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

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:

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.