Ch 63 Tibia fracture Flashcards
tibia fracture
- majority are diaphyseal fractures.
- 10-20% are open fractures
- repair procedure depends on: type/location of the fracture, age, open fractures, economic, surgeon’s preference
- overall prognosis following fracture of the tibia and fibula is generally good
What major muscles attach to the tibia and what is their function?
Quadriceps femoris (stifle extension)
Biceps femoris (stifle flexor)
Caudal part of sartorius (stifle flexor)
Cranial tibial muscle (tarsal flexor)
tibia/fibula muscles
- semitedndinosus, gracilis, sartorius
- peroneus
- popliteus
- digitial extensor/flexor
Fibula
fibula serves as an attachment site for a few muscles and for collateral ligaments of the stifle and the tarsal joints
List the 4 epiphyses of the tibia
Proximal epiphysis
Tuberosity epiphysis
Distal epilphysis
Medial malleolar epiphysis
What is an apophysis?
A traction epiphysis such as the tibial tuberosity
How much of the longitudinal length of the tibia is from the proximal and distal epiphyses respectively?
Proximal 40%
Distal 60%
At what age does the tuberosity epiphysis fuse with the proximal epiphysis?
At what age does the tuberosity physis normally close?
Fuses to proximal epiphysis 5-9m in large dogs
Physis closes over 12m in large dogs
At what age does the medial malleolar epiphysis fuse to the distal epiphysis?
Very early, approx 4-5m in large breeds.
What part of the tibial plateau is articular?
The caudal 1/2
What muscles attach to the tibial tuberosity? (3)
Quadriceps femorus - patella ligament
biceps femoris
sartorius
tibia ad fibula anatomy
Tibia
- tibial body is three sided proximally
- distal half is essentially cylindrical
- S- shaped
- distal part of the tibia forms the articular surface and the medial malleolus.
- medial malleolus = attachment of the medial collateral ligament of the tarsocrural joint.
Fibula
- head = attachment of the lateral collateral ligament of the stifle
- form the lateral malleolus = attachment of the lateral collateral ligament of the tarsus
What are the main vessels which supply blood to the tibial and fibula?
Tibia
- Cranial tibial artery
(turns into nutrient artery and the periosteal vessels)
Fibula
- Cranial tibial artery (head)
- Peroneal artery (fibula)
tibial bone blood supply
- nutrient artery divides into proximal and distal branches that anastomose with the metaphyseal arteries at each end
- These anastomoses permit the metaphyseal arteries to sustain the medullary arterial supply when the principal nutrient artery is disrupted
- The medullary arteries supply the inner two-thirds of the tibial cortical circulation
- periosteal arteries supply the outer one-third of the cortical circulation
What vessels and nerves surround the tibia
medial
- saphenous artery and vein
- saphenous nerve
lateral and caudal
- Tibial and popliteal artery
- Peroneal and cutaneous nerves
Fracture Epidemiology
- Open fractures accounted for 12% of diaphyseal fractures and 37% of distal fractures
- Proximal region, diaphyseal, and distal region fractures accounted for approximately 1%, 83%, and 18% of fractures
Proximal Region
- Tibial tuberosity avulsion
- physeal fracture (Salter-Harris type I or II)
- articular surface only 2%
Diaphysis
- mid-diaphysis most common location
- Oblique/spiral fractures and comminuted most common
Distal Region
- Physeal fractures
- medial or lateral malleolus (Salter-Harris type I or II)
successful fracture management
biology (5) , mechanics (3), clinical (3)
biologic factors
- age
- health
- blood supply
- soft tissue damage
- location of the fracture
mechanical factors
- type/stability of the fracture,
- size and activity of the patient,
- number of limbs injured
clinical and practical factors
- financial constraints,
- patient and client compliance,
- surgeon’s preference
pre-op
- stabilise
- manage open fracture
- assess neurologically
- rads
Fractures of the Proximal Region of the Tibia
- generally involve the physis in young animals and the metaphysis in mature animals
- approach: medial, lateral (Care not to damage the tendon of origin of the long digital extensor muscle during elevation of the cranial tibial muscle)
Avulsion of the Tibial Tuberosity
- usually between 4 and 8 months of age
- large dogs the growth plate associated with the tuberosity closes late in development
- normally wide growth plate in the immature animal for a fracture; therefore radiographs of the opposite limb should be taken for comparison
What can result in a tibial tuberosity avulsion?
Contraction of the quadriceps while the stifle is flexed and the foot is firmly on the ground
What is Osgood Schlatter disease?
Considered to be a form of osteochondrosis but has been suggested that it should be classified as a minimally displace tibial tuberosity fracture
What leg position can aid in reduction of a tibial tuberosity fracture? What are the repair options?
Hip flexed and stifle extended
Repair options:
- cast if minimally displaced, small-breed dog, 2-3 weeks
- 2 K-wires in a caudoproximal direction (very young small dogs with minimal displacement)
- Pin and tension band (preferred)
- Reattachment of patella tendon to bone tunnel if not enough bone to reattach
large and medium breeds < 6 months old, and small breeds < 4 months old
- the fixation should be removed as early as possible
- when clinical and radiographic union
- avoid premature fusion of the tuberosity to the shaft and distal translocation of the tuberosity.
tuberosity can fragment easily in young
complications of tuberosity avulsion
- reavulsion,
- wire or pin breakage,
- bending of a pin,
- pin migration,
- entry of a pin into the proximal epiphysis,
- deformity of the proximal tibia.
Premature closure of the apophyseal growth plate and deformity of the tibial tuberosity are common
prognosis for normal function is generally good.
Fractures of the Physis
- Salter-Harris type I or II
- combined proximal epiphysis and tibial tuberosity are usually involved
- may be accompanied by collateral ligament damage
What are the repair options for a proximal physeal fracture?
Pinning!
- At least 2 cross pins
- Third pin through tuberosity recommened for better stability
- gentle levering of the epiphysis onto the metaphysis may be necessary
- prognosis for normal function is generally good.
What are the repair options for proximal metaphyseal fractures?
IM pin, cross pins, plate, lag screws
If fibular head had detacted from tibia, should be reattached with screws
If comminuted, plate must be placed on side of comminution to act as buttress plate
approach to proximal tibia
External Skeletal Fixation
- minimal soft tissue interference.
- advantage: employ the biologic osteosynthesis (fracture closed or with a very limited open approach)
- Early dynamization to reduce the rigidity of the fixation
- type Ia with an intramedullary pin to improve stability
- Bilateral uniplanar (type II)
Intramedullary Pin Fixation
- limited to stable fractures in small dogs and cats with good healing potential
- Closed normograde pinning
approach to distal tibia
Immature Animals
Fractures of the Physis
- Salter-Harris type I or type II
- closed reduction sometimes possible
- reduced by gently levering the epiphysis onto the metaphysis
- cross-pinning is often the only practical method
- TA pin ONLY if not enough bone for cross pinning
- avoid entering the joint, because the malleoli extend distal to the articular surface
- clinical union usually within 4 to 6 weeks.
What are the repair options of malleolar fractures?
Pins alone
Pin and tension band
Screw
- associated with tarsocrural instability, (subluxation or luxation)
- If joint instability persists, the integrity of the ligaments should be further evaluated
- prognosis generally good; however, degenerative joint disease may develop.
Fractures of the Distal Metaphysis
- distal segment is very short
- many of these fractures are open fractures
- T-plate,
- two locking screws in the distal segment may be enough
- Circular (ring) or hybrid external skeletal fixators
- TA ESF
- no hope of preserving a functional joint, arthrodesis
Complications
- proximal metaphysis is a common location for primary bone neoplasia
- infection,
- implant failure (
- delayed union, nonunion, and malunion (usually inappropriate fixation)
STUDY: Closed reduction and type II, clinical union was approximately 3 to 4 months
- 14% of the dogs had major complications
Pes Varus and Pes Valgus
- Varus: eccentric medial closure of the distal tibial physis, limg shortening
- Tx: open wedge corrective osteotomy with ESF, hybrid, plate, and plate-rod
- valgus is thought to result from abnormal growth of the distal fibular physis
- both may be associated with MPL
Management of feline tibial
diaphyseal fractures using
orthogonal plates performed
via minimally invasive plate
osteosynthesis
Craig 2018
eight
One major complication
medial plate has a high P:B length ratio, and that the distal screw is placed as close to the talocrural joint as possible, in order to mitigate the risk of iatrogenic fracture of the tibia
plates are placed orthogonally, each plate will
be effectively edge-loaded, increasing the implant’s
area moment of inertia, which increases the resistance
to bending.
Increasing WL has been described to
result in greater elasticity, which allows micro-motion at
the fracture, potentially encouraging rapid formation of
periosteal callus.24,43–45 A higher WL also lowers the pullout
forces exerted on the screws.
when nonlocking
plates are used and the plates were contoured
accurately to the bone, the WL was the length of the fracture
itself
Ex vivo biomechanical evaluation of 2.4 mm LCP plate rod
constructs versus 2.7 mm LCP applied to the feline tibia
Gutbrod 2024
Ex vivo study.
Sample population: Thirty-three unpaired tibiae
10 mm
diaphyseal gap. Group 1: 2.4 mm locking compression plate (LCP) and 1.0 mm
intramedullary pin (IMP). Group 2: 2.4 mm LCP and 1.6 mm IMP. Group 3:
2.7 mm LCP.
Constructs with a 2.4 mm LCP and 1.6 mm IMP provided the strongest and most rigid constructs in a feline tibia gap model (stiffness and maximum axial force)
Efficacy of virtual surgical planning and a
three-dimensional-printed, patient-specific reduction
system to facilitate alignment of diaphyseal tibial fractures
stabilized by minimally invasive plate osteosynthesis in
dogs: A prospective clinical study
Scheuermann 2024
would need to compare to control grooup, ned to assess outcome
Prospective clinical trial.
Sample population: Fifteen client owned dogs
Guides were 3D printed, sterilized, and applied, in conjunction with transient
application of a circular fixator
50.7 h elapsed between presentation and surgery
Virtual planning and fabrication of a 3D-printing
patient-specific fracture reduction system is practical and facilitated acceptable,
if not near-anatomic, fracture alignment during MIPO.
Change in tibial torsion resulted in an increase in external
tibial torsion in 14 dogs.
near-anatomic in 87% of cases and
acceptable in 13% of cases.
Surgical correction of pes varus deformity in dachshunds using three-dimensional-printed patient-specific guide system: nine tibiae in seven cases (2018-2022)
Oxley 2024
retrospectively report the clinical and radiographic outcome.
9 limbs
gait abnormality resolved in all limbs. The osteotomy healed uneventfully in eight tibiae. Implant failure occurred in one
mean translational error <1 mm in all planes, and mean angulation correction error <2° in all planes.
Opening osteotomy, stabilised with orthogonal locking plates and without the application of bone graft
technique complicated by the small distal segment
and the risk of screw violation of the tarsocrural joint.
without fibular osteotomy or fracture, under-correction
is likely
(Petazzoni et al.,
Additionally, torsional correction
will be hampered.
this study not based on CORA (which is 2D planning, not as accuarte, not assess for torsion)
75% cortical bone healing was noted by 6 to 8 weeks
post-operatively
and marked osseous infilling was present. In
four cases imaged over 10 weeks post-operatively
Placement of beta-tricalcium
phosphate (Izumisawa et al., 2005)
and autogenous cancellous bone graft or hydroxyapatite synthetic
bone graft substitute (Chau & Wilson, 2022
Feline Distal Tibial Physeal Fracture Repair Using
a Modified Cross-Pin Technique with Four Pins
Miraldo 2020
modified cross-pin technique for feline distal tibial physeal fracture
- addition of second medial and a craniolateral K-wire to traditional cross-pin
→ additional rotational stability to remove need for coaptation
- pin entry: 1x lateral malleolus, 2x medial malleolus, 1x craniolateral aspect of distal tibia
