Conservative management

Minimally displaced and closed tibial shaft fractures can be managed in a long leg cast. This is applied from the upper thigh to metatarsal neck with 10–20° of flexion in the knee and the neutral position of the ankle. After reduction and application of cast, plain radiographs are required. To prevent malunion, the reduced fracture should have less than 5° of varus–valgus angulation, less than 10° of anterior–posterior angulation, more than 50% cortical apposition, less than 1 cm of shortening and less than 10–20° of flexion and less than 10° of rotational malalignment.

The process of wedging can also be utilized post-application of leg cast by making a transverse cut in the plaster for correction of minor degrees of angulation.

Repeat plain radiographs are taken at 2 weeks to check position. Changing to a below knee cast or Sarmiento (patella tendon bearing cast) can be considered around 4–6 weeks post-injury or when signs of bony union are identified.

Surgical management

External fixation: external fixators help stabilize and support tibial shaft fractures through the placement of 5 mm or 6 mm (in diameter) pins or transfixion wires perpendicularly into the tibia and attaching them to a rigid rods or frames outside the body.

This modality of fixation is may be considered in the closed and isolated tibial shaft fractures but are associated with increased risks of pin track, deep infection/osteomyelitis and malunion. Furthermore, this fixation device can only control cyclical movement at the fracture site by dynamization. This infers inferior bone healing compared to other surgical modalities and has been supported by other studies.

On the other hand, external fixators have been shown to be the treatment of choice particularly when significant soft tissue compromise is present or in the polytrauma patient where damage control orthopaedics is needed. These devices can be applied in a short time frame with minimal physiological insult and can provide fracture stability and alignment. This surgical option also means there are no metal implants across the fracture site with less vascular damage to a tibia that may already be compromised. More often than not, external fixators are used as a temporizing measure prior to definitive fixation with a plate or intramedullary nail.

External fixators fall can be subdivided into three broad categories, each with their own unique mechanical properties that affect the stability of the fracture and bone healing.

Unilateral/uniplanar fixators have asymmetrical mechanical properties with resistance to flexion in the plane of the screws but relatively flexible when stressed perpendicular to that plane. This leads to cantilever bending at the fracture leading to high shear and torque. Because of this, patients are not allowed to immediately weight-bear. They are useful for temporary fixation in the diaphyseal region. Common pitfalls often lead to insufficient rigidity of the construct which include pins that are placed far from the fracture, non-optimally sized pins selected, using a single rod (unstacked) device or placing the bars too far from the skin. Some fixators also incorporate a telescoping piston in the body of the fixator to enable the load-sharing construct which promotes micromotion at the fracture site, also known as dynamization, to promote bone healing.

Mulitplanar fixators on the other hand have improved axial and sagittal stability. Perpendicular linkage between the rods helps to control each plane of deformation which consequently leads to reduced shear and torque at the fracture site. However, dynamization and control micromotion cannot be reliably achieved because multiple connecting rods are seldom completely parallel to each other or the tibial shaft.

Circular frames have been increasingly used in limb reconstruction and non-union surgery. As a result of this, they have been increasingly used as the definitive modality of fixation for tibial shaft fractures particularly in high energy open tibia fractures with bone loss and/or soft tissue loss. Transosseous wires are tensioned onto interconnected rings which help to secure and align bone fragments. This allows for controlled compression, along with decreased shear and increased micromotion. The stiffness of the frame can be altered by repositioning or removing connecting rods, hence allowing for increased load transfer onto the bone as the fracture heals. Despite the benefits and potential role in treating tibial shaft fractures, these devices remain a tool for subspecialist limb reconstruction trauma surgeons and are unlikely to gain widespread use.

Intramedullary nailing: for closed unstable fractures or where contraindications are present for conservative management, intramedullary nailing is the treatment of choice. This involves performing a closed reduction of the fracture under intra-operative radiographic guidance. The proximal end of the tibia is then exposed and a guidewire passed through the fracture site. An appropriately sized nail is then selected and placed. Following this, transverse locking screws are placed proximally and distally. The benefits of intramedullary stabilization of tibial fractures are an insertion point that is distant from the traumatized soft tissues around the fracture site, a mechanical advantage of being positioned in the centre of axis when loadbearing and the lack of a requirement for precise reduction of individual fracture fragments.

With regards to exposure of the proximal tibia to identify the entry point of the intramedullary nail, either a supra-patella or infra-patella approach can be utilized. A recent meta-analysis involving 1196 patients reported that a supra-patella approach had significantly better patient-reported outcome measures (PROMs), increased accuracy in reduction by degrees of angulation at the fracture site and decreased intraoperative time. However, it was noted that most of the studies analysed were level-III studies and hence diminish the certainty of the conclusions made. Furthermore, there had been some discussion that a transverse rather than longitudinal incision when performing the supra-patella approach could reduce the risk of infra-patella nerve injury. This was proven significant in a randomized control trial with 136 patients, but no significant difference was noted in anterior knee pain and functional outcomes.

The decision to ream the intramedullary canal prior to nail placement has also been a topic of debate. Previous literature had suggested that there was benefit in performing reamed intramedullary nailing as it reduced rates of non-union and implant failure. In addition to this, a previous Cochrane review had reported ‘moderate’ quality evidence to suggest there was no significant difference in the rate of re-operations but reported a lower incidence of implant failure when reaming was conducted. However, a more recent systematic review published noted that non-union rates with and without reaming were statistically insignificant in 87.5% of studies but more than 78% of these findings were statistically fragile.

Plate fixation: another method of internal fixation is the application of a plate and screws construct. This approach is often indicated in metaphyseal fractures. These fractures are distal tibial or proximal third fractures where an intramedullary nail would be unable to cross the fracture site and have adequate locking both proximally and distally. Plate fixation may also be considered in the paediatric population as passing an intramedullary nail through a growing physis may lead to premature growth arrest.

This approach was previously avoided due to the risk of exposing the fracture site, leading to significant soft tissue and periosteal damage which was associated with increased infection and delayed bony union. Furthermore, biomechanical studies have shown that a locked medial plate system used for tibial shaft fractures had significantly lower interfragmentary movement under torsional loading conditions compared to intramedullary nails. However, given that intramedullary nails have significant rate of malalignment (5–58%) when managing distal and proximal tibial shaft fractures, the advancement of plating with minimally invasive percutaneous plate osteosynthesis (MIPPO) may have an added advantage in these fracture configurations.

MIPPO plates are placed along the anterolateral aspect of the fracture site via proximal and distal ‘access incisions’. The plate is then fixed to the bone only at the levels of these incisions. The placement of the plate in the submuscular plane helps to reduce injury to the surrounding soft tissues around the fracture site compared to conventional plating systems. This technique also allows for a more favourable biomechanical environment for fracture healing. These advancements have meant that plating devices are now considered as a viable option and alternative for closed tibial shaft fixation. A recent study showed there was no statistical significance in terms of complications between MIPPO and intramedullary nailing but have suggested that this could be due to the small samples sizes.

Management of open tibial shaft fractures

Patients with open tibial shaft fractures are often associated with high energy mechanisms and hence are associated with significant life-threatening injuries. It is important that these patients are assessed and resuscitated as per the Advanced Trauma Life Support protocol, prioritizing life before limb. This includes checking for catastrophic haemorrhage along with C-spine immobilization and assessing the status of the patient’s airway, breathing, circulation, disability and exposure. The appropriate resuscitative interventions must be taken at each step when indicated. Any external haemorrhage requires immediate control either by applying direct pressure or, as a final resort, applying a tourniquet with a clear documentation of exact time this was applied. Once haemodynamic stability is achieved in these patients, the open fractures should be addressed urgently as per the British Orthopaedic Association Standard for Trauma and Orthopaedics (BOAST) for open fracture guidelines (BOAST 4). Patients for whom an initial trauma CT is indicated should have the inclusion of the affected limb as well as angiography. It is important to identify any neurovascular injury early by performing a thorough peripheral nerve and vascular examination of the affected limb. Furthermore, it would be prudent to maintain a degree of suspicion towards compartment syndrome as this can be easily missed the acute setting. Gross contaminants should be removed but further washout in the emergency department is contraindicated due to concerns of pushing contaminants deeper into open wounds. Other aspects of open fracture management include clinical photography of the open wound, sealing the wound with a saline soaked gauze along with an adhesive film dressing, along with aligning and splinting of the fracture. Repeat orthogonal plain radiographs should be taken including both the joints above and below the fracture site. In terms of prescriptions, the patient should have adequate analgesia as per the World Health Organization pain ladder, antibiotics as per local microbiology protocols or broad-spectrum antibiotics, and tetanus prophylaxis. It can be assumed that all open fractures are tetanus-prone and hence should have prophylaxis prescribed as follows:

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  Patients with unknown immunity or no previous immunization:

  
  
  
  
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    Dose of the tetanus vaccine along with a dose of tetanus immunoglobulin at a different site is required.

  
  
  
  
• 2.
  

  Patients with incomplete immunization:

  
  
  
  
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    Reinforcing dose of the tetanus vaccine along with a dose of tetanus immunoglobulin at a different site is required.

  
  
  
  
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  Patients with complete immunization (previously completed five doses of tetanus vaccine at the recommended intervals):

  
  
  
  
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    Dose of tetanus vaccine is not required. However, if there is a heavily contaminated wound present, a dose of tetanus immunoglobulin would be required.

  
  

In the UK, the current consensus for open fractures between the British Orthopaedic Association (BOA) and the British Association of Plastics, Reconstructive and Aesthetic Surgeons (BAPRAS) is for joint management of the patient. Hence, these patients should be taken directly or transferred to a specialist centre that can provide orthoplastics care to facilitate a stepwise and disciplined management approach.

With regards to open fractures and where significant soft tissue compromise is present, there is currently no consensus on the best method of obtaining and maintaining alignment and stability in the tibia for this subset of patients. Intramedullary nails, external fixators, or external fixation followed by intramedullary nailing or plates have previously been proposed. The management sequence of using an external fixator initially and followed by delayed reamed intramedullary nailing has been advocated particularly in Gustilo–Anderson Type 3 open fractures where definitive soft-tissue cover is not feasible, as well as in polytrauma patients. Unfortunately, the risk factors leading to infection and non-union when managing fractures in this sequence are not clear and the optimal time for conversion from external fixator to intramedullary nailing is currently unknown. A major component of this is understanding and knowing the time interval during which the host’s defence mechanisms can eradicate any residual bacteria around the pin sites and hence prevent further metalwork infection after definitive surgery an intramedullary nail or other internal fixation device. A systematic review with 96 patients who had a two-stage procedure where they were initially treated with external fixation and proceeded to have a reamed intramedullary nail noted 92% union rate at a mean time of 38.5 weeks. The mean time for the patients undergoing the second procedure was 26 days, when they were deemed to have complete healing of the pin track and normal erythrocyte sedimentation rate on monitoring bloods. However, it was reported that the rate of deep infection was 17%, with 2.5% progressing into chronic osteomyelitis.

It was previously thought that the decision for primary or delayed wound closure of open fractures should be guided by the Gustilo–Anderson classification. Historically, it was noted that grade 3 open fractures had significantly higher rates of infection on primary closure. However, it was then understood that bacteria in cultures before lavage and debridement did not correlate with bacteria identified in cases of a postoperative infection which lead to the suspicion this was caused by nosocomial infections. As there is now a clear correlation between rates of infection and non-union with a delay in soft tissue closure, it is now recommended that definitive soft tissue coverage should be achieved within 72 hours of injury or if possible during the initial surgical debridement. When local and free flaps are indicated for soft tissue coverage, the ‘fix and flap’ approach, where definitive fracture fixation occurs in the same surgical session as soft tissue coverage, is recommended.

When soft-tissue coverage is feasible and a single stage operation can be conducted, external fixators have been compared to intramedullary nails as a definitive fixation option as this would prevent a second operation for removal and exchange of fixation and would have positive implications in terms of cost effectiveness and patient morbidity. A recent meta-analysis comparing the two modalities of fixation in the context of a single stage definitive procedure noted that intramedullary nailing was recommended over external fixation in patients with Gustilo–Anderson Type 1 to 3a open tibial fractures due to reduced risk of superficial infection and malunion. However, subgroup analysis comparing intramedullary nails to circular external fixators did not show any significant difference in malunion due to their good mechanical stability and could potentially be used as an alternative to intramedullary nailing. It is also important to note that circular fixators do not confer a reduced rate of deep infection compared to intramedullary nails as a recent randomized control trial with 254 patients noted no significant difference. Nevertheless, circular frames are a favourable option in open tibial fractures with significant bone loss, contamination or multilevel fracture patterns.

Primary amputation

Considerations towards primary amputation are required particularly in severe open tibial fractures with extensive soft tissue injury and bone loss. Understandably, this treatment method may be difficult to be accepted by the patient and this decision should ideally involve multidisciplinary discussions which include clinicians from other specialties such as vascular and plastic surgery. Various predictive scoring systems such as the Predictive Salvage Index (PSI), mangled extremity severity score (MESS), Nerve injury, Ischaemia, Soft tissue injury, Skeletal injury, Shock & Age patient score (NISSA), Limb Salvage Index (LSI), and Hannover Fracture Scale (HFS) have been used to help clinicians decide between limb salvage or amputation. The LEAP study assessed the validity of usage of these scores. It found that although these scoring systems were quite useful in predicting limb salvage, they had low sensitivity and could not be accurate predictors of amputation. As the previous scoring systems mentioned above place a heavy emphasis on vascular deficit, they perform poorly in the absence of vascular injury. Hence, the Ganga Hospital Open Injury Severity Score (GHOISS) was proposed to assess open injuries without vascular deficit, looking mainly to address the need for assessment of Gustilo–Anderson Grade 3B injuries.

Although no optimal scoring systems currently exist, these scoring systems can be used to assist clinicians faced with challenging decision-making provided they are aware of the pitfalls of the scoring systems used. It is important to remember that the success of salvage strategies is not only dependant on the severity of limb injury, but also multiple other factors such as patient co-morbidities, facilities available and the expertise of the treating team.

BOA/BAPRAS have recommended that immediate amputation is indicated in the following:

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  Incomplete amputations where there is almost complete severance of the affected limb from injury and the distal portion is subjected to significant trauma

  
  
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  Extensive crush injury

  
  
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  Limb avascularity with a warm ischaemia time of more than 4 hours.

Furthermore, BOA/BAPRAS have suggested that amputation be considered in less certain ‘grey areas’ which include the following:

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  Limb ischaemia with clinical evidence of nerve dysfunction particularly absent plantar sensation

  
  
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  Segmental loss of muscle involving three or more compartments, particularly when the posterior compartment is affected

  
  
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  Segmental bone loss which exceeds one-third the length of the tibia

  
  
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  Significant open foot injury accompanied by a tibial fracture.