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Tibial Shaft Fractures
台中榮民總醫院 骨科部王舜平 醫師
General concept Stable, low-energy fractures Nonsurgical management Unstable and high-energy fractures ORIF
External fixation (uniplanar and multiplanar) Plate fixation Intramedullary nailing
Open tibial shaft fractures the associated bone and soft tissue loss
Trauma Mechanism Direct or indirect trauma
Low-energy trauma: Simple falls, twisting injuries Sports injuries
High-energy trauma : motor vehicle or motorcycle crashes
Classification Fracture classification : AO/OTA fracture classification
AO/OTA fracture classification
Physical examination
Patient’s skin Gross deformity of the extremity Neurovascular examination : Nerve function and Pulse Identify associated injuries :
ipsilateral hip, knee, and ankle
Suspicion risk of compartment syndrome !!
Compartment syndrome Younger patients High-energy tibia fractures Patients with diaphyseal tibia fractures
(8.1%) 【 proximal (1.6%) and distal (1.4%) 】
Difficult to assess “cardinal signs – 5P” due to fracture pain Anterior and deep posterior
compartments are susceptible
J Orthop Trauma. 2009 Aug;23(7):514-8
Compartment syndrome
Intra-compartmental pressures Delta pressure < 30 mm Hg (diastolic pressure - tissue pressure)
Should not be measured after anesthesia (diastolic pressure ↓)
Four-compartment fasciotomy Anterior compartment is most frequently incompletely released
Radiographic examination
Antero-posterior, lateral radiographs of the entire tibia
Ipsilateral knee and the ankle
Associated injuries Intra-articular knee injuries Tibial plateau or ankle fracture Posterior malleolus fracture (high association to spiral tibia fractures)
Concomitant Ipsilateral fractures of the left tibial plateau and left tibial pilon
Nonsurgical Treatment
Nondisplaced, low-energy tibia fractures Initial immobilization : long leg splinting (Not casting) an ipsilateral fibula fracture is a relative
contraindication
Results : High union rates with angulation(<8°) and shortening(<12 mm)
Surgical indication
Absolute indications Open fractures Concomitant vascular injuries or
compartment syndrome, Irreducible or unstable fractures Failure of closed treatment
Displacement : > 50% of shaft Angulation : > 5° to 10° Rotation : > 10° Shortening : > 1 cm
Surgical Treatment - External Fixation
Minimally invasive Relative stability Easier wound care
Temporary usage Damage control techniques
Definitive usage soft-tissue injury bone loss
Surgical Treatment - Plate Fixation
An open surgical approach MIPPO technique
Three different approaches Anteromedial incisions – wound healing
problems and prominent hardware Anterolateral or Posteromedial – preferred
Minimally invasive percutaneous plating
Medial or anteromedial plating Hardware, wound breakdown, and
saphenous vein and nerve injury Anterolateral percutaneous plating
injury to the superficial peroneal nerve (distal screws)
For comminuted fractures bridge plating techniques
Surgical Treatment - Plate Fixation
Higher rates of complications (19% to 30%) and worse outcomes
For specific indications Periprosthetic fractures Open physes Too small of a medullary canal s/p cruciate ligament reconstruction Open wound provides the surgical exposure
Surgical Treatment Intramedullary Nailing
The gold standard
for displaced tibial shaft fractures
Complication Anterior knee pain(67%) Decreased ankle motion(42%) Knee or ankle arthrosis(35%)
Proximal and distal tibia fractures
Malunion (84%) of proximal tibial fracture Lower (58%) in distal tibial fractures Improved reduction :
blocking or Pöller screws
Open Tibia Fractures
Urgent management Early antibiotic Wound coverage - sterile Tetanus prophylaxis Surgical débridement Fracture stabilization
Open Tibia Fractures
Choice of antibiotics : Gustilo-Anderson classification
Type 1 or 2 – gram(+) bacteria, a 1st or 2nd generation cephalosporin Type 3 – gram(-) bacteria, Aminoglycoside
With soil contamination,
Penicillin (gram(+) anaerobes)
Open Tibia Fractures Fracture stabilization
Soft-tissue healing Prevention of infection
External fixation : an excellent alternative to nailing or plating
Conversion to nailing : < 2 weeks
Open Tibia Fractures
Immediate nailing : up to type IIIB fractures (reamed or unreamed)
Plating : a higher rate of infection
Soft tissue coverage Split-thickness skin grafts (STSG) Flaps reconstruction – bone, nerves…
Proximal : rotational gastrocnemius flap middle third : a soleus flap Distal defects : a sural flap or free flap
Complication - Nonunion
定義 : Not healed at 6 months or no progressive healing for 3 consecutive months
Patient factors : Smoking or medical comorbidities (diabetes)Poor nutritionUnderlying metabolic or endocrine disorders
Surgeon factors : Distraction of the fractureExcessive soft-tissue strippingExcessive reaming
Complication - Nonunion
Surgical treatment Hypertrophic non-unions : Exchange nail Atrophic non-unions : bone graft or orthobiologics Infected nonunions - ring (Ilizarov) E.F
Tibial Plafond Fractures (Pilon fractures)
Tibial Plafond Fractures
Higher energy with axial load Significant articular damage More compromised soft-tissue
envelopes High complication rate
At Emergency Room
Clinical evaluation : associated injuries Associated fracture (calcaneus…..) Neurologic or vascular compromise Compartment syndrome
Radiographic evaluation X-ray : AP, mortise, and lateral view CT scan : useful The timing of CT : after external fixation X
Classification Ruedi and Allgöwer system : articular displacement and comminution AO/OTA system : base on continuity to the tibial shaft
Type I Type II Type III
Ruedi and Allgöwer system
Articular Surface Fracture
A : anterolateral or Chaput fragment M : medial malleolar fragment P : posterior malleolar or Volkmann fragment
※ Additional articular pieces are created via secondary fracture lines
Primary fracture lines
J Bone Joint Surg 2005;87:692-697
Surgical Treatment
Immediate ORIF External Fixation Staged ORIF
Immediate ORIF
Principles Reconstruction of the fibula Anatomic reconstruction of the
articular surface Cancellous grafting of defects Plating via the medial aspect of the
tibia
Immediate ORIF
Complication (Ruedi and Allgöwer type III )
Wound dehiscence Infection Hardware failure
Related to Energy associated with the injury Experience of the surgeons !!
External Fixation With/Without Limited ORIF
For complex Pilon fractures The goal of preventing major
complications Worse quality of reduction
Timing to open surgery “ Wrinkle sign “
Staged ORIF
Advantages of an open approach while minimizing complications
Temporizing spanning E.F secondary soft-tissue trauma Pain control Provisional reductions via ligamentotaxis Improved soft-tissue evaluation
Staged ORIF Approaches – medial / lateral With the no-touch technique (no retraction of the soft tissues)
Approach 的選擇 : Fracture pattern: Articular/Metadiaphysis Direction of talar displacement Soft-tissue quality Necessity of fibular fixation Surgeon preference
Orthopedics, October 2010, 33 (10), p734-8
Staged ORIF
Multiple approaches Maximizing the interval between the
approaches may be safely less than 7 cm apart Wound complications/infection
J Orthop Trauma2008;22(5):299-305
Complications
Wound-healing and deep infections Malunions and nonunions Postoperative scarring and stiffness Hardware prominence Posttraumatic arthritis
How to get Better outcome ?
Changes in treatment techniques and implant design Staged management Soft-tissue handling Less extensile approaches Indirect reduction techniques Lower profile plates definitive external fixation
Honest assessments of individual capabilities ! ( 該轉就轉 !!)
Take home message Poor soft tissue envelope around ankle Be aware of compartment syndrome Respect soft tissue in surgery “No touch technique” Choose correct treatment strategy
Honest assessments of individual capabilities ! ( 該轉就轉 !!)
Thanks for your attentions !!