Tibia Fractures

Proximal Tibial Fractures

Mechanism

young pt - high energy trauma
old pt minor fall

Classification AO

extrarticular
intraarticular, unicondylar
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

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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

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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

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Tibial Shaft Fractures

Classification AO

Type A simple

a single circumferential disruption of the diaphysis - may be:

Spiral
Oblique ( angle more than 30 deg)
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:

Spiral wedge
Bending wedge
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:

Spiral
Segmental
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

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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

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