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Tibial Shaft Fractures

     I.   Introduction—Tibial shaft fractures are one of the most common diaphyseal fractures treated by
orthopaedic surgeons. The majority of these fractures heal without complication and most patients return
to their preinjury level of functioning. Specific types of tibial shaft fractures are more prone to complication
and require the expertise of a well-trained orthopaedist to avoid complication and optimize functional
outcome.

    II.   Evaluation
          A.   History and Physical Examination
                1.      History—Patients with tibial shaft fractures experience pain in the leg after sustaining a low- or high-energy
injury. Information about the nature and timing of the accident, any reduction or manipulation performed
on the extremity and the patient’s significant medical history should be obtained.
                2.      Visual examination—All clothing should be removed from the extremity. The overall appearance of the
extremity should be noted for open wounds, alignment, contusions, swelling, and color. Wounds should
be assessed for size, location, degree of contamination, and severity of tissue injury.
                     •   Deformities—Often a significant deformity is present at the level of the fracture. Contusions may indicate
the point where a force was applied to the leg to create the fracture, or they may be incidental. The
location of a significant contusion is important because it can necessitate a change in the treatment plan
to avoid incising through badly traumatized tissue.
                     •   Comparison to the contralateral leg—Comparison of the injured leg to the contralateral leg usually reveals
a large amount of swelling. This swelling progresses with time. The amount of swelling present should
serve as a preliminary index of the severity of injury to the tissues.
                     •   Color—The color of the extremity reveals essential information about a limb’s perfusion. A pinkish color
indicates oxygenated blood in the capillaries of the skin but reveals little about the deep circulation. A gray
or dusky color, however, indicates circulatory compromise and a potential for limb loss if proper treatment
is not provided promptly.
                     •   Movement—After visually inspecting the leg, the physician should observe what the patient can do with
the leg before the physician palpates or manipulates it. Attention should be directed at flexion and
extension of the knee, ankle, and toes. Occasionally, the patient is too uncomfortable to comply with this
part of the examination.
                3.      Palpation
                     •   Pulses—An effort should be made to feel for pulses of the popliteal, dorsalis pedis, and posterior tibial
arteries. If strong pulses are not appreciated, Doppler ultrasound should be used to evaluate the dorsalis
pedis and posterior tibial arteries. If triphasic pulses are not present on Doppler ultrasound and the leg is
deformed, traction should be applied to the extremity and the pulses reevaluated. If the pulses remain
abnormal, emergent arteriography and/or consultation with a vascular surgeon should be obtained.
                     •   Direct palpation—Occasionally, the injured leg appears fairly normal, and the results of the neurovascular
exam are unremarkable. Direct palpation of the fracture, however, elicits pain and possible crepitation,
which are indicative of a tibial shaft fracture.
                4.      Compartment syndrome—After ruling out vascular injury, the physician must evaluate for compartment
syndrome. If the patient can actively flex and extend the ankle and toes without severe pain, compartment
syndrome is not likely to be present at that time. Compartment syndrome can, however, evolve with time;
thus serial examination and attention to the patient’s symptoms are necessary.
                     •   Signs and symptoms—The alert patient commonly has a significant amount of pain from the fracture, and
so ruling out compartment syndrome becomes more difficult. Pain out of proportion to the injury
should make the physician suspicious. The most sensitive sign on physical examination is pain
on passive stretch of the muscles in the involved compartment. Other significant signs are tight
compartments, decreased sensation, and muscle weakness, although these signs may not always be
present. Examination of the pulses is misleading since pulses may be palpable when compartment
syndrome is present.
                     •   Compartment Pressure—Evaluation of the compartments in the unconscious, intoxicated, or otherwise
mentally impaired patient is more difficult because the patient has an altered response to pain. If there is
any suspicion of compartment syndrome, then slit-catheter measurement of pressure in all four
compartments is necessary to confirm or rule out the diagnosis. The exact pressure at which
compartment syndrome occurs is variable. In general, a compartment-diastolic pressure difference of
less than 30 mm Hg in any compartment is an indication for emergent four-compartment
fasciotomy.
                5.      Open fractures—It must be assumed that open wounds in the vicinity of a tibial shaft fracture communicate
with the fracture, and urgent irrigation and debridement should be planned (Fig. 11-1). Open wounds a
distance away from the fracture may communicate with the fracture. Probing or inspection of extremity
wounds for communication with the fracture should be performed in the operating room after sterile
preparation and draping of the extremity.
          B.   Radiographic Evaluation—Radiographic evaluation of a tibial shaft fracture requires anteroposterior and
lateral X-ray films. These X-ray films must include the entire tibia in addition to the distal femur and ankle,
since associated fractures may be present and could alter the treatment plan. Computed tomography is
occasionally helpful in delineating subtle fracture extension in very distal and very proximal shaft
fractures. Stress fractures of the tibial shaft may not be visible on plain X-ray films. In this instance, an
MRI scan or a three-phase bone scan assists in making the diagnosis.
 FIGURE 11-1 Clinical photograph of a young man involved in a coal mining accident showing severely
contaminated wounds overlying his tibia fracture. Because of the significant tissue destruction this is a
Gustilo type IIIb open tibia fracture.

   III.   Classification
          A.   Fracture—Several classification systems exist for the tibial shaft fracture. The importance of any system is
its ability to differentiate fractures into treatment groups and its ability to predict outcome. For the closed
tibial shaft fracture, the classification of Johner and Wruhs is straightforward and simple (Fig. 11-2). This
classification system is based on the fracture location, the mechanism of injury, and the amount of energy
dissipated in the fracture (i.e., the fracture comminution). The Arbeitsgemeinshaft für Osteosynthesfragen
(AO) or Orthopaedic Trauma Association (OTA) classification is somewhat similar in scope but more
detailed and complex. This classification is probably best used for accurately classifying fractures for
research purposes because it allows for meaningful evaluation and comparison of fractures in different
patients from different studies.
          B.   Open Fracture—Open fractures are best described using Gustilo’s grading system. Type I open fractures
have small (<1 cm), clean wounds; minimal injury to the musculature; and no significant stripping of
periosteum from bone. Type II open fractures have larger (>1 cm) wounds but no significant soft-tissue
damage, flaps or avulsions. Type III open fractures have larger wounds and are associated with extensive
injury to the integument, muscle, periosteum, and bone. Gunshot injuries and open fractures caused by a
farm injury are special categories of Type III open fractures on account of their higher risk of
complications, particularly infection. Type IIIa injuries have extensive contamination and/or injury to the
underlying soft tissue, but adequate viable soft tissue is present to cover the bone and neurovascular
structures without a muscle transfer. Type IIIb injuries have such an extensive injury to the soft tissues
that a rotational or free muscle transfer is necessary to achieve coverage of the bone and neurovascular
structures. These injuries usually have massive contamination. Type IIIc injuries are any open fractures
with an associated vascular injury that requires an arterial repair. Often, what appears to be a Type I or
Type II open fracture on initial examination in the emergency room is noted to have significant periosteal
stripping and muscle injury at the time of operative debridement and may require muscle transfer for
coverage with serial debridements. Thus there is a tendency for the Gustilo classification type to increase
with time.
 Fracture by torsion (A1, B1, C1): One spiral fracture line, the others ± longitudinal fibular fracture are usually at a different level
Fracture by bending (A2, A3, B2, B3, C2): Transverse on tension side (i.e., opposite fulcrum). Fibular fracture is usually at the same level
Fracture by crushing (C3)
FIGURE 11-2 Johner and Wruh’s classification system for tibial shaft fractures.
          C.   Soft-Tissue Injury—Tscherne has classified closed fractures according to the severity of the soft-tissue
injury. Grade 0 injuries have negligible soft tissue injury. Grade 1 closed fractures have superficial
abrasions or contusions of the soft tissues overlying the fracture. Grade 2 closed fractures have
significant contusion to the muscle and/or deep contaminated skin abrasions. The bony injury is usually
severe in these injuries. Grade 3 closed fractures have a severe injury to the soft tissues, with significant
degloving, crushing, compartment syndrome, or vascular injury. The influence of the soft-tissue injury on
treatment is discussed later.

   IV.   Associated Injuries
          A.   Fractures—Most tibial shaft fractures result from low-energy trauma and do not have associated injuries.
As the severity of the tibial fracture increases, the incidence of associated injuries increases to greater
than 50%. Injuries to the ipsilateral extremity, including knee ligament disruption, femur fracture, and
ankle fracture, are among the most common associated injuries. Thus physical examination should be
directed at ruling out these injuries before and after treatment of the tibial shaft fracture.
                1.      Ipsilateral fibula—Fracture of the ipsilateral fibula occurs with most tibial shaft fractures. This fracture can
occasionally signify a significant injury to the ankle or proximal tibiofibular articulation, so the importance
of a fibula fracture should not be underestimated.
          B.   Neurovascular Injuries—Injury to the neurovascular structures is also common; thus thorough serial
examination of the circulation, sensation and motor function is necessary to detect these injuries early
and to provide proper treatment.
           C.   Other Injuries—Associated injuries to the head, chest, and abdomen occur most commonly in patients with
severe tibial fractures sustained from high-energy trauma. These patients require a thorough, systematic
evaluation according to the advanced trauma life support (ATLS) guidelines to detect and treat these
injuries as expediently as possible.
    V.   Treatment and Treatment Rationale (Table 11-1)
          A.   Nonoperative Treatment—Closed treatment of most tibial shaft fractures produces good-to-excellent
results. Because it is inexpensive and fairly quick to perform, and because it carries little risk of
complication, closed treatment should be the treatment considered first for most stable tibial shaft
fractures.
                1.      Reduction—The technique of closed treatment begins with the administration of sedation or anesthesia to
perform closed reduction of the fracture, if necessary. Reduction is achieved by hanging the leg over the
stretcher and applying longitudinal traction. Manipulation of the fracture may be required to achieve
proper alignment. X-ray films should be obtained after manipulation to ensure acceptable reduction.
                2.      Immobilization—The fracture should initially be placed in a well-padded long leg splint. Circumferential
casting will not accommodate swelling and can lead to increasing pain and parasthesias
subsequent to reduction. If a cast is applied, it must be bivalved to allow for soft-tissue swelling.
The long leg splint or cast can be changed to a patella-tendon bearing (PTB) cast when soft callus has
formed at the fracture site, at which time the fracture site will not have tenderness when pressure is
applied. This may take as little as 8 to 10 days or, with some fractures, as long as 3 to 4 weeks. X-ray
studies in the PTB cast are essential to confirm proper alignment. At this point, the patient may begin to
bear weight on the extremity.

TABLE 11-1
                3.      Alignment—There is considerable controversy regarding how much malalignment of a tibia fracture can be
tolerated. Certainly, anatomic alignment with no angulation on the anteroposterior and lateral X-ray films
is the goal, but this is not always achieved. Angulation in the sagittal plane is tolerated better than
angulation in the coronal plane. This increased tolerance is due to the fact that the knee and ankle move
in the sagittal plane, so this motion “makes up for” some angulation. Coronal plane angulation, however,
results in varus or valgus malalignment, which produces asymmetric loading of the ankle and knee joints.
                     •   Angulation—It is not clear how much angulation is required to produce osteoarthritis, since multiple factors
influence the progression of osteoarthritis, including the location of the fracture and the age of the
patient. In general, angulation of more than 10° in the sagittal plane and more than 5° in the
coronal plane are significant enough to warrant remanipulation of the fracture or wedging of the
cast. On the other hand, some surgeons argue that a tibia fracture that heals with as much as 20°
angulation can be tolerated by most patients. (The authors do not agree with these surgeons.)
                     •   Shortening—Shortening of 1 cm or less is rarely symptomatic, and shortening of 2 or 3 cm can be made
tolerable with a 1.25 cm (0.5 in) shoe insert.
                     •   Rotational malalignment—The amount of rotational malalignment that can be tolerated varies from patient
to patient. In general, if the rotational malalignment affects gait or causes knee or ankle symptoms,
operative correction should be considered.
                4.      Assessment of healing—The patient in a patella-tendon bearing cast should have radiographic evaluation
of the fracture every 6 or 8 weeks. When the healing appears complete on X-ray films and the patient has
clinical evidence of healing (i.e., no motion or pain with force applied across the fracture), then the cast is
no longer required. This may be as early as 8 weeks after the injury but most commonly occurs 12 to 16
weeks after the injury. At this point, a rehabilitation program, including gait training, ankle rehabilitation,
and strengthening of the quadriceps and gastrocsoleus muscles, quickens the return to normal function.
          B.   Operative Treatment
                1.      Indications
                     •   Absolute—There are several absolute indications for operative stabilization of tibial shaft fractures. Open
fractures should have stabilization of the fracture to provide a stable environment for soft-tissue healing
and to facilitate wound care. Fractures with a vascular injury require skeletal stabilization to protect the
vascular repair. Fractures with compartment syndrome should have skeletal stabilization to provide a
stable environment for the injured tissues. Stabilization of the tibia should be performed in tibial shaft
fractures in patients with multiple injuries to improve patient mobility, minimize pain, and possibly
reduce the release of pro-inflammatory mediators.
                     •   Relative—Relative indications for operative stabilization include significant shortening of the fracture on
initial X-ray studies, significant comminution, a tibia fracture with an intact fibula (Fig. 11-3), and a
displaced tibia fracture with a fibula fracture at the same level. In each of these fractures, there is a high
incidence of malunion or nonunion with nonoperative treatment.
                2.      External fixation
                     •   Standard—External fixation of a tibial shaft fracture is a quick and technically easy way to achieve fracture
stability. For this reason, it is useful in a patient with multiple injuries who is hemodynamically unstable
(“damage control”) or in a patient who would benefit from quick fracture stabilization before emergent
repair of an arterial injury. It also can be used if an open fracture wound is severely contaminated and the
 surgeon has reservations about putting hardware in the wound. An external fixator can be applied through
small incisions, thus avoiding additional trauma to tissues that may lack the ability to heal.

FIGURE 11-3 Anteroposterior X-ray film of a leg demonstrating a segmental tibia fracture with an intact
fibula, a very unstable fracture.
                     •   Ring fixators—Ring fixators, including Ilizarov and hybrid fixators (which use half-pins on one side of the
fracture and rings with wires on the other side), offer the same advantages of traditional external fixators.
These fixators obtain fixation with wires passed through bone. The wires are then placed on tension and
attached to a ring. The ring is then attached to the external fixation frame, which may consist of a single
bar or multiple, smaller threaded rods. The bars are secured to half-pins inserted into the bone. The
advantage of wires and rings is that they provide a relatively noninvasive means of fracture fixation, and
obtain good fixation strength, particularly with metaphyseal proximal or distal tibia fractures. Ring fixators
require more expertise than traditional external fixators do, but can be used to fix fractures that are more
complex and fractures with intraarticular extension without spanning the associated joint (Fig. 11-4).
Furthermore, the wires of these fixators do not loosen as quickly as the half-pins used with traditional
external fixators, so these fixators are useful for treating fractures that are likely to heal slowly.
                3.      Open reduction with internal fixation (ORIF)—ORIF is an excellent means by which to achieve stable
fixation of a tibial shaft fracture and allow early postoperative motion. Successful healing is usually the
rule. The chief risk of the procedure is wound-healing problems. In fractures with significant injury to the
soft tissues of the leg, the use of a plate and screws may not be appropriate because the risk of wound-
healing problems with this treatment may be too high. Severely traumatized legs with open tibial
fractures (Gustilo type III) have a high incidence of wound-healing complications and deep
infection when treated with ORIF.
                     •   Fracture fragments—When ORIF of a tibial fracture is performed, the surgeon must respect the biology
and physiology of all of the tissues. It is unnecessary and unwise to attempt to reduce and stabilize
every fracture fragment, since attempts to do this often require extensive dissection and
 periosteal stripping. The result will be an attractive postoperative X-ray film of a tibia that lacks the
ability to heal. It is preferable to obtain proper alignment and secure fixation of the proximal and distal
tibia. The intervening bone fragments should be gently reduced with a dental pick, leaving their soft-tissue
attachments alone so that they maintain their capacity to heal.
                     •   Postoperative treatment—After ORIF of a tibial fracture, the incision should be closed over a suction drain
and the leg splinted in neutral position to protect the soft tissues in the early healing phase. In 3 to 5 days,
active motion of the knee and ankle should be initiated. Weightbearing should be prohibited until in the
judgment of the surgeon, sufficient healing has occurred and the bone-plate construct can tolerate this.
Often, a tibial fracture that has been treated with ORIF heals with minimal fracture callus (primary cortical
healing). In these patients, a useful radiographic sign of fracture healing is “fading” or “blurring” of the
fracture lines as new bone grows across the fracture line (Fig. 11-5) Weightbearing should begin with a
protective orthosis, from which the patient can be weaned as healing nears completion and the patient
becomes more comfortable.
 FIGURE 11-4 A. Anteroposterior X-ray film of a multifragmentary tibial shaft fracture caused by a gunshot
wound. B. Postoperative X-ray film demonstrating excellent alignment achieved with an Ilizarov external
fixator. C. Clinical photograph demonstrating minimal dissection of the skin in the fracture region.
                     •   Minimally Invasive Plate Osteosynthesis (MIPO)—Techniques and devices have been developed that
allow plate and screw fixation of tibial shaft fractures through small incisions and with limited dissection.
 This technique has the advantage of minimizing disruption of the peripheral blood supply to the bone, and
potentially decreases wound healing problems. However, acceptable fracture reduction and stable fixation
must be achieved if this technique is to be successful.
                4.      Intramedullary nailing
                     •   Advantages—Intramedullary nailing has emerged as the most popular method for stabilizing displaced
tibial shaft fractures. The advantages of intramedullary nailing are that proper alignment of the fracture is
not difficult to achieve and the intramedullary location of the nail makes it more resistant to fixation failure
(Fig. 11-6). Intramedullary nails are inserted through incisions near the knee, so badly traumatized tissues
in the mid-leg can be avoided. Placement of interlocking screws can be performed percutaneously
through small incisions. The use of proximal and distal interlocking screws maintains proper length and
rotation of even an unstable, comminuted fracture until healing has occurred.
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Jun 12, 2016 | Posted by admin in ORTHOPEDIC | Comments Off on Tibial Shaft Fractures

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