Nonoperative treatment

The use of nonoperative treatment is largely limited to un-displaced tibial shaft fractures. Applying a long-leg cast for the first 2 weeks and afterwards a Sarmiento cast or a fracture brace can lead to good results in these injuries [2, 5].

Intramedullary nailing

Intramedullary nailing is the gold standard in treating closed midshaft tibial fractures as well as open grade I and II fractures. The technique is also used, more controversially, in grade III open fractures [ 6, 7]. The application of locking screws has expanded the indications of intramedullary nailing to the fixation of unstable fracture patterns and this has led to recommend nailing of most tibial shaft fractures, including proximal-third and distal-third fractures. As may have been predicted, very favorable results have been seen in midshaft tibial fractures with healing rates of up to 99% [ 8]. The results in proximal-third and distal-third tibial shaft fractures [ 9] have not been that promising.

Contraindications to intramedullary nailing include:

• 
  

  Small (< 8mm) or deformed canals

  
  
• 
  

  Previous surgeries with implants in place

  
  
• 
  

  Gross contamination of the intramedullary canal

  
  
• 
  

  Severe soft-tissue injury at the site of nail entry

  
  
• 
  

  Compartment syndrome, which means fixation must be delayed and muscle necrosis is inevitable

  
  
• 
  

  Vascular injury requiring repair

  
  
• 
  

  Diaphyseal fractures with articular extensions

  
  
• 
  

  Proximal-third or distal-third extraarticular fractures (relative)

  
  
• 
  

  Periprosthetic fractures

Plating

Plating is indicated when intramedullary nailing is not a suitable option. Conventional plate fixation with formal surgical approaches leads to more wound complications than intramedullary nailing. Modern and soft-tissue-friendly plating techniques result in fewer complications and have shifted surgical practice back to plating tibial shaft fractures when nailing is contraindicated. There is some evidence that the results of plating proximal-third and distal-third tibial shaft fractures are comparable to intramedullary nailing in terms of union and complications. Plating achieves better results when alignment is used as the criterion [ 10, 11].

External fixation

External fixation is mainly used when there is a severe open or closed soft-tissue injury, gross contamination, or bone defect. It can be used as a temporary or definitive treatment; nowadays it is mainly a temporary stabilization method used in polytrauma, multiple-fracture patients, open fractures, and closed fractures with severe soft-tissue injury. The external fixator is applied so that the proper alignment is maintained and the fixator can be used as a reduction tool either for intramedullary nailing or percutaneous plating. In case of bone defect the external fixator can be applied as a definitive treatment and used for bone transport and deformities correction ( Fig 20.1-1 ).

Problems associated with external fixation include:

• 
  

  Pin-track infection

  
  
• 
  

  Patient discomfort

  
  
• 
  

  Delayed union

  
  
• 
  

  Malunion

Indications

Minimally invasive plating is indicated for closed and open (grade I and II) tibial shaft fractures in which intramedullary nailing is not a suitable treatment alternative. It is indicated for:

• 
  

  Fractures extending to the articular surface of the tibia

  
  
• 
  

  Proximal- and distal-third shaft fractures

  
  
• 
  

  Some segmental fractures

  
  
• 
  

  Small medullary canals (< 8 mm)

  
  
• 
  

  Canal occupied by implants

  
  
• 
  

  Periprosthetic fractures

  
  
• 
  

  Deformed canals

  
  
• 
  

  Open growth plates

  
  
• 
  

  After bone transport, to decrease external fixation time

  
  
• 
  

  Absence of adequate equipment for intramedullary nailing (C-arm)

Contraindications

Minimally invasive plating is contraindicated when the patient presents with:

• 
  

  Severe soft-tissue injuries (open grade III)

  
  
• 
  

  Skin problems (diabetes, peripheral vascular disease

  
  
• 
  

  Associated vascular injuries

  
  
• 
  

  Compartment syndrome

  
  
• 
  

  Pathological fracture

  
  
• 
  

  Active infection

  
  
• 
  

  Delayed reconstruction

Medial surface of the tibia

There are two structures to be particularly aware of:

• 
  

  Saphenous nerve (including its infrapatellar branch)

  
  
• 
  

  Saphenous vein

The saphenous nerve emerges from between the gracilis and sartorius muscles and runs down the leg with the long saphenous vein ( Fig 20.1-3 ). At the posteromedial aspect of the knee, it gives off its infrapatellar branch, which runs across to the anterior aspect of the proximal tibia. If the infrapatellar branch is cut, its ends should be buried in the subcutaneous fat to minimize the chance of forming a painful neuroma.

The saphenous nerve and the long saphenous vein run along the posteromedial border of the tibia and then cross the distal tibia to lie anterior to the medial malleolus.

When carrying out MIPO incisions on the medial side of the tibia injury to the saphenous nerve and vein should be avoided by using blunt dissection. They should be identified if they are situated along the path of the incision. Tunneling should be performed deep to the plane of the saphenous nerve and vein, especially in the distal tibia.

Lateral surface of the tibia

There are three structures to be aware of:

• 
  

  Anterior tibial vessels

  
  
• 
  

  Superficial and deep branches of the peroneal nerve

  
  
• 
  

  Superior and inferior syndesmosis

In the proximal and midshaft of the tibia, there are no structures at risk and it is safe to perform tunneling and plating. In the distal tibia, however, the deep peroneal nerve, along with the anterior tibial vessels, lie superficially over the anterior aspect of the distal tibia. Therefore, these important structures must be identified and protected before tunneling and plate fixation. It is advisable to prepare the tunnel right against the bone from the distal tibia to the midshaft to avoid injury to the deep peroneal nerve and anterior tibial vessels. When inserting screws in the distal third, a sleeve is of paramount importance to avoid damaging the abovementioned neurovascular structures.

Cross-sectional anatomy

At the level of the proximal tibial shaft ( Fig 20.1-3a ), the bone is triangular in shape and flat on its anteromedial surface. The anterior tibial vessels and deep peroneal nerve lie anterior to the interosseous membrane while the posterior tibial vessels and nerve lie posterior to the interosseous membrane. These neurovascular structures lie close to the posterolateral corner of the tibia. The long saphenous vein lies along the posteromedial crest of the tibia.

At the level of the midshaft of the tibia ( Fig 20.1-3b ), the bone is triangular in shape. The deep peroneal nerve and anteri or tibial vessels move closer to the posterolateral corner of the bone while the posterior tibial vessels and nerve move to lie over the posterior aspect of the tibia. The long saphenous vein still lies along the posteromedial aspect of the tibia.

At the level of the distal tibia ( Fig 20.1-3c ), the bone is circular in shape and the posterior aspect is slightly flat. The anterior tibial vessels with the deep peroneal nerve move onto the anterolateral surface of the tibia and run close to the bone. The posterior tibial vessels and nerve move close to the posteromedial part of the tibia. The long saphenous vein moves from the posteromedial to the medial surface of the distal tibia.