Tibial Shaft Fractures

Question 1

hyperflexing a proximal tibial shaft fx for nailing will:

Answer 1

exaggerate deformity through the extensor mechanism and cause procurvatum and anterior translation

Question 2

proximal tibial malreduction deformity includes:

Answer 2

flexion and valgus

Question 3

Suprapatellar advantages over infrapatellar nailing?

Answer 3

• improved coronal alignment
• improved start point location
• no difference in knee pain
• restoration of accurate length is more reliable
  (Jones et. al)

Question 4

Does suprapatellar nailing injure the articular surface?

Answer 4

Cadaveric arthroscopic and microscopic studies demonstrate no damage to the articular surface.

One clinical study demonstrates no changes to the articular surface

Question 5

Plating vs nailing of proximal tibial shaft fractures: outcome differences?

Answer 5

essetnailly equal time to union, malunion, nonunion

- hardware removal 3x more common in plating

Question 6

Plating vs Nailing of Distal tibia fractures? Outcomes:

Answer 6

Vallier showed nails had higher rates of delayed union, malunion, and secondary procedures compared with plates.
- higher incidence of ankle and knee pain

*** the opposite has also been shown (Mauffrey et al)

Question 7

Is there a role in plating the fibula in distal tib-fib shaft fractures?

Answer 7

EGol showed that it helps in complex, communited fractures to stabilize and hold reduction

Vallier demonstrated a higher rate of nonunion in patients with fibular plates

Question 8

Can you bear weight after a tibial nail?

Answer 8

yes, there is no difference in healing or complications with early weight bearing after nailing

Question 9

Early failures in first generation tibial nails was due to:

Answer 9

• “wedge effect” of the Herzog bend

- use of a single proximal interlocking bolt, or use of dynamic interlocking mode

Question 10

Rules for use of Blocking screws:

Answer 10

• 3.5mm screws of 3.2mm Schanz pins
• drill bits are too brittle to use as blocking pins
• beware of fracture propagation - put them 1cm away from the fx site to minimize risk

Question 11

In proximal 1/3 fractures, medial parapatellar incision may cause:

Answer 11

valgus malreduction

Question 12

In proximal 1/3 fractures, a more lateral starting point may:

Answer 12

help decrease valgus malreduction

Question 13

Acceptable techniques to prevent proximal tibial fracture malreduction during nailing:

Answer 13

• blocking screws (posterior and lateral)
• more lateral start point (1mm medial to lateral tibial spine)
• anterior unicortical plate
• semi-extended nailing

Question 14

This complication is associated with MIPO of proximal tibial shaft fractures (laterally based plate)

Answer 14

superficial peroneal nerve injury

Question 15

This molecule is FDA approved for open tibial shaft fractures treated with an IM nail:

Answer 15

rh-BMP-2

- was historically described to decrease need for revisions, nonunions, and allowed for estimated cost savings

Question 16

For open tibia fractures, does reamed or undreamed nailing have a benefit?

Answer 16

no benefit to reaming seen in the literature

• bhandari (SPRINT) showed no difference for open fx (for closed fx, reamed is better)
• schemitsch showed no difference in reamed vs unreamed

Question 17

Risk factors for bad outcome in open tibial shaft fx:

Answer 17

• high energy
• use of stainless steel (vs titanium) rods
• > 1cm residual fracture gap
• ??? smoking (this study did not show, but other studies have)

Question 18

Definition of tibial delayed union and nonunion

Answer 18

delayed = lacking union 20-26 weeks post-injury

nonunion = lacking union by 9 months OR no progression of healing for 3 months

Question 19

Most important factor to decrease infection rate in open fractures?

Answer 19

• timing to antibiotics

Patzakis, CORR 1989

Question 20

What is rate of concomitant posterior malleolus fracture in spiral tibial shaft fractures?

Answer 20

39% (Boraiaha CORR 2008)

Dx missed in 5% before CT scans were implemented

Question 21

Should you ream the tibia with a tourniquet in place?

Answer 21

no

• increases risk of pulmonary morbidity due to tourniquet ischemia, causing microembolization, associated with reamed femoral nailing
• can induce pulmonary microvascular injury
• pulmonary microbmeolization

Does NOT increase thermal injury during reaming… this is related to reaming

Question 22

Does exchange nailing work for comminuted tibial shaft fracture nonunions?

Answer 22

no
union rates of 45%-85%

alternatively, for oblique fx has been shown to be 80-95%

Question 23

Risk factor for tibial varus after shaft fx?

Answer 23

intact fibula

- can’t treat these non-operatively due to the risk

Question 24

IS absent plantar sensation of the foot after tibia fracture an indication for amputation?

Answer 24

LEAP project (lower extremity assessment project) demonstrates  that at 2 year follow up 55% had return of plantar sensation, and functionally salvage was equivalent to amputation.
- therefore, absent plantar sensation is not prognostic for long-term plantar sensory status or functional outcome

Question 25

how can you avoid intra-capsular placement of a tibial ex-fix pin?

Answer 25

capsular reflection at knee is 14mm distal to subchondral bone posteromedial or posterolatera. anteriorly it is 6mm. put it distal to that

Question 26

Where does the deep peroneal nerve live (in the leg)

Answer 26

between the tibialis anterior and the EHL, superficial to the anterior tibial artery
- 12.5mm proximal to the ankle joint

Question 27

atrophic tibial nonunions require:

Answer 27

exchange nail + biology (graft, bmp, etc.)