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Updated: Oct 16 2023

Proximal Third Tibia Fracture

Images
https://upload.orthobullets.com/topic/1062/images/proximal_third.jpg
https://upload.orthobullets.com/topic/1062/images/0bdaf342-b77b-4898-acd6-c6890c7114d1_prox_third_illustration.jpg
https://upload.orthobullets.com/topic/1062/images/deform.jpg
https://upload.orthobullets.com/topic/1062/images/liss.jpg
https://upload.orthobullets.com/topic/1062/images/proximal_third_tibia_fx_-_surgical_technique_-_im_nail_-_coronal_blocking_screw.jpg
https://upload.orthobullets.com/topic/1062/images/unicortical_plate.jpg
  • 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
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