Date post: | 17-Dec-2015 |
Category: |
Documents |
Upload: | lilian-murphy |
View: | 218 times |
Download: | 0 times |
Closed Fractures of the Tibial Diaphysis
• Much emphasis to High Energy fractures• In Fact: 76.5% are closed
53.5% have mild soft tissue damage
Tibial Fractures
• Most common long bone fracture
• 492,000 fractures yearly• Average 7.4 day hospital
stay• 100,000 nonunions per
year
History & Physical
• Pain, inability to bear weight, and deformity
• Local swelling and edema variable
• Careful inspection of soft tissue envelope, including compartment swelling
• Thorough neurovascular assessment including motor/sensory exam and distal pulses
Physical Exam
• Soft tissue injury with high-energy crush mechanism may take several days to fully declare itself
• Repeated exam to follow compartment swelling
Radiographic Evaluation
• AP and Lateral views of entire tibia from knee to ankle
• Oblique views can be helpful in follow-up to assess healing
Associated Injuries• Up to 30% of patients
with tibial fractures have multiple injuries
• Ipsilateral fibula fracture common
• Ligamentous injury of knee with high energy tibia fractures
Browner and Jupiter, Skeletal Trauma, 3rd Ed
Associated Injuries
• Ipsilateral femur fx, “floating knee”
• Neuro/vascular injury less common than in proximal tibia fx or knee dislocation
• Foot and ankle injury
Classification
• Numerous classification systems
• Important variablesPattern of fracture
location of fracture
comminution
associated fibula fracture
degree of soft tissue injury
OTA Classification• Follows Johner &
Wruh system
• Relationship between fracture pattern and mechanism
• Comminution is prognostic for time
to union Johner and Wruhs, Clin Orthop 1983
Henley’s Classification
• Applies Winquist & Hansen grading of femur 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
• 5-15%• HISTORY
Hi-Energy
Crush
• 4 leg compartments
Nerve is the Tissue most Sensitive to Ischemia
• PAIN first Symptom
• PAIN with Passive Stretch first Sign
Each Compartmenthas Specific Innervation
• Ant Comp - Deep Peroneal N.• Lateral - Sup Peroneal N.• Deep Post. - Tibial N.• Sup Post. - Sural N.
Anterior Compartment
• Dorsiflexes ankle
• Tib ant, EDL, EHL, and peroneus tertius muscles
• Anterior tibial a./v.• deep peroneal n.
1st webspace sensation
Lateral Compartment
• Everts the foot
• Peroneus brevis and longus muscles
• Superficial peroneal n.dorsal foot
sensation
Superficial Posterior Compartment
• Plantarflexes ankle
• Gastrocnemius, soleus, popliteus, and plantaris muscles
• Sural nerveLateral heel sensation
• Greater and lesser saphenous veins
Deep Posterior Compartment
• Plantarflexion and inversion of foot
• FDL, FHL, Tib post muscles
• Post tibial vessels, peroneal a.
• tibial nervePlantar foot sensation
Compartment Syndrome is a Clinical Diagnosis
Pressure Measurements are Helpful
• Various Thresholds
P = 30
P = 45
∆ P < 30= Diastolic BP - Compartment Pressure
McQueen, JBJS-B, 1990
Pressures Not Uniform
• Highest at Fracture Site
• Highest Pressures in Posterior & Anterior Compartments
•Heckman JBJS 76
Clinical Monitoring
• Need Close Observation
• Repetitive Exams• Some instances
repetitive Pressure measurements
• Indwelling Monitors?
Goals of Fasciotomy
• Decompress The Compartment
• Do Not Strip Muscle From The Bone
• Single vs. Two incisions
• Plan for fracture fixation
• Plan for wound closure
Closed Tibial Shaft Fractures
• Broad Spectrum of Injures w/ many treatments
• Nonsurgical management
• Intramedullary nails• Plates• External Fixation
Nonoperative Treatment Indications
• Minimal soft tissue damage
• Stable fracture pattern• < 5° varus/valgus• < 10° pro/recurvatum• < 1 cm shortening
• Ability to bear weight in cast or fx brace
• Frequent follow-up
Schmidt, et.al., ICL 52, 2003
Fracture Brace
• Closed Functional Treatment
1,000 Tibial Fractures
60% Lost to F/u
• All < 1.5cm shortening• Only 5% more than 8° varus
• Average 3.7wks in long leg cast, then
Functional fracture brace
Sarmiento, JBJS 1984
Sarmiento
• Union 98.5%• Time 18.1 Wks.• Short >20mm
1.4%
Initial shortening = final shortening
Ankle Motion after tibia fractures
• 25% patients with 25% loss of ankle-ROM
Natural History
• Long-term angular deformities may be well tolerated without associated knee or ankle arthrosis
• Kristensen F/U: 20-29 yrAll patients >10 degree deformity
• Merchant & Dietz F/U: 29 yrs. Outcome not associated with ang., site, immob.
(37/108 patients)
Surgical Indications
• High energy fracture
• Moderate soft tissue injury
• Unstable fracture patternInability to maintain reduction
• Open fracture
• Compartment syndrome
• Ipsilateral femur fracture
• Pt cannot tolerate long-leg cast
Schmidt, et.al., ICL 52, 2003
Surgical Options
• Intramedullary nail
• ORIF with plate
• External Fixation
Advantages of IM Nail
• Less malunion and shortening
• Earlier weight bearing• Early ankle and knee
motion• Possibly cheaper than
casting if time off work included
Tovainen, Ann Chir Gynaecol, 2000
IM Nails – Hooper, et.al.
• In a prospective study if displacement >50% angulation >10°
• Nails superior to cast treatment
Hooper, JBJS-B, 1991
IM Nails – Bone, et.al.
Retrospective review 99 patients
Cast Nail
Time to union 26wks 18wks
SF-36 74 85
Knee score 89 96
Ankle score 84 97 Bone, et.al. JBJS, 1997
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, et.al. Injury Mar 2005Bhandari, et.al., JOT 2000
Blachut JBJS 79A
Reamed Non-Reamed
# pts. 73 63
Nonunion 4% 11%
Malunion 4% 3%
Broken Bolts3% 16%
Reamed vs. Nonreamed Nails
IM Nails – Interlocking Bolts
• Loss of alignment w/out interlocking
• Spiral 7/22
• Transverse 0/27
• Metaphyseal 7/28
•Templeman CORR 1997
Complications
• Infection 1-5%
• Union >90%
• Knee Pain 56%w/ kneeling 90%
w/ running 56%
at rest 33%
Court-Brown, JOT 1996
IM Nail Removal – Knee Pain
• Pain resolved 27%
• Marked improvement 69%
• Pain worse 3%
• No difference in knee pain based on tendon sparing approach
Court-Brown, JOT 1996
Iaquinto, Am J. Orth 1997
Neurological Complications
63 patients reviewedCompared type of anesthesia
4.1 X greater risk of Neurologic injury w/ epidural
Need to monitor exam postop
Disadvantages of IM Nail
*Court-Brown et al. JOT 96
• Anterior knee pain (up to 56.2%)
• Risk of infection• Increased hardware
failure with unreamed nails
Expanded Indications
• Proximal 1/3 fractures• Beware Valgus and Procurvatum
• Distal 1/3 fractures• Beware Varus or valgus
Proximal Tibia Fracture
• Entry site is critical
• Reference is Lateral Tibial Spine
Just Right
Too Low! Too Medial!Procurvatum Valgus
Semiextended Position
• Neutralize quadriceps pull on proximal fragment
• Medial parapatellar approach – sublux patella laterally
• Use handheld awls to gently ream through the trochlear groove
Tornetta, CORR Jul 1996
Hyperextended position
• Pulls patella proximally to allow straight starting angle.
• Universal distractor
Beuhler & Duwelius, JOT 1997
Blocking (Poller) Screws
• Functionally narrows IM canal
• Increases strength and rigidity of fixation
• 21 patients
• All healed within 3-12 months• Mean alignment 1 degree valgus, procurvatum 2 degrees.
Krettek C, et al. JBJS 81B: 963, 1999
Technique
• Screws placed on concave side of deformity.
• Proximal or distal fractures
Distal Tibial Fractures
• Reduction before reaming
• Distractor• Fibula plate• Joy Stick• Calcaneal Traction
Universal Distractor Reduction
Beuhler & Duwelius, JOT 1997
Plate Fibula
Egol, et.al. JOT Feb 2006
Distal Tibia 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 Feb. 2004.
Plating of Tibial Fractures
• Narrow 4.5mm DCP plate can be used for shaft fractures
• Newer periarticular plates available for metaphyseal fractures
AO Technique of Tibia Plating
• Anterior longitudinal incision• Plate on medial border of tibia• 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
Subcutaneous Tibial Plating
• Newer alternative is use of limited incisions and subcutaneous plating- requires indirect reduction of fracture
Advantages of Plating
Anatomic reduction usually obtained
In low energy fractures 97% very good/good results have been reported
Ruedi et al. Injury vol 7
Disadvantages of Plating
• Increased risk of infection and soft tissue problems, especially in high energy fractures
• Higher rate hardware failure than IM nail
Johner and Wruhs, Clin Orthop 1983
External Fixation
• Generally reserved for open tibia fractures or periarticular fractures
Technique of External Fixation
• Unilateral frame with half pins • 5mm half pins (‘near-near and
far-far’)• 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
Outcomes of External Fixation
Anderson et al. Clin Orthop 1974Edge and Denham JBJS[Br] 1981
• 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
Conclusions
• Common fracture w/ several treatment options.
• Closed stable fxs. can be treated in a cast.
• Unstable fxs. often best treated by intramedullary nail