Fig. 7.1
(a) Midshaft transverse fracture of the tibia (AO/OTA type 42-A3) after a soccer accident in an 18 year old male. Radiograph ad admission. (b, c) Intramedullary nailing with dynamic locking was performed. Immediate full weight bearing was allowed. Stable callus formation is visible 2 months after surgery
Fig. 7.2
(a) Spiral tibial fracture with wedge fragment (AO/OTA type 42-B1) after a skiing accident in a 49-year old male. Radiographs at admission. (b, c) The fracture was stabilized with a statically locked intramedullary nail. Early full weight-bearing led to failure of the proximal interlocking bolt at the distal end of the tibia 6 weeks after injury. (d, e) Excessive sporting activities led to failure of both distal and one proximal bolt 4 months after the injury with slight shortening of the fracture. Progressive callus formation is visible
Fig. 7.3
(a, b) Distal tibia fracture (AO/OTA type 42-B3) with an additional fracture of the fibula in a 74-year old alcoholic patient after a fall from a stair. Radiographs at admission. (c, d) The tibia fracture was primarily stabilized with an intramedullary nail. The distal fragment was secured with three 4.0 mm static interlocking bolts. Plate fixation of the distal fibula in order to increase the overall stability of fixation. Postoperative radiographs. (e, f) Premature full weight-bearing lead to failure of the distal locking bolts and intrusion of the distal tip of the nail into the ankle joint 8 weeks after the injury. Secondary varus displacement of the distal fragment and shortening of the fracture. Revision was done with implant removal, restoration of correct alignment, locked plate fixation and local bone grafting
Elderly patients often are not able to comply with partial weight bearing since many of them had restricted walking capacities already before their fracture. The nailing osteosynthesis therefore should be stable enough in order to allow immediate full weight-bearing. If this has not been achieved, patients are bound to bed or wheel chair.
7.2.2 Evaluation of Fracture Healing
Radiologic documentation of the operative result needs to be done early after surgery. Both the quality of fracture reduction and the implant position should be judged thoroughly. If the initial result is not satisfactory, early correction within the first days after the initial procedure is often better than waiting and reacting when complications occur. In the early phase after the injury, fracture fragments are still mobile and corrections are easier to perform than at a later stage (Fig. 7.4a–i). Since personal bias may occur, discussing unfavorable reduction and fixation results in the team may be very helpful in order to define the further management strategy together.
Fig. 7.4
(a–c) Mid-shaft tibia fracture (AO/OTA type 42-B2) in a 58 year old overweight male patient (BMI = 35). Radiographs ad admission. (d, e) Radiographs after internal fixation with a tibia nail. Fracture reduction is imperfect and the diameter of the implant is too thin in relationship to the diameter of the medullary canal. Due to the persisting instability, complications are likely to occur. (f, g) Decision for an early re-intervention. Implant removal, slight reaming and insertion of a 2 mm thicker and longer implant. Alignment was improved by the use of a blocking screw. Improved proximal and distal interlocking contributed to an increased stability. (h, i) Uneventful healing at 1.5 years without any further procedures
If loss of reduction occurs, this is most likely to happen within the first days to weeks after surgery. It therefore is recommended to check fracture alignment and implant position clinically and radiologically 1–2 weeks postoperative.
In cases where an uneventful healing is expected, routine radiographs are taken at 6, 12 and 24 weeks. The progress of callus formation and fracture healing is assessed and any signs of implant loosening or failure should not be missed. A fracture is estimated to be healed when at least three cortices show stable bridging on radiographs.
Broken locking bolts often are an expression of instability. Surgeons should be aware that bolt failure may contribute to an increased instability that may impair further fracture healing. Unless autodynamization leads to compression at the fracture site, bolt failure may be an alarm signal and a potential indicator of impending delayed or nonunion. It should be checked carefully at this stage whether either fracture healing is still likely to occur or whether delayed union risks to develop. Reducing the amount of weight-bearing may be considered especially in lower extremity fractures. Persisting or even increasing pain complaints during mobilization may also be an expression of instability.
Diaphyseal fractures usually need 4–6 months to heal. Time to bony union is longer in fractures with severe open and closed soft tissue damage.
References
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