6.8.2 Tibia, shaft
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1 Introduction
1.1 History
The tibial fracture, beyond all other long-bone fractures, has been a challenging problem for surgeons. Whether open or closed in nature, this fracture has a history of difficult healing and before the advent of antibiotics, an open tibial fracture was often enough to kill a person from infection. It is the most common long-bone fracture.
1.2 Epidemiology
The overall incidence has been estimated to be 20 per 100,000-person years. It is teenage boys who carry the highest risk of sustaining this injury, with an incidence of 39 per 100,000-person years. Up to 24% of all tibial diaphyseal fractures present as open injuries [1].
1.3 Special characteristics
The anterior one third of the tibia has no muscle cover and lies directly beneath the skin. Therefore, most tibial fractures are associated with an injury to the skin and subcutaneous tissues, even in closed fractures. Compartment syndrome occurs more often with tibial fractures than with any other fracture. This may be because the fascia is particularly thick and strong in the lower leg. Causes include swelling, bleeding, ischemia, or rebound edema following restoration of vascularity (reperfusion injury). The anterior compartment is most commonly involved.
2 Evaluation and diagnosis
2.1 Case history and physical examination
The severity of the soft-tissue damage is vital in the decision making for treatment of tibial fractures and must be fully evaluated. The whole leg must be inspected for the presence of wounds, contamination, bruising, swelling, and blisters. These are signs of soft-tissue compromise that may influence the timing of definitive treatment. These lesions must be clearly documented.
Neurovascular examination of a lower limb following trauma is essential and must never be omitted. Arterial injury is relatively common. The dorsalis pedis and posterior tibial pulses must be examined. The ankle-brachial index can be helpful but may be difficult to measure in the presence of a tibial fracture. Capillary return in the toes should be assessed but can be misleading as young patients with major arterial injury often have sufficient collateral circulation to keep the foot pink while the muscles in the leg are ischemic. Any abnormality of the pedal pulses following tibial fracture is a surgical emergency. Deformity should be corrected and if the pulses remain abnormal, the patient has a vascular injury until proven otherwise: immediate vascular surgery consultation is required.
Compartment syndrome occurs in up to 9% of tibial fractures [2]. The pulses are usually present. The cardinal symptom is pronounced pain, which is not relieved by opiates. Key clinical signs include tense, shiny skin, pain on passive stretch of the foot and toes, and paresthesia in the first interdigital space. The suspicion of compartment syndrome requires immediate action, with either measurement of compartment pressures or operative release of the deep fascia. In tibial fractures, nerve injuries are less common than arterial injuries, but motor and sensory function of the common peroneal and posterior tibial nerves must be accurately assessed.
2.2 Imaging
Radiographic imaging of the tibia is usually confined to standard AP and lateral x-rays. The knee and ankle should be included or x-rayed separately. Trauma workup of badly injured patients often necessitates computed tomographic (CT) angiograms of the limbs, which can be useful to assist in assessment of the peripheral circulation and bony integrity.
3 Anatomy
The midtibia is unique with its lack of muscle coverage and with four muscle compartments surrounding the tibia and fibula ( Fig 6.8.2-1 ). Soft tissues are of utmost importance in this anatomical area; thus, this is one long bone where minimally invasive techniques have a favorable history, whether it be nailing or plating or ring fixation for definitive care. When soft tissues are compromised, lost or in need of reconstruction, the expertise of a plastic surgical team is essential. It is now recognized that early, combined orthoplastic care gives the best outcome for patients with open tibial fractures [3]. It is not uncommon for bone loss with a multifragmentary fracture. Special techniques are then required for management of bone loss, such as the Masquelet technique [4] or Ilizarov method.
4 Classification
4.1 AO/OTA Fracture and Dislocation Classification
The alphanumerical AO/OTA Fracture and Dislocation Classification designates tibial shaft fractures as bone 4 (tibia) and segment 2 (diaphysis). Type A corresponds to simple fractures with a single fracture line. This is the most common fracture type. Type B fractures have an intermediate wedge fragment. Type C fractures are due to high-energy trauma and are multifragmentary and segmental fractures ( Fig. 6.8.2-2 ).
4.2 Other key classifications
With 25% of tibial fractures being open fractures, the Gustilo classification of open fractures is important [5]. This classification helps with early management: primary closure can be performed in types 1 and 2, a second debridement is usually needed for type 3A, a soft-tissue coverage procedure is needed for type 3B, and vascular repair is required for type 3C. This classification correlates with infection and union rates.
5 Surgical indications
Open fractures [1]
Polytrauma
Floating knee or ankle
Failure to obtain or maintain an acceptable reduction with closed techniques
Neurovascular compromise
Compartment syndrome [2]
In open fractures and closed fractures associated with arterial injury or compartment syndrome, stabilization of the fracture is a key part of the soft-tissue management.
6 Preoperative planning
Key management decisions will depend upon the “personality of the injury”: patient factors, the soft tissues, and the fracture itself. Available facilities and expertise are also key to decision making.
6.1 Nonoperative treatment
Currently, nonoperative treatment should be considered for incomplete fractures, stress fractures, and complete undisplaced or minimally displaced fractures resulting from low-energy trauma [6]. Although nonoperative treatment has been common in the past, the current standard for closed, displaced fractures of the tibial shaft is tibial nailing [7–9]. Several studies comparing the results of nonoperative versus operative treatment using the interlocking nail have shown that the nonoperative group had more pain, higher malunion and delayed union rates, and less good functional outcomes.
Nonoperative treatment, if chosen, can be performed initially with a well-molded plaster cast. As soon as the patient shows improvement in pain, progressive weight bearing should be encouraged, using a functional brace until there is complete fracture healing [6].
6.2 Timing of surgery
The timing of surgery will be determined by patient factors (eg, polytrauma, comorbidities, and soft-tissue considerations, such as wounds, swelling, and blisters). If the tibial fracture is open or the patient is a polytrauma patient, wound debridement with damage control may be the best tactic [10]. Reduction and external fixation is a reasonable first step for soft-tissue care with further debridement and soft-tissue cover when it is possible. Compartment syndrome is always a risk and must be carefully monitored: remember, open fractures may still get compartment syndrome. Optimum fracture care involves early operative treatment with careful monitoring for complications. Best practice for soft-tissue care involves early debridement followed by repetitive debridement and soft-tissue coverage by 5–7 days although some trauma systems recommend definitive soft-tissue care within 72 hours [3].
6.3 Implant selection
Many studies have compared implants for tibial fracture. External fixators are good for early care of tibial shaft fractures (for temporization only) but nails have fewer complications when used definitively [1]. A number of large randomized control trials [11–15] determined that reamed tibial nails had the advantages of better healing rates with fewer complications compared with unreamed tibial nails for diaphyseal tibial fractures. Open tibial fractures may be also treated with reamed tibial nails safely [13]. It has been shown that the endosteal circulation, destroyed by reaming the canal, is completely reestablished between 8 and 12 weeks. During this period, the periosteum remains the main source of blood supply for the cortical bone. Reaming of the medullary canal has several potential benefits for fixation of the tibia. Mechanically, it allows the use of larger and stronger nails that improve stability. Biologically, the reaming material composed of thousands of pluripotent cells can be deposited throughout the fracture site, serving as a biological stimulus for fracture healing.
Diaphyseal tibial fractures may extend toward either joint and it is in these instances when plating may have some advantages with lower rates of malunion, although the union rate remains better with nails [16]. Special techniques, such as Poller screws, are required when nails are used for proximal or distal fractures in the diaphysis of the tibia [17].
6.4 Operating room set-up
Light manual traction is maintained on the limb (if it is not already in traction) during preparation to avoid excessive deformity at the fracture site. The exposed area is disinfected from the hip distally, including the foot with an appropriate antiseptic. The limb is draped with a single-use U-drape or extremity drape. A stockinette (or sterile glove) covers just the foot and is fixed with tape. Care is taken not to hide the distal-locking screw positions ( Fig 6.8.2-3 ).
The operating room personnel and surgeons stand on the lateral side of the affected limb. The image intensifier is positioned on the opposite side of the table medial to the fracture, perpendicular to the long axis of the tibia. The image intensifier display screen is placed in full view of the surgical team and the radiographer ( Fig 6.8.2-4 ).
7 Surgery
7.1 Positioning and approaches
7.1.1 Intramedullary nailing
Once the decision for an intramedullary (IM) nail has been made, it is important to evaluate the width of the canal at the narrowest point (sometimes it can be smaller than the smallest reamer).
Fig 6.8.2-5 shows the many ways to position the patient for nailing a tibia. The classic approaches for insertion of an IM nail are the transpatellar tendon or the parapatellar approach. The decision depends on the surgeon′s experience and preference since the literature has shown no difference in terms of knee pain or other complications comparing both options ( Fig 6.8.2-6 ) [18, 19]. The correct starting point is midline and just off of the cartilage anteriorly and well above the tibial tuberosity. The start point must be checked with AP and lateral views on the image intensifier before opening the medullary canal. In some proximal oblique fractures, a lateral parapatellar start point helps to ensure that there is little fracture displacement during nail insertion ( Video 6.8.2-1 ). Modern IM nails have a curve in the proximal sagittal plane (Herzog curve). The knee should be flexed to avoid perforation of the posterior cortex of the tibia [20].
Recently, an alternative approach, the suprapatellar approach, has been described for treating proximal fractures of the tibia. The advantage of this approach is that the affected limb is placed with the knee in semiextension avoiding the classic deformities of extension and valgus of the proximal tibial fragment [21–23]. The semiextended position neutralizes the deforming forces, favoring fixation with satisfactory reduction. To protect the femoropatellar cartilage, special instruments have been designed and soft-tissue protection sleeves are used to decrease the potential damage to the cartilage. Long-term follow up is necessary to ensure the efficacy of this approach ( Fig 6.8.2-7 ).
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