41 Tibia and Fibula Shaft Fractures

10.1055/b-0040-176982

41 Tibia and Fibula Shaft Fractures

Jonah Hebert-Davies and Conor P. Kleweno

Introduction

The tibia is the most commonly fractured long bone. Tibial fractures can result either from direct, high-energy impact mechanism or from low-energy twisting or fall mechanisms. The relatively subcutaneous location makes it particularly at risk for open fractures. Thorough initial management, adequate preoperative imaging and planning, as well as good surgical techniques are necessary to ensure optimal outcomes.

I. Preoperative Evaluation and Assessment

History and physical examination
1. Commonly associated with high-energy mechanism.
2. Full orthopaedic workup including careful examination for associated fractures.
3. Skin integrity must be evaluated to look for open fractures.
4. Detailed initial neurovascular and compartment examination should be documented. Repeat (and document) neurovascular examination after reduction and splinting.
5. Patients are at risk for compartment syndrome and should be re-examined frequently with corresponding documentation. Disproportionate pain or pain with passive flexion/extension should alert the surgeon to the high probability of compartment syndrome (see section “III, Complications” in this chapter).
Imaging and anatomy
1. Adequate quality orthogonal X-ray views of the tibia.
2. X-rays of knee and ankle are also recommended because articular extension at both the knee and at the ankle is common (▶ Fig. 41.1a ).
  
  Fig. 41.1 Distal third tibia shaft fracture with (a) lateral X-ray revealing associated posterior malleolar fracture (arrow). (b) CT scan axial cut at tibial plafond showing associated posterior malleolar fracture that can guide trajectory of clamp and screw. (c) Lateral X-ray after placement of clamps, reducing the fracture.
  1. Distal third fractures—high rate of associated posterior malleolus fracture.
  2. If this is suspected and not seen on X-ray, a CT scan should be obtained. The axial views are most helpful to plan potential fixation of the posterior malleolus fragment (▶ Fig. 41.1b ).
3. Plain radiographs can help identify many specific details about the fracture.
  1. Suspected open fractures, high-energy mechanisms (segmental, comminuted) with severe soft-tissue injury can be identified on X-rays.
  2. Fibula fractures seen on X-ray can also give clues to the energy of the fracture mechanism. Fibula fractures at the same level as the tibia fracture tend to be higher energy than at distant (either proximal or distal) sites.
Classification
1. The AO/OTA classification is useful to describe tibia shaft fractures.
  1. Type A—simple patterns, progressing from spiral (A1) to transverse (A3).
  2. Type B—wedge fractures increasing in complexity from B1 to B3.
  3. Type C—complex fractures with increasing comminution from C1 to C3.
2. Open fractures are typically classified according to the Gustilo–Anderson classification (for further reference, please see Chapter 2, Open Fractures).

II. Treatment

Initial management
1. Reduction in the emergency department and placement into a padded long leg splint as soon as possible.
2. Open wounds should have sterile dressings applied. Any gross contamination should be removed, but formal debridement should be reserved for the operating room.
3. Appropriate antibiotics (typically a first-generation cephalosporin) and tetanus update are administered.
Definitive management
1. Historical data suggest that many tibia fractures can be treated nonoperatively with reduction and casting.
2. However, most displaced tibia fractures are currently treated surgically.
3. Operative management has the following advantages: improved alignment, earlier ankle and knee range of motion, immediate weight bearing, and improved functional outcomes.
4. Rarely fractures treated nonoperatively should meet the following criteria:
  1. Closed, isolated, simple, nondisplaced, or minimally displaced tibial shaft fractures in patients willing to comply with non–weight bearing.
  2. Able to tolerate multiple cast changes and frequent X-ray follow-ups.
  3. Medically moribund patients are also candidates for cast treatment.
5. Open fractures should undergo urgent surgical debridement:
  1. Types I, II, and IIIA can generally be treated definitively immediately following debridement assuming there is not gross contamination present.
  2. Types IIIB and IIIC typically undergo staged management with an external fixator prior to definitive fixation depending on the amount of contamination and severity of soft-tissue injury.
  3. Traumatic wounds are extended proximally and distally to expose the entire zone of injury and facilitate adequate debridement.
  4. Consider soft-tissue friendly counter incisions for debridement in select locations. For example, small to medium traumatic anterior medial wounds can be accessed through an anterolateral approach.
6. The vast majority of extra-articular fractures are treated with intramedullary nails (IMN).
7. Proximal third and distal third fractures (with or without simple articular fracture involvement) can be treated with open reduction and internal fixation (ORIF) with plates and screws or IMN. Recent data suggest no clinically significant difference in malalignment rates and infectious/wound complications between ORIF with plates and IMN.
8. Modern nail designs incorporate far proximal and far distal multiplanar interlocking screw options to allow for treatment of proximal and distal fractures (i.e., “extreme nailing”).
9. Compartment syndrome (Refer to Chapter 13, Compartment Syndrome, for detailed discussion of pathophysiology, diagnosis, and treatment).
  1. Tibia fracture is the most common cause of compartment syndrome.
    - i. High risk in crush injuries even with minimally displaced fractures.
    - ii. Common in tibia fractures associated with sports (football and soccer).
    - iii. Dysvascular limbs following revascularization.
  2. Primarily a clinical diagnosis. Intracompartmental pressure monitor can assist in diagnosis when the clinical examination is equivocal and in obtunded patients.
  3. Treatment is emergent fasciotomy.
Surgical approaches
1. Most common approaches for tibial nailing are the following:
  1. Infrapatellar (or transpatellar).
  2. Suprapatellar (“retropatellar”).
  3. Lateral parapatellar (retinacular release).
2. Advantages of infrapatellar:
  1. Avoiding articular involvement.
  2. No need for specific instrumentation.
3. Advantages of suprapatellar approach:
  1. Semi-extended leg position: minimizes knee range of motion throughout nailing (▶ Fig. 41.2 ).
    
    Fig. 41.2 Intraoperative image showing semiextended leg position used for suprapatellar and lateral parapatellar retinacular release approaches.
    - i. Easier to maintain starting point.
    - ii. Facilitates achieving and maintaining fracture reduction.
    - iii. Improved quality of fluoroscopic imaging.
  2. Patellar mobility should be evaluated prior to committing to suprapatellar nailing.
4. Advantages of lateral parapatellar retinacular release include the following:
  1. All advantages of semi-extended position.
  2. Remain extra-articular.
5. If plate fixation is planned:
  1. Typically, laterally based plate is used for proximal to mid-shaft fractures.
  2. Standard anterolateral approach is used, centered on Gerdy’s tubercle.
  3. Anterior compartment fascia is opened and plate can be slid distally in minimally invasive, submuscular fashion.
  4. Distal third fractures can also be treated with either direct medial or anterolateral plate used in a minimally invasive technique.
Reduction techniques
1. Indirect reduction—standard closed/indirect methods include traction, manual manipulation, universal distractor, and external fixator.
2. Percutaneously placed clamps are placed through small (<1 cm) incisions (▶ Fig. 41.3a, b ).
  
  Fig. 41.3 Distal third tibia spiral shaft fracture. (a) Initial anteroposterior view and (b) after placement of multiple percutaneous clamps. Care should be take when placing these to respect soft tissue.
3. Unicortical plates can be placed in open or closed fractures either temporarily (diaphyseal) or permanently (metaphyseal) to effect and maintain a reduction (▶ Fig. 41.4 ).
  
  Fig. 41.4 Intraoperative fluoroscopic anteroposterior image of type 3b open, segmental tibia shaft fracture. Multiple 2.7-mm plates with unicortical screws were utilized to temporarily maintain reduction during nailing.
4. Open reduction remains an appropriate option with good soft-tissue handling (typically lateral or posterior medial approaches; avoid anterior medial incisions).
5. Supra- or infraisthmic fractures must be reduced prior to reaming and nailing—nail insertion will not fix malreduction and often will only accentuate it.
Fixation techniques
1. Tibia shaft fractures are typically treated with reamed, statically locked nails with at least one, and preferably two, interlocking bolt above and below the fracture.
2. Starting point for tibial nail insertion:
  1. Medial to the lateral tibial eminence on the anteroposterior (AP) view.
  2. Anterior to the articular margin and at or posterior to the apex of the tibia on the lateral view.
  3. Guidewire should be inserted in line with the medullary canal.
  4. The starting point ultimately determines nail position and is especially critical for IMN of proximal third and distal third fractures.
3. Important to obtain accurate AP and lateral fluoroscopic views as inadequate views can result in as much as 1 cm of displacement of the starting point.
4. Proximal tibial fractures:
  1. High propensity for malreduction into valgus, procurvatum (apex anterior) and posterior translation of the distal segment.
  2. Techniques to help avoid malalignment include the following:
    - i. Correct starting point (▶ Fig. 41.5a ).
      
      Fig. 41.5 (a, b) Demonstrates the use of a blocking drill bit to avoid malpositioning of the nail and to prevent and/or correct a procurvatum deformity in this proximal tibia fracture.
    - ii. Semi-extended positioning.
    - iii. Large universal distractor.
    - iv. Provisional unicortical plate.
    - v. Blocking (Poller) screws (▶ Fig. 41.5a, b ).
    - vi. Percutaneous clamps.
  3. Insert multiple (three if possible) multiplanar interlocking screws proximally.
5. Distal tibia fractures:
  1. Most common direction of malalignment is valgus, followed by recurvatum and varus.
  2. Techniques to avoid malalignment:
    - i. Precise positioning of the distal aspect of the nail:
      - Center or slightly lateral to the center of the tibia/talus on the AP view.
      - Center on the lateral fluoroscopic views.
    - ii. Blocking screws.
    - iii. Percutaneous clamps.
    - iv. Semi-extended positioning.
    - v. Fibula fixation may help improve alignment if there is difficulty obtaining a reduction:
      - Conflicting results on whether ORIF fibula increases the risk of tibia nonunion.
      - ORIF fibula may prevent late malunion, although this was found with previous generation nails with fewer interlocking options.
  3. Insert multiple (three if possible) multiplanar interlocking screws distally.
6. Associated posterior malleolus fractures:
  1. Common in distal third tibial fractures (▶ Fig. 41.1a–c ).
  2. Minimally displaced and small fractures can be clamped anterior to posterior (▶ Fig. 41.1c ) and fixed prior to beginning reaming or can be fixed after the nail has been inserted.
  3. Fixation: independent AP screws and possibly AP interlocking screw.
  4. Large fractures should be reduced and fixed prior to nail insertion; a separate formal posterior approach to ankle should be considered.
7. Bone loss:
  1. Antibiotic cement spacer can be placed into the bone defect for induced membrane formation and secondary bone grafting (Masquelet’s technique).
  2. Bone transport through use of ring fixator.