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Tibia Fracture Menu:

    • Head Injury Cranio-Maxillary-Facial Injuries Cervical Spine Clavicle Fractures Shoulder Shoulder Spine Humerus Humerus Elbow Joint Elbow Joint Radius Radius Ulna / Ulnar Shaft Ulna / Ulnar Shaft Wrist Wrist Pelvic Pelvic Hand Hand Sacrum and Sacral Pelvic Hip Joint Hip Joint Femoral Shaft Femoral Shaft Knee Joint Tibia / Tibia Frx Ankle Joint Orthopaedic Foot Orthopaedic Foot
        
                    Frx Treatment Methods:               (Synthes) 
                              Casting of Tibial Fractures
                              External Fixators
                              Plating of Tibial Fractures:
                              Intramedullary Nails for Tibial Fracture: 

                     Amputation following Fractures of the Tibia
                     Blood Supply
                     Blounts Disease
                     Bone Grafting for Tibial Fracture
                     Bowing of Tibia:
                             - Anterolateral Bowing:
                             - Posteromedial Tibial Bowing:
                     Casting of Tibial Fractures 
                     Compartment Syndrome following Tibial fx
                     Congenital Pseudarthrosis
                     Flaps for the Tibia:
                     Indications for Internal Fixation
                     Intercondylar Eminence Frx
                     Infections in Fractures of the Tibia:
                     Lengthening of the Tibia
                     Malunion of the Tibia
                     Mangled Extremity Severity Score
                     Non Unions
                     Open Fractures of the Tibia (classification)
                     Pediatric Tibial Fracture
                     Pilon Frx:
                     Plateau Fractures:
                     Posterolateral Bone Grafting:
                     Prognosis of Tibial Fractures
                     Pseudoarthrosis of the Tibia:
                     References for Tibial Injury
                     Shin Splints:
                     Stress Frx:
                     Surgical Approaches to the Tibia
                     Tibial Defects
                     Tibial Hemimelia
                     Triplane Fracture
                     Tubercle Frx
                     Tumors of the Proximal Tibia
                     Vascular Injuries from Tibial Fractures;
                     X ray features 

         









      Patient considerations
                     Treatment Methods:              
                              Nonsurgical
                                 indications -- These are based on "personality" of the fracture as described by Nicoll EA:Fractures of the 
      Tibial Shaft -- a survey of 705 cases.  JB JS Br. 1964; 46: 373 -- 387.  He listed factors favoring union.  These include
       
    • displacement: if the fracture fragments on are or can be opposed to 25% in a transverse fracture, casting or bracing is permissible
    • comminution: internal fixation necessary
    • soft tissue wounds: open fractures should be treated by external fixation or intramedullary nailing
    • infection: external fixation is used until prominent fixation can be accomplished.
                                   cast--  yesterday I did cast
                                   Brace -- defer to Dr. Sarmiento
                               Surgical
                                  External Fixation
                                  plate
                                  intramedullary nail
                     classifications
                                soft tissue
                                bone
                     Indications for treatment-closed fracture
                                   proximal tibia
                                      intrarticular
                                      nonintrarticular Intramedullary nailing can be used if the interlocking screws can be placed in the proximal fragment.  Plating, both locked and unlocked is also an option.

      Reduction of the fracture -- reason for valgus reduction
       Intramedullary nail fixation of proximal tibia fractures results in more complications than nailing of diaphysis  fractures.  Malunion is common whenever the fracture is adjacent to junction of metaphysis and diaphysis. The battle union can day in the coronal plane -- Varus or valgus or in the sagittal plane -- flexion or extension.  The nail tends to follow path of least resistance.  This path begins with the starting point.  If the starting point is medial, the medial cortex of the tibia forces of the nail laterally.  The fracture line is often more proximal on the lateral side.  This provides less resistance to guide the nail so the nail and extends obliquely through the proximal fragment.  This direction of the nail places the fracture site in valgus when it enters the distal fragment.  Muscles of the anterior compartment also act as a tether which increases the valgus configuration.
      To prevent valgus configuration
         1 use a lateral starting point, either lateral parapatellar or through the patellar tendon
         2 use a curved awl for the starting point and sink it to the hilt thereby directing the direction of the nail.
         3 maintain reduction during reaming and insertion of the nail
         4 use a blocking screw on the lateral side of the proximal fragment.  This takes the place of the lateral cortex of the tibia.

        Flexion deformity may result during IM nailing of proximal tibia fractures.  This may result if the bend of the nail is distal to the fracture.  It is essential to maintain reduction of the fracture during reaming and nail insertion.  Reduction may be achieved by flexing the proximal fragment to 110° flexion or extending the distal fragment by inserting the nail proximal to the patella.  The figure 4 position can be used to flex the proximal fragment.  This allows the nail to past through the fracture site in optimum position.  The entrance hole can be placed at the edge of the articular surface, but flexion of the proximal fragment allows the entrance to be placed more distally.  When making the entrance hole with a curved awl, direct the awl anteriorly as you sink it to the hilt.

        If the posterior cortex of the tibia is  short, a blocking screw placed from medial to lateral will direct the nail.  It takes the place of the short posterior tibia cortex.  Always place a blocking screw where you do not want the nail to go.

        Some surgeons place a small plate, which holds the reduction during nailing

            diaphysis
        Intramedullary nailing is the preferred internal fixation of diaphyseal fractures.  Always check the stability of the fracture in all directions before beginning closed reduction.  Stability in all directions assures the surgeon that the nail is in the canal of the distal fragment.
        Reduction may be accomplished by gravity with a foot off the end of the table or the figure 4 position.  Ream until chatter over 4 cm of the canal.  The size of the nail may be one or 2 mm less than the size of the last reamer.
        Do not allow the nails to touch the skin as it is being inserted.
        The nail should extend to the metaphysis of the tibia.  Be sure the proximal end of the nail is not prominent.  There is disagreement about the proximal end of the nail causing knee pain after surgery.
        Interlocking screws are then placed.  There is disagreement about the number of interlocking screws needed.  Two screws should be used if the position of the screws is within 4 cm from the fracture site.  The screws should extend 2 threads past the far cortex and the head should be available for removal at a later date.
        Weight-bearing on crutches should be done a day after surgery.

              distal tibia
                 intrarticular
                 nonintrarticular
        Most distal fractures can be treated with intramedullary nailing if one were preferably two screws can be placed through the distal fragment.  The fact that this is a diaphyseal -- metaphysis junction predisposes to malunion as in the proximal tibia fractures.  Reduction must be maintained during the remaining and nail insertion.  Plating the fibula can give additional stability during nail and insertion.  Surgeons provide different indications for plating the fibula.  The fibula should be plated if the fragments are overlapping or the ankle mortise will be in valgus.  It should also be plated if only one screw can be placed in the distal fragment.
                        Indications for treatment-open fracture
                                      treatment options for soft tissue closure
                        Complications
                                      infection
                                      soft tissue defect
                                      nonunion
                                      malunion
                                      compartment syndrome
                                      amputation
                         Pediatric tibia fractures


























Original Text by Clifford R. Wheeless, III, MD.

Last updated by Clifford R. Wheeless, III, MD on Saturday, January 12, 2008 9:25 pm