Tibial Shaft Fractures Flashcards
hyperflexing a proximal tibial shaft fx for nailing will:
exaggerate deformity through the extensor mechanism and cause procurvatum and anterior translation
proximal tibial malreduction deformity includes:
flexion and valgus
Suprapatellar advantages over infrapatellar nailing?
- improved coronal alignment
- improved start point location
- no difference in knee pain
- restoration of accurate length is more reliable
(Jones et. al)
Does suprapatellar nailing injure the articular surface?
Cadaveric arthroscopic and microscopic studies demonstrate no damage to the articular surface.
One clinical study demonstrates no changes to the articular surface
Plating vs nailing of proximal tibial shaft fractures: outcome differences?
essetnailly equal time to union, malunion, nonunion
- hardware removal 3x more common in plating
Plating vs Nailing of Distal tibia fractures? Outcomes:
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)
Is there a role in plating the fibula in distal tib-fib shaft fractures?
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
Can you bear weight after a tibial nail?
yes, there is no difference in healing or complications with early weight bearing after nailing
Early failures in first generation tibial nails was due to:
- “wedge effect” of the Herzog bend
- use of a single proximal interlocking bolt, or use of dynamic interlocking mode
Rules for use of Blocking screws:
- 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
In proximal 1/3 fractures, medial parapatellar incision may cause:
valgus malreduction
In proximal 1/3 fractures, a more lateral starting point may:
help decrease valgus malreduction
Acceptable techniques to prevent proximal tibial fracture malreduction during nailing:
- blocking screws (posterior and lateral)
- more lateral start point (1mm medial to lateral tibial spine)
- anterior unicortical plate
- semi-extended nailing
This complication is associated with MIPO of proximal tibial shaft fractures (laterally based plate)
superficial peroneal nerve injury
This molecule is FDA approved for open tibial shaft fractures treated with an IM nail:
rh-BMP-2
- was historically described to decrease need for revisions, nonunions, and allowed for estimated cost savings
For open tibia fractures, does reamed or undreamed nailing have a benefit?
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
Risk factors for bad outcome in open tibial shaft fx:
- high energy
- use of stainless steel (vs titanium) rods
- > 1cm residual fracture gap
- ??? smoking (this study did not show, but other studies have)
Definition of tibial delayed union and nonunion
delayed = lacking union 20-26 weeks post-injury
nonunion = lacking union by 9 months OR no progression of healing for 3 months
Most important factor to decrease infection rate in open fractures?
- timing to antibiotics
Patzakis, CORR 1989
What is rate of concomitant posterior malleolus fracture in spiral tibial shaft fractures?
39% (Boraiaha CORR 2008)
Dx missed in 5% before CT scans were implemented
Should you ream the tibia with a tourniquet in place?
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
Does exchange nailing work for comminuted tibial shaft fracture nonunions?
no
union rates of 45%-85%
alternatively, for oblique fx has been shown to be 80-95%
Risk factor for tibial varus after shaft fx?
intact fibula
- can’t treat these non-operatively due to the risk
IS absent plantar sensation of the foot after tibia fracture an indication for amputation?
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
how can you avoid intra-capsular placement of a tibial ex-fix pin?
capsular reflection at knee is 14mm distal to subchondral bone posteromedial or posterolatera. anteriorly it is 6mm. put it distal to that
Where does the deep peroneal nerve live (in the leg)
between the tibialis anterior and the EHL, superficial to the anterior tibial artery
- 12.5mm proximal to the ankle joint
atrophic tibial nonunions require:
exchange nail + biology (graft, bmp, etc.)
