Closed Fractures of the
Tibial Diaphysis
David L. Rothberg, MD
Erik N. Kubiak, MD
University of Utah
Original Authors: Robert V. Cantu, MD and David Templeman, MD; March 2004
Interim Authors: David Templeman and Darin Friess, MD; Revised June 2006
New Authors: David L. Rothberg, MD & Erik N. Kubiak, MD; Revised June 2010
Tibia Fractures

Most common long bone fracture

492,000 fractures yearly

Average 7.4 day hospital stay

100,000 non-unions per year
History & Physical

Low Energy
– Minimal soft-tissue injury
– Less complicated fracture
pattern and management
decisions

76.5% closed

53.5% mild soft-tissue energy
History & Physical

High Energy
– High incidence of
neurovascular energy
and open injury
– Low threshold for
compartment syndrome
– Complete soft-tissue
injury may not declare
itself for several days
Radiographic Evaluation

Full length AP and
Lateral Views
– Check joint above &
below

Oblique views may
be helpful in followup to assess healing
Injuries Associated

30% of patients will
have multiple
injuries
– Ipsilateral Fibula
Fracture
– Foot & Ankle injury
– Syndesmotic Injury
– Ligamentous knee
injuries
Injuries Associated

Ipsilateral Femur Fx
– “Floating Knee”

Neurovascular Injury
– More Common In:




High Energy
Proximal Fracture
Floating Knee
Knee Dislocation
Classification

Numerous systems

Important variables
– Fracture Pattern
– Location
– Comminution
– Associated Fibula Fx
– Degree of soft-tissue
injury
OTA Classification

Follows Johner
& Wruh system

Describes
relationship
between
fracture pattern
& mechanism

Comminution is
prognostic for
time to union
Henley’s Classification

Applies Winquist &
Hansen Femur
classification to
fractures of the
Tibia
Tscherne Classification of
Soft-Tissue Injury
•
Grade 0
• negligible soft tissue injury
•
Grade 1
• superficial abrasion or contusion
•
Grade 2
• deep contusion from direct trauma
•
Grade 3
• Extensive contusion and crush injury with possible
severe muscle injury, compartment syndrome
Compartment Syndrome

Incidence:
– 5-15%

History
– High-Energy
– Crush

Exam
– 4 Compartments
– 6 P’s






Pain
Pain with passive stretch
Parasthesias
Pulsless
Pallor
Paralysis
Compartment Anatomy

Anterior
– Deep Peroneal N.

Lateral
– Sup. Peroneal N.

Deep Post.
– Tibial N.

Sup. Post.
– Sural N.
Anterior Compartment
•
•
•
Action
• Ankle dorsiflexion
Muscles
• Tib. Ant.
• EDL
• EHL
• Peroneus Tertius
Vessels
•
•
Anterior Tibial A./V.
Nerves
•
Deep Peroneal N..

1st webspace sensation
Lateral Compartment
•
Action
• Foot Eversion
•
Muscles
• Peroneus Brevis &
Longus
•
Nerves
• Superficial Peroneal
N.
•
Dorsal foot sensation
Deep Posterior
•
Actions
• Ankle plantarflexion
• Foot inversion
•
Muscles
• FDL
• FHL
• Tib. Post.
•
Vessels
• Post Tibial A./V.
• Peroneal A.
•
Nerve
• Tibial N.
 Plantar foot sensation
Superficial Posterior
•
Action
• Ankle Plantarflexion
•
Muslces
•
•
•
•
•
Gastrocnemius
Soleus
Popliteus
Plantaris
Vessels
• Greater and Lesser
Saphenous V.
•
Nerve
• Sural N.
 Lateral heel sensation
Compartment Syndrome
Remains a Clinical Diagnosis
Pressure Measurements

May be helpful in borderline cases
– Basic Science


Muscle ischemia present at 20 mmHg below DBP
and 30 mmHg below MAP
Various Thresholds
– P = 30 mmHg
– P = 45 mmHg
– Whiteside’s Theory

∆ P = DBP – CP = < 30 mmHg
Pressures Not Uniform

Highest at Fracture
Site

Highest Pressures
in:
– Deep Posterior
– Anterior

Heckman JBJS ’76
Clinical Monitoring

Close Observation
– Repeat Exams
– Repeat Pressure
Measurements

Indwelling Monitors
– Reserved for
intubated patient with
high suspicion
Goals of Fasciotomy

Decompress the
compartment
– Minimize further soft-
tissue damage

Single vs. Two incisions
– Go long





No increased morbidity
No difference in longterm outcome
Plan for fracture fixation
Plan for wound closure
Coordinate with location
of future incisions
and/or internal fixation
Closed Tibial Shaft Fracture


Broad Spectrum of
Injures w/ many
treatments
Closed
Management
 Intramedullary Nails
 Plates
 External Fixation
Non-Operative Treatment
Indications
Minimal soft tissue damage
 Non-intact fibula



Stable fracture pattern




Higher rate of nonunion & varus with intact fibula
< 5° varus/valgus
< 10° pro/recurvatum
< 1 cm shortening
Ability to bear weight in cast or fx brace
– Requires frequent follow-up
Fracture Brace

Closed Functional Treatment
–
–

1,000 Tibial Fractures
60% Lost to F/U
Fracture Characteristics
– All < 1.5cm shortening
– Non with intact fibula
– Only 5% more than 8° varus

Treatment Course
– Average 3.7 wks in long leg cast
– Transition to Function Fracture Brace
• Sarmiento JBJS ‘84
Sarmiento

Union Rate
– 98.5%

Time to Union
– 18.1 weeks

Shortening
– <1.4%

Initial Shortening = Final Shortnening
Natural History

Long-term angular deformities
– Well tolerated without associated knee or
ankle arthrosis
– Kristensen


All patients >10 degree deformity
No radiographic Ankle arthrosis
– Merchant & Dietz


22 pt F/U: 20-29 yrs
37 pt F/U: 29 yrs
76% of Ankles had G/E radiographic results
92% of Knees had G/E radiographic results
Post Tibia Fracture Ankle
Motion

25% Post Tibia
Fracture will lose
25% of Ankle ROM
Surgical Indications

Patient Characteristics
– Obesity
– Poor compliance with non-
operative management
– Need for early mobility

Injury Characteristics
–
–
–
–
–
–
High Energy
Moderate soft-tissue injury
Open Fracture
Compartment Syndrome
Ipsilateral Femur Fx
Vascular Injury

Fracture Characteristics
–
–
–
–
–
–
–
Meta-Diaphyseal location
Oblique fracture pattern
Coronal Angulation > 5°
Sagittal Angulation > 10°
Rotation > 5°
Shortening > 1cm
Comminution > 50%
cortical circumference
– Intact fibula
Surgical Options
• Intramedullary Nail
• ORIF with Plate
• External Fixation
• Combination of fixation
Advantage of IM Nail





Less malunion
Early weight-bearing
Early motion
Early WB (load sharing)
Patient satisfaction


L Bone, JBJS
Cost
– Less expensive to society
when compared to casting
– Busse Acta Ortho ‘05
Disadvantages of IM Nail

Anterior knee pain

2/3, improve w/in year
• Risk of infection

Increased hardware
failure with
unreamed nails
 Thermal Necrosis
 Medial HW
prominence
IM Nails

PRCT 62 pts
– If displacement >50%
angulation >10°
– Nails superior to cast
treatment
Hooper JBJS-B ‘91
IM Nails – Bone et.al.
Retrospective review 99 patients
Cast
Time to union 26 wks
SF-36
74
Knee score
89
Ankle score 84
Nail
18 wks
85
96
97
Bone JBJS ‘97
Reamed vs. Nonreamed Nails

Reamings (osteogenic)

Larger Nails (& locking bolts)
– Hardware failure rare w/ newer nail
designs

Damage to endosteal blood supply?
– Clinically proven safe even in open fx
Forster Injury ‘05
Bhandari JOT ‘00
Reamed vs. Nonreamed Nails
# pts.
Nonunion
Malunion
Broken Bolts
Reamed
73
4%
4%
3%
Non-Reamed
63
11%
3%
16%
Blachut JBJS ‘97
Time to Union 16.7 wks 25.7 wks
Larsen JOT ‘04
IM Nails – Interlocking Bolts
 Loss
of alignment w/o interlocking
 Spiral
 Transverse
 Metaphyseal
7/22
0/27
7/28
Templeman CORR ‘97
Complications

Infection
 Union
 Knee Pain
– w/ kneeling
– w/ running
– at rest
1-5%
>90%
56%
90%
56%
33%
Court-Brown JOT ‘96
Knee Pain after IMN

Incidence
– Varied in lit. 10-86%

Attributed to:
–
–
–
–
–
Skin Incision
Approach
Insertion Site
Quad weakness
Nail Prominence

Removal
– 27% resolved
– 69% marked
improvement
– 3% worse
Court-Brown JOT ‘96
Neurologic Complications

63 pts – compared types of anesthesia
– Epidural Anesthesia
 4.1 x greater risk of neurologic injury
– Illustrates need to monitor post-op exam
• Iaquinto Am J Orth ‘97
Expanded Indications

Proximal 1/3 fractures


Beware Valgus and Procurvatum
Distal 1/3 fractures


Beware Varus or valgus
Beware of intraarticular extension
Proximal Tibia Fracture

Entry site is
critical

Reference
– Lateral Tibial
Spine
Too Low!
Procurvatum
Too Medial!
Valgus
Semiextended Position

Neutralize quadriceps pull on proximal
fragment

Medial parapatellar approach
– subluxate patella laterally

Use handheld awls to gently ream through
the trochlear groove
Tornetta CORR ‘96
Hyperextended position

Pulls patella
proximally to allow
straight starting
angle
 Universal distractor
Beuhler JOT ‘97
Blocking (Poller) Screws

Functionally narrows IM canal
– Increases strength and rigidity of fixation
– Place on concave side of deformity

21 patients
– All healed within 3-12 months
– Mean alignment 1° valgus, 2°
Krettek JBJS ‘99
procurvatum
Technique

Screws placed on
concave side of
deformity

Proximal or distal
fractures
Distal Tibial Fractures


Reduction before
reaming
Distractor
 Fibula plate/nail
 Joy Stick
 Calcaneal Traction
Universal Distractor Reduction
Beuhler JOT ‘97
Plate Fibula
Distal Tibial Joystick
Outcomes of IM Nailing
•
•
•
•
•
859 closed tibia fractures
92.5% union rate
18.5 weeks to union
1.9% infection rate
4.4% aseptic nonunion
• “Reamed intramedullary nailing will probably continue
to be the best method of treating tibial diaphyseal
fractures.”
Court-Brown JOT ‘04
Plating of Tibial Fractures
• 3.5 mm or Narrow
4.5mm DCP plate
can be used for
shaft fractures
• Newer
periarticular
plates available
for metaphyseal
fractures
Subcutaneous Tibial Plating
• Newer alternative is
use of limited
incisions and
subcutaneous
plating- requires
indirect reduction of
fracture and hybrid
screw fixation
options
Advantages of Plating

Anatomic reduction
usually obtained

In low energy
fractures
– 97% G/E results
reported
• Ruedi Injury
Disadvantages of Plating
• Increased risk of
infection and soft tissue
problems, especially in
high energy fractures
• Higher rate hardware
failure than IM nail
• Delayed WB (load
bearing)
Johner CORR ‘83
External Fixation
• Generally
reserved for open
tibia fractures or
periarticular
fractures
AO Technique of Tibia Plating
•
Anterior longitudinal incision
•
•
1 cm lateral to tibial crest
Maintain AT paratenon and periosteum
•
Plate on medial border of tibia
•
3.5 mm or 4.5mm LCDCP plate secured to bone on distal
fragment
•
Butterfly fragment can be secured with interfragmentary
screw
•
The AO articulating tension device can be secured to
proximal part of plate to aid reduction
•
With fracture reduced, screws placed through plate on
either side of fracture
Technique of External Fixation
• Unilateral frame with half pins
• 5mm half pins
• near-near and far-far
• Stay out of zone of injury
• Pre-drilling of pins
recommended
• Fracture held reduced while
clamps and connecting bar
applied
Advantages of External
Fixator
• Can be applied quickly in
polytrauma patient
• Allows easy monitoring
of soft tissues and
compartments
• Modifiable
• No long term deep HW
Outcomes of External Fixation

95% union rate for
group of closed and
open tibia fractures
 20% malunion rate
 Loss of reduction
associated with
removing frame
prior to union
 Risk of pin track
infection
Anderson CORR ‘74
Edge JBJS ‘81
Conclusions

Common fracture w/ several treatment
options

Closed stable fx can be treated in a cast

Unstable fx often best treated by
intramedullary nail
Acknowledgments
1st Edition lecture R. Cantu M.D.
 Cases Courtesy R. Winquist M.D.
E. Kubiak M.D.

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