)

3

Interlocking the nail in a semi-extended knee position

3%

(11/321)

4

Anteriorly directing the nail

6%

(19/321)

5

Anterior blocking screw

74%

(236/321)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5
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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? Review Topic

QID: 212
FIGURES:
1

Compartment syndrome

14%

(49/360)

2

Common peroneal nerve injury

16%

(57/360)

3

Superficial peroneal nerve injury

60%

(216/360)

4

Deep peroneal nerve injury

10%

(36/360)

5

Popliteal artery injury

1%

(2/360)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ10.140) Which of the following techniques does not help prevent valgus angulation during intramedullary nailing of proximal one-third tibia fractures? Review Topic

QID: 3228
1

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

12%

(258/2165)

2

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

48%

(1038/2165)

3

Use of a lateral tibial nail starting point

6%

(137/2165)

4

Use of supplementary plate and screw fixation

2%

(40/2165)

5

Use of a suprapatellar nailing portal

32%

(682/2165)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

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

QID: 286
1

Decrease risk of nail breakage

18%

(153/838)

2

Eliminate use of interlocking screws

1%

(8/838)

3

Allow for larger nail use

8%

(65/838)

4

Enhance construct stiffness

69%

(575/838)

5

Decrease torsional rigidity

4%

(35/838)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(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? Review Topic

QID: 4366
FIGURES:
1

Insertion of blocking screws lateral and posterior to the nail

63%

(3361/5294)

2

Insertion of blocking screws medial and posterior to the nail

14%

(751/5294)

3

Insertion of blocking screws lateral and anterior to the nail

10%

(535/5294)

4

Insertion of blocking screws medial and anterior to the nail

10%

(520/5294)

5

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

1%

(71/5294)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(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? Review Topic

QID: 3002
FIGURES:
1

Medial starting point

9%

(123/1384)

2

Lateral starting point

65%

(905/1384)

3

Aiming the nail posteriorly in the proximal segment

1%

(19/1384)

4

Anterior blocking screw in the proximal segment

8%

(105/1384)

5

Medial blocking screw in the proximal segment

16%

(227/1384)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(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? Review Topic

QID: 3616
1

Tibial nailing with increased knee flexion

2%

(34/2008)

2

Lateral blocking screw in the proximal fragment

1%

(20/2008)

3

Medial blocking screw in the proximal fragment

1%

(15/2008)

4

Anterior blocking screw in the proximal fragment

13%

(261/2008)

5

Posterior blocking screw in the proximal fragment

83%

(1675/2008)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(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? Review Topic

QID: 3584
FIGURES:
1

Nail of a lesser radius of curvature

3%

(83/2825)

2

Nail with a more distal Herzog curve

5%

(136/2825)

3

Application of an anterior unicortical plate

81%

(2277/2825)

4

Nailing while in a hyperflexed position

6%

(164/2825)

5

A more distal and medial nail entry site

6%

(158/2825)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(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? Review Topic

QID: 3687
1

Semiextended position during nailing

77%

(2485/3224)

2

Lateral blocking screws in proximal tibia fragment

3%

(102/3224)

3

Use of a radiolucent triangle to flex the knee

4%

(140/3224)

4

Anterior blocking screw in the proximal tibia fragment

14%

(456/3224)

5

Medial parapatellar arthrotomy avoiding the patellar tendon

1%

(26/3224)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(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? Review Topic

QID: 1141
FIGURES:
1

Apex anterior and varus

11%

(172/1614)

2

Apex anterior and valgus

81%

(1302/1614)

3

Apex posterior and varus

1%

(20/1614)

4

Apex posterior and valgus

4%

(70/1614)

5

Rotational

3%

(47/1614)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2
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