3.16 Tibial shaft
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1 Introduction
Tibial shaft fractures (TSFs) constitute one of the most common indications for surgery in trauma centers [1]. In the general population, most TSFs are the result of high-energy trauma, such as motor vehicle collisions, falls from a height, and sports-related collisions. Conversely, in older adults, TSFs occur predominantly in osteoporotic women following a low-energy fall [2].
As the population ages, the prevalence of osteoporosis and number of falls or risk for falls is on the rise. Nevertheless, some registries have noted a decrease in the incidence of TSF in older adults during the last decade [3].
Due to the mechanism of injury as well as the delicate soft-tissue envelope of the tibia, soft-tissue compromise is often a complicating factor. In the older population, this situation is even more pronounced:
Medical comorbidities negatively impact the condition of the soft-tissue envelope.
Vulnerability and impaired healing of the skin, subcutaneous tissue, and muscle can result in surgical site infection with more serious complications to follow. Trauma always results in a certain amount of stress to the soft tissues (first hit) as does surgery and possible complications (second hit).
Meticulous soft-tissue handling techniques and dissection are of utmost importance. It is essential that reduction and osteosynthesis cause as little harm as possible, making minimally invasive plate osteosynthesis a preferred technique.
An interdisciplinary team including a plastic surgeon, vascular surgeon, and dietician should address extensive soft-tissue damage.
Some important facts about TSFs:
In the geriatric population, TSFs occur preponderantly in women following a low-energy fall from standing height.
The incidence of compartment syndrome with TSFs is between 1.5% and 9% [4, 5].
Compartment syndrome can result from the induced swelling (primary) or secondary to reperfusion syndrome.
Intramedullary (IM) nail fixation is the preferred operative treatment in the general population; its high-load capacity allows for early weight bearing and its low invasiveness allows for minimal interaction with the skin and subcutaneous tissue around the fracture.
Open fractures and fixations that do not use a nail are predictive factors for nonunion [3]. Optimizing fracture reduction is essential as greater diastases are associated with higher rates of nonunion [6].
2 Epidemiology and etiology
Tibial shaft fractures have an incidence of 17–22 per 100,000 population per year. They account for 2% of all fractures and 36.7% of all long bone fractures in adults making them the most common long bone fracture [2, 7].
Patient age-related fracture distribution displays two main demographic peaks: young men and older women. Incidence rates in women show a steady increase with patient age and reach their maximum at > 90 years of age at 36 per 100,000 per year. Incidence rates in men, however, decrease with patient age reaching a relatively stable level of around 13 per 100,000 per year from > 60 years of age [7]. The typical bimodal fracture distribution in young men and older women implies that osteoporosis is an underlying etiological factor in the geriatric population [2].
The traumatic etiology of TSFs varies significantly between countries. While in developing countries traffic accidents are the leading cause, in developed countries ground-level falls have become the most common mechanism [2, 7, 8]. This is probably due to differences in road safety, life expectancy, and the age distribution of the population.
Most TSFs are closed injuries. However, between 20% and 30% are open fractures. Open fractures are significantly associated with perioperative complications. Motor vehicle collisions are the most common cause of injury for open fractures (60%) [7]. In developed countries, pedestrians older than 65 years involved in motor vehicle collisions account for about 30% of TSFs and almost 60% of open TSFs.
The incidence of open fractures tends to rise with age in women, from 200 per million per year between the age of 60 and 69 years to over 525.7 per million per year over the age of 80 years. In men, the incidence of open fracture decreases linearly to reach 232.0 per million per year over the age of 90 years [9].
Interestingly, open TSFs increase with age in both women (351.6 per million per year in those ≥ 80 years versus 24.4 per million per year in those ≤ 65 years) and men (149.3 versus 31.5, respectively). About 60% of open TSFs in women older than 80 years are caused by a fall. The higher incidence of open fractures in women may partly be explained by the relatively thicker skin in men (1.8-fold, P < .05) [6]. Skin aging decreases collagen and elastin organization and skin thickness decreases from the fourth to fifth decade of life [10]. Furthermore, skin thickness is a predictor of bone density. Those two factors likely explain the increase in open TSF with age.
A major complicating factor is the development of compartment syndrome. This potentially devastating injury is often associated with tibial fractures. The incidence of compartment syndrome with TSFs is between 1.5% and 9% [4], in the general population [5], with little data available for older adults. Clement et al [3] reported a prevalence of 2.6% in 6 of 233 patients older than 65 years with TSFs. In those patients, all underwent four compartment fasciotomies and 3 of them (50%) developed deep infections. Compartment syndrome and fasciotomy was not associated with a higher mortality.
3 Diagnostics
The implication of comorbidities and medication on treatment decision are thoroughly described in chapters 1.1 Principles of orthogeriatric medical care and 1.4 Preoperative risk assessment and preparation. Special attention should be paid to the tetanus vaccine status, as immunity is often waning in this population.
3.1 Clinical evaluation
The affected leg and adjacent ankle and knee should be examined. In high-energy trauma, a systematic approach should be followed (eg, airway, breathing, circulation, disability, exposure/examination (ABCDE) following advanced trauma life support), with additional evaluation of common relevant geriatric conditions like chronic edema, arterial insufficiency, and degenerative joint disease. A thorough full body examination should exclude any concomitant fractures, contusions, and wounds ( Case 1: Fig 3.16-1 ).
CASE 1
Patient
A 72-year-old woman presented following a motor vehicle collision. Upon workup by the trauma team, she was found to have an isolated open left distal tibial shaft fracture (TSF) ( Fig 3.16-1a–c ). She had a past medical history significant for a left Charcot hindfoot arthropathy and a previous left total knee arthroplasty.
Comorbidities
Insulin-dependent diabetes
Obesity
Peripheral vascular disease
Treatment and outcome
The patient received immediate intravenous antibiotics, and her tetanus status was up to date. Initial operative management included irrigation and debridement and placement of an external fixator to stabilize the injury ( Fig 3.16-1d–e ). Given the nature of the open wound, the debridement involved excision of the fracture fragments that had been contaminated and devitalized at the time of injury ( Fig 3.16-1f–g ).
Multiple factors dictated the definitive management of this patient, including her medical comorbidities, proximal total knee implant as well as previous ipsilateral ankle and hindfoot fusion. To stabilize the leg and facilitate mobilization, the decision was made to proceed with a loadbearing hindfoot fusion nail, with the plan to return for later bone grafting once the soft tissues were stable and healed ( Fig 3.16-1h–i ).
Key points
Older patients have multiple comorbidities, including diabetes and obesity, that may compound the healing and infection risks associated with open fractures. These need to be considered when making treatment decisions.
Prior to orthopedic surgery, other conditions may also commonly impact treatment decisions in this patient population. While the typical treatment for this TSF may have involved a standard antegrade tibial intramedullary nail, the ipsilateral total knee arthroplasty and prior hindfoot/ankle autofusion made a hindfoot fusion nail an acceptable option.
The local skin status is critically important in suspected TSF. Any pathological finding should be photographed and documented. Skin compromise can result from both open and closed fractures. Any malalignment and areas under pressure from bony fragments should prompt timely restoration of alignment. A closed fracture can quickly convert to an open fracture resulting in full-thickness skin necrosis and impaired wound healing with catastrophic consequences. In cognitively impaired patients, repeated evaluations are advised, especially after moving the patient or during limb manipulation (eg, x-ray, cast application).
In case of primary open TSF, the wound should be thoroughly irrigated in the emergency department, photographed and documented (with ruler and patient identification), and covered with a wet sterile dressing to prevent further unnecessary manipulation and contamination. A radical debridement should follow in the operating room.
Motor and sensory status of the affected leg should be evaluated. Evaluation may be limited by pain, limb instability, and dementia, if present. Sensation in the tibial, saphenous, superficial peroneal, and deep peroneal nerves should be tested. In case of suspected polyneuropathy, a monofilament examination is advised.
Vascular examination is best done with both tactile pulse examination and Doppler scan. Absence of pulse should prompt a reposition and reexamination as well as further vascular investigation (eg, computed tomographic [CT] angiography, digital subtraction angiography).
General assessment of geriatric patients should include preinjury level of function, cognitive status, and recent functional trajectory, in addition to evaluating closely for cardiovascular and other comorbidities. For open fractures findings such as fracture contamination, length of skin tear, and proximal based flap should be assessed ( Table 3.16-1 ) [11].
Significant findings | Present in older adult |
Preexisting venous stasis | Yes/No |
Pitting edema | Yes/No |
CHF/CVD | Yes/No |
Fracture comminution | Yes/No |
Fracture contamination | Yes/No |
Length of skin tear | < 1 cm, 1–5 cm, > 5 cm |
Proximal based flap | Yes/No |
Knows time of the day | 1 |
Remembers recent events | 1 |
Is picking, disorderly, restless | 0 |
Pulls intravenous tubing, feeding tubes, catheters, etc | 0 |
Easily or suddenly emotional | 0 |
Sees/hears things which are not there | 0 |
3.2 Compartment syndrome
Compartment syndrome is a well-known and feared complication of TSF. Tibial shaft fractures are the leading cause of acute compartment syndrome and are the primary etiology in 36% of all compartment syndromes. The incidence of compartment syndrome after TSF ranges from 1.5% to 11%. Patients with a TSF-associated compartment syndrome tend to be younger (ie, mean age 30 years) than those with compartment syndrome without TSF [12]. In the general population, open TSFs are not associated with a higher rate of compartment syndrome than closed TSFs. No data are specifically available for the geriatric population. It should be kept in mind that the older patient, because of tissue aging as well as confounding comorbidities, has diminished physiological reserves, prompting a need for rapid diagnosis and therapy. Further analyses are required to determine to what extent anticoagulation plays a role in the development of compartment syndrome in older adults [13].
Generally, compartment syndrome can occur as a result of the induced swelling or secondary to reperfusion syndrome. Since cognitively impaired patients are unable to clearly communicate their pain, a low threshold of suspicion should always trigger an examination by an experienced surgeon. Physical examination may be supplemented by compartment pressure measurement.
When in doubt, fasciotomy of the affected compartments should be performed. A missed compartment syndrome has dramatic consequences for the patient, the surgeon, and the health system.
The rate of amputation for TSFs is low. Amputation is typically a result of severe soft-tissue trauma with neurovascular compromise, arterial injury, compartment syndrome, or infection. The Swedish National Patient Register reports an amputation rate of 3.6% in open tibial fractures [14], with age as a significant predictive factor.
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