Tibial Shaft Fractures | Lower Extremity Trauma

 

Usually classified by location (proximal, middle, distal)

tibial shaft tibia

AO/OTA Classification of Tibial Shaft Fractures

  • AO/OTA Classification of Shaft Fractures (see Figure)
    • proximal, middle, or distal
    • Types A, B, and C
  • Oestern & Tscherne Classification of Soft Tissue Injury (Closed)
    • C-0: little or no soft tissue injury
    • C-I: superficial abrasion
    • C-II: deep, contaminated abrasion with local contusion damage to skin or muscle
    • C-III: extensive skin contusion or crushing muscle damage (compartment syndrome)
  • Mangled Limbs
    • tibial shaft is a common area
    • none of the mangled limbs scoring systems have really been shown to be predictive of outcomes
      • i.e. MESS score, etc.
    • don’t get fooled by going one way or another based upon the score
    • the key thing is the patient’s psychosocial support
      • this is most predictive of how they will do
    • antibiotic adminstration and time to trauma center are important
  • Conservative Indications
    • most are treated operatively, however, Sarmiento did described key factors associated with nonoperative success
    • short oblique or transverse
    • less than 2cm of shortening
    • 50% cortical apposition
    • varus/valgus 5 degrees
    • flexion/extension 10 degrees
  • Proximal Tibia – Operative Treatment
    • Intramedullary (IMN) Nail
      tibial shaft tibia   tibial shaft tibia

      Blocking (Poller) Screw Position for a Proximal Tibial Fracture with IMN (Screws Placed Lateral and Posterior)

      • proximal fractures have typical deformity
      • procurvatum and valgus
        • quads pull proximal piece into extension, and medially the hamstrings and the pes pull the piece medially (valgus)
      • blocking screws to prevent this
        • lateral side and posteriorly
      • can also use semi-extended nailing position (including suprapatellar nail)
        • plate
        • clamp
        • external fixator
      • safe zone start point
        • just medial to the lateral tibial spine
  • Tibial Shaft – Operative Treatment
    • can nail an open fracture, but make sure there is not gross contamination
    • external fixation is a less popular definitive treatment
    • studies say convert to 7 days, but clinically many people wait a little longer (14 days)
    • Grade III open – increased time to union and increased malalignment
  • Distal Tibia – Operative Treatment
    • may need blocking screws for IMN
    • consider reduction of fibula
    • can plate or ex-fix when necessary
  • Biologics
    • BMP-2 has been shown in recent studies to increase union rates and decrease infection rates in open fractures treated with a nail
    • OP-1 and BMP-7 have only been approved for nonunion
  • Complications
    • IMN has shown to have about 50% incidence of anterior knee pain, will usually improve
    • Nonunion
      • SPRINT study said wait 6 months, most of these will heal
      • options for treatment after 6 months include exchange nail and dynamization
    • Intact fibula increases risk of varus malalignment
  • Soft Tissue Loss and Flaps
    • proximal third – rotation flap (gastroc is common)
    • middle third – soleus or fascio-cutaneous flap
    • distal third – free flap or fascio-cutaneous flap (if not too large)
  • Compartment Syndrome
    • proximal tibial fractures especiall
    • increased during reaming or nailing
    • blood pressure is lower under ansesthesia so if delta P is 20-25, you will probably wake them up and check compartment pressures again in the PACU