tibial shaft fracture

Question 1

Oestern and Tscherne Classification of Closed Fractuer Soft Tissue Injury

Answer 1

Question 2

Nonoperative

Answer 2

closed reduction / cast immobilization

• indications
  
  • closed low energy fxs with acceptable alignment
    
    • < 5 degrees varus-valgus angulation
    • < 10 degrees anterior/posterior angulation
    • > 50% cortical apposition
    • < 1 cm shortening
    • < 10 degrees rotational malalignment
    • if displaced perform closed reduction under general anesthesia
  • certain patients who may be non-ambulatory (ie. paralyzed), or those unfit for surgery
• technique
  
  • place in long leg cast and convert to functional (patellar tendon bearing) brace at 4 weeks
• outcomes
  
  • high success rate if acceptable alignment maintained
  • risk of shortening with oblique fracture patterns
    
    • mean shortening is 4 mm
  • risk of varus malunion with midshaft tibia fractures and an intact fibula
  • non-union occurs in 1.1% of patients treated with closed reduction

Question 3

Operative

Answer 3

external fixation

IM Nailing

percutaneous locking plate

Question 4

IM Nailing

Answer 4

• indications
  
  • unacceptable alignment with closed reduction and casting
  • soft tissue injury that will not tolerate casting
  • segmental fx
  • comminuted fx
  • ipsilateral limb injury (i.e., floating knee)
  • polytrauma
  • bilateral tibia fx
  • morbid obesity
• contraindications
  
  • pre-existing tibial shaft deformity that may preclude passage of IM nail
  • previous TKA or tibial plateau ORIF (not strict contraindication)
• outcomes
  
  • IM nailing leads to (versus external fixation)
    
    • decreased malalignment
  • Suprapatellar nailing (vs infrapatellar)
    
    • improved fracture alignment
• IM nailing leads to (versus closed treatment)
  
  • decrease time to union
  • decreased time to weight bearing
• reamed vs. unreamed nails
  
  • reamed possibly superior to unreamed nails for treatment of closed tibia fxs for decrease in future bone grafting or implant exchange (SPRINT trial)
  • recent studies show no adverse effects of reaming (infection, nonunion)
  • reaming with use of a tourniquet is NOT associated with thermal necrosis of the tibial shaft

Question 5

percutaneous locking plate

Answer 5

• indications
  
  • proximal tibia fractures with inadequate proximal fixation from IM nailing
  • distal tibia fractures with inadequate distal fixation from IM nail
• complications
  
  • non-union and delayed union
  • wound infection and dehiscence
  • long plates may place superficial peroneal nerve at risk
• Percutaneous plate shown to have (versus infrapatellar IMN)
  
  • Equivalent time to union
  • Greater radiation exposure
  • Longer surgical duration
  • Lower postoperative pain scores
  • More difficulty in hardware removal

Question 6

Amputation

Answer 6

indications

• no current scoring system to determine if an amputation should be performed
• relative indications for amputation include
  
  • significant soft tissue trauma
  • warm ischemia > 6 hrs
  • severe ipsilateral foot trauma

outcomes

• LEAP study
  
  • most important predictor of eventual amputation is the severity of ipsilateral extremity soft tissue injury
  • most important predictor of infection other than early antibiotic administration is transfer to definitive trauma center
  • study shows no significant difference in functional outcomes between amputation and salvage
  • loss of plantar sensation is not an absolute indication for amputation

Question 7

LEAP study

Answer 7

LEAP study

• most important predictor of eventual amputation is the severity of ipsilateral extremity soft tissue injury
• most important predictor of infection other than early antibiotic administration is transfer to definitive trauma center
• study shows no significant difference in functional outcomes between amputation and salvage
• loss of plantar sensation is not an absolute indication for amputation