Tibia Fractures

Proximal Tibial Fractures

Mechanism

young pt - high energy trauma
old pt minor fall

Classification AO

  1. extrarticular
  2. intraarticular, unicondylar
  3. intraarticular, bicondylar
60% are lat plateau
15% are med plateau
25% involve both

Evaluation

assess assoc injuries, neurovasc examination
XRay: plain films, biplanar tomography, CT

Treatment

Extraarticular

CR if necessary, AKPOP or cast brace

Intraarticular

Undisplaced
AKPOP/ cast brace
Displaced
ORIF / BG/ cast brace for split depression
simple depression fracture may be amenable to elevation without plating using an arthroscopic assisted technique
type C fracture- often very comminuted, difficult to reconstruc, thus CR/cast bracing often preferable
Note association with meniscal lesions in ~20%
collateral or cruciate lig injuries in ~20%

Complications

nonunion
rare
malunion
more common with nonop treatment
Bicondylar fracture
knee instability due to either malunion or ligament injury
infection
more common in bicondylar fracture - increased op time, exposure, hardware

Prognosis

ref: Anglen and Healy "tibial plateau fractures" Orthopaedics 11:1527-1534, 1988
Undisplaced fracture 85% satisfactory with nonop treatment
Displaced fracture 78% satisfactory with ORIF, 54% with nonop treatment
Lachiewicz and Funcik "factors influencing the results of ORIF of tibial plateau fractures"
CORR 259: 210-215, 1990
44 fractures, 2.7 yr FU, 91% good or excellent, implant removal needed in 1/3 pts

Tibial Spine Fractures

Mechanism

hyper extension or hyperflexion® avulsion

Classification

Meyers and McKeever "Fractures of the intercondylar eminence of the tibia"
JBJS 52A: 1677-1684, 1970

Type 1: undisplaced
Type 2: displaced hinging posteriorly
Type 3: displaced with complete separation

Treatment

Type 1 + 2 CR with knee in extension likely to be successful- if not ORIF
Type 3 ORIF

Prognosis

good , low incidence of late instability
if malunion may get impingement in extension

Avulsion of the Tibial Tubercle

ref: Ogden etal "fractures of the tibial tuberosity in adolescents" JBJS 62A:205-215, 1980

Mechanism

usually in vigorous sports- violent contraction of quads in sudden acceleration or deceleration

Classification

Type 1 fracture
across the secondary ossification centre level with the post border of the inserting patellar tendon
Type 2 fracture
at the junction of the primary and secondary ossification centres
of the prox tibial epiphysis
Type 3
fracture propagates across the primary ossification centre= SH type 3

Treatment

ORIF , protect in extension , ROM exs

Prognosis

excellent

Tibial Shaft Fractures

Classification AO

Type A simple

a single circumferential disruption of the diaphysis - may be:
  1. Spiral
  2. Oblique ( angle more than 30 deg)
  3. Transverse (angle less than 30 deg)

Type B multifragmentary: wedge

a fracture with one or more intermediate fragments in which after reduction, there is some contact bw the main fragments- may be:
  1. Spiral wedge
  2. Bending wedge
  3. Fragmented wedge

Type C Multifragmentary: complex

a fracture with one or more intermediate fragments in which after reduction , there is no contact bw the main prox and distal fragments- may be:
  1. Spiral
  2. Segmental
  3. Irregular

Treatment - closed injury

Nonoperative

best for fracture without significant comminution, shortening or displacement at the time of fracture. ie low energy fracture
AKPOP for 6/52, then convert to cast brace or PTB
union in approx 16 wks for simple fracture, longer for more complex injury (av 18 wks)
ref: Sarmiento etal "Tibial shaft fractures treated with functional braces: experience with 780 fractures" JBJS 71B: 602-609, 1989
90% healed with 1cm or less shortening
nonunion rate 2.5%

Operative

indicated in:
pt requires early return to work
displaced ie higher energy fracture
Failure of closed treatment
IM nailing:
ref: Hooper etal "Conservative management or closed nailing for tibial shaft fractures : a randomised prospective trial " JBJS 73B: 83-85, 1991
infection rate ~ 1-2%
angulatory deformities rare
shorter hospital stay, less OPD visits
earlier return to work

Treatment - Open Fractures

Wound management as for any compound fracture
IM Nailing
Court-Brown etal "Infection after intramedullary nailing of the tibia" JBJS 74B: 770-774, 1992
Tornetta etal " treatment of grade 3B open tibial fractures- a prospective randomised comparison of external fixation and nonreamed nailing" JBJS 76A:13-19, 1994
Grade 1
IM nailing - same figures as for closed fracture
Grade 2
infection 3.8%
Grade 3
A: infection 5.6%
B: infection 12.5%
External fixation:
Use for grade 3B and 3C
rates of infection same as nailing for grade 3B with added problem of pin tract infection, delayed union also a feature of ex fixation.
sometimes need to convert from ex fix to IM nail- risk of infection in the face of recent pin tract infection is ~ 20%, However if the ex fix is removed within 3 wks of application + wait another 2 wks,can nail with infection rate of ~ 5%
Ref: Johansen etal " Objective criteria accurately predict amputation following lower extremity trauma " J Trauma 30: 568-573, 1990

The MESS

1. Skeletal/ soft tissue injury
a. Low energy
eg simple fracture, civilian gunshot
 1
b. Medium energy
eg open or multiple fractures, dislocation
 2
c. High energy
eg close range shotgun, military gunshot, crush
 3
d. Very High energy
above + gross contamination
 4
2. Limb Ischaemia ( score doubled for ischaemia more than 6 hrs)
a. Pulse reduced or absent but perfusion normal
 1
b. Pulseless, parasthesias, reduced capillary refill
2
c. Cool, paralysed, insensate
 3
3. Shock
a. Systolic BP always more than 90 mm Hg
 1
b. Hypotensive transiently
 2
c. Persistent Hypotension
 3
4. Age
less than 30
 0
30-50
 1
more than 50
 2

A score of 7 or higher indicates amputation

Malunion

malalignment of more than 15 deg varus or valgus may require corrective osteotomy
intact fibula predisposes to varus
malrotation
IR more than 10 deg may cause gait problems
ER up to 20 deg acceptable
shortening
less than 2cm not a problem

Delayed union or Nonunion

more common in high energy fracture
with intact fibula- osteotomise fibula + FWB in cast- 80% unite
hypertrophic: unite with fixation
hypotrophic: unite with fixation and grafting

Infection

see above for rates

Bone defects

graft or bone transport

Skin loss

Neuro-Vascular injuries

Joint stiffness

knee stiffness rare, occasional ankle or ST jt stiffness

Tibial Plafond Fractures

Mechanism

axial compression (= pilon fracture)

Classification AO

A Extra articular


1. Metaphyseal simple
2. Metaphyseal wedge
3. Metaphyseal complex

B Partial articular


1. pure split
2. split depression
3. depression multifragmentary

C Complete articular

1. articular simple, metaphyseal simple
2. articular simple, metaphyseal complex
3. articular and metaphyseal complex

Treatment

Nonoperative

type A fracture - CR/POP
type B and type C if jt congruity restorable via CR

Operative

if jt surface reconstructible- ORIF/BG
if not reconstructible use closed treatment and may need later fusion

Prognosis

Bourne etal " Pilon fractures of the distal tibia" CORR 240:42-46, 1989
36% satisfactory results in intra artic fracture treated with closed means
76% satisfactory for operative treatment
32% at 4.5 yrs had undergone ankle arthrodesis for failed result