| Classification |
| Oestern and Tscherne Classification of Closed Fractuer Soft Tissue Injury |
| Grade 0 |
Injuries from indirect forces with negligible soft-tissue damage |
| Grade I |
Superficial contusion/abrasion, simple fractures |
| Grade II |
Deep abrasions, muscle/skin contusion, direct trauma, impending compartment syndrome |
| Grade III |
Excessive skin contusion, crushed skin or destruction of muscle, subcutaneous degloving, acute compartment syndrome, and rupture of major blood vessel or nerve |
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| Gustilo-Anderson Classification of Open Tibia Fractures |
| Type I |
Limited periosteal stripping, clean wound < 1 cm |
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| Type II |
Mild to moderate periosteal stripping, wound >1 cm in length |
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| Type IIIA |
Significant soft tissue injury (often evidenced by a segmental fracture or comminution), significant periosteal stripping, wound usually >5cm in length, no flap required  |
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| Type IIIB |
Significant periosteal stripping and soft tissue injury, flap required due to inadequate soft tissue coverage (STSG doesn't count). Treat proximal 1/3 fxs with gastrocnemius rotation flap, middle 1/3 fxs with soleus rotation flap, distal 1/3 fxs with free flap. |
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| Type IIIC |
Significant soft tissue injury (often evidenced by a segmental fracture or comminution), vascular injury requiring repairto maintain limb viability |
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| For prognostic reasons, severely comminuted, contaminated barnyard injuries, close range shotgun/high velocity gunshot injuries, and open fractures presenting over 24 hours from injury have all been later included in the grade III group. |
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| Presentation |
- Symptoms
- pain, inability to bear weight, deformity
- Physical exam
- inspection and palpation
- deformity / angulation / malrotation
- contusions
- blisters
- open wounds
- compartments
- palpation
- pain
- passive motion of toes
- intracompartmental pressure measurement if indicated (i.e., sedated or intubated)
- neurologic
- deep peroneal n.
- superficial peroneal n.
- sural n.
- tibial n.
- saphenous n.
- pulse
- dorsalis pedis
- posterior tibial
- be sure to check contralateral side
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| Imaging |
- Radiographs
- recommended views
- full length AP and lateral views of affected tibia
- AP, lateral and oblique views of ipsilateral knee and ankle
- CT
- indications
- intra-articular fracture extension or suspicion of joint involvement
- CT ankle for spiral distal third tibia fracture
- to exclude posterior malleolar fracture
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| Treatment of Closed Tibia Fractures |
- Nonoperative
- 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
- risk of varus malunion with midshaft tibia fractures and an intact fibula
- non-union occurs in 1.1% of patients treated with closed reduction
- Operative
- external fixation
- indications
- can be useful for proximal or distal metaphyseal fxs
- complications
- pin tract infections common
- outcomes
- higher incidence of malalignment compared to IM nailing
- IM Nailing
- 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)
- 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
- percutaneous locking plate
- 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
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| Treatment of Open Tibia Fractures |
- Operative
- antibiotics, I&D
- indications
- all open fractures require an emergent I&D
- timing of I&D
- surgical debridement 6-8 hours after time of injury is preferred
- grossly contaminated wounds are irrigated in emergency department
- antibiotics
- standard abx for open fractures (institution dependent)
- cephalosporin given for 24-48 hours in Grade I,II, and IIIA open fractures
- aminoglycoside added in Grade IIIB injuries
- minimal data to support this
- penicillin administered in farm injuries
- minimal data to support this
- tetanus prophylaxis
- outcomes
- early antibiotic administration is the most important factor in reducing infection
- emergent and thorough surgical debridement is also an important factor
- must remove all devitalized tissue including cortical bone
- external fixation
- indications
- provisional external fixation an option for open fractures with staged IM nailing or plating
- falling out of favor in last decade
- indicated in children with open physis
- IM Nailing
- indications
- most open fx can be treated with IM nail within 24 hours
- contraindicated in children with open physis (use flexible nail, plate, or external fixation instead)
- outcomes for open fxs
- IM nailing vs. external fixation
- no difference with respect to
- infection rate
- union rate
- time to union
- IM nailing superior with respect to
- decreased malalignment
- decreased secondary surgeries
- shorter time to weight bearing
- reamed nails vs. unreamed nails
- reaming does not negatively affect union, infection, or need for additional surgeries in open tibia fractures
- gapping at the fracture site is greatest risk for non-union
- transverse fx pattern and open fractures also at increased risk for non-union
- rhBMP-2
- prior studies have shown use in open tibial shaft fractures
- accelerate early fracture healing
- decrease rate of hardware failure
- decrease need for subsequent autologous bone-grafting
- decrease need for secondary invasive procedures
- decrease infection rate
- recent studies have not fully supported the above findings and rhBMP-2 remains highly controversial
- amputation
- 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
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| Technique |
- IM nailing of shaft fractures
- preparation
- anesthesia
- general anesthesia recommended
- positioning
- patient positioned supine on radiolucent table
- bring fluoro in from opposite, non-injured, side
- bump placed under ipsilateral hip
- leave full access to foot and ankle to help judge intraoperative length, rotation, and alignment of extremity
- tourniquet
- tourniquet placed on proximal thigh
- not typically inflated
- use in patients with vascular injury or significant bleeding associated with extensive soft tissue injuries
- deflate during reaming or nail insertion (weak data to support this)
- approach
- options include
- medial parapatellar
- most common starting point
- can lead to valgus malalignment when used to treat proximal fractures
- lateral parapatellar
- helps maintain reduction when nailing proximal 1/3 fractures
- requires mobile patella
- patellar tendon splitting
- gives direct access to start point
- can damage patellar tendon or lead to patella baja (minimal data to support this)
- semiextended medial or lateral parapatellar
- used for proximal and distal tibial fractures
- suprapatellar (transquadriceps tendon)
- requires special instruments
- can damage patellofemoral joint
- starting point
- medial parapatellar tendon approach with knee flexed
- incision from inferior pole of patella to just above tibial tubercle
- identify medial edge of patellar tendon, incise
- peel fat pad off back of patellar tendon
- starting guidewire is placed in line with medial aspect of lateral tibial spine on AP radiograph, just below articular margin on lateral view
- insert starting guide wire, ream
- semiextended lateral or medial parapatellar approach
- skin incision made along medial or lateral border of patella from superior pole of patella to upper 1/3 of patellar tendon
- knee should be in 5-30 degrees of flexion
- choice to go medial or lateral is based of mobility of patella in either direction
- open retinaculum and joint capsule to level of synovium
- free retropatellar fat pad from posterior surface of patellar tendon
- identify starting point as mentioned previously
- fracture reduction techniques
- spanning external fixation (ie. traveling traction)
- clamps
- femoral distractor
- small fragment plates/screws
- intra-cortical screws
- reaming
- reamed nails superior to unreamed nails in closed fractures
- be sure tourniquet is released
- advance reamers slowly at high speed
- overream by 1.0-1.5mm to facilitate nail insertion
- confirm guide wire is appropriately placed prior to reaming
- nail insertion
- insert nail in slight external rotation to move distal interlocking screws anteriorly decreasing risk of NVS injury
- if nail does not pass, remove and ream 0.5-1.0mm more
- locking screws
- statically lock proximal and distally for rotational stability
- no indication for dynamic locking acutely
- number of interlocking screws is controversial
- two proximal and two distal screws in presence of <50% cortical contact
- consider 3 interlock screws in short segment of distal or proximal shaft fracture
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| Complications |
- Knee pain
- >50% anterior knee pain with IM nailing
- occurs with patellar tendon splitting and paratendon approach
- pain relief unpredictable with nail removal
- lateral radiograph is best radiographic views to make sure nail is not too proud proximally
- Malunion
- high incidence of valgus and procurvatum (apex anterior) malalignment in proximal third fractures
- varus malunion leads to ipsilateral ankle pain and stiffness
- chronic angular deformity is defined by the proximal and distal anatomical/mechanical axis of each segment
- center of rotation of angulation is intersection of proximal and distal axes
- Nonunion
- definition
- delayed union if union at 6-9 mos.
- nonunion if no healing after 9 mos.
- treatment
- nail dynamization if axially stable
- exchange nailing if not axially stable
- reamed exchange nailing most appropriate for aseptic, diaphyseal tibial nonunions with less than 30% cortical bone loss.
- consider revision with plating in metaphyseal nonunions
- posterolateral bone grafting if significant bone loss
- non-invasive techniques (electrical stimulation, US)
- BMP-7 (OP-1) has been shown equivalent to autograft
- often used in cases of recalcitrant non-unions
- compression plating has been shown to have 92-96% union rate after open tibial fractures initially treated with external fixation
- fibular osteotomy of tibio-fibular length discrepancy associated with healed or intact fibula
- Malrotation
- most commonly occurs after IM nailing of distal 1/3 fractures
- can assess tibial rotation by obtaining perfect lateral fluoroscopic image of knee, then rotating c-arm 105-110 degrees to obtain mortise view of ipsilateral ankle
- reduced risk with adjunctive fibular plating
- Compartment syndrome
- incidence 1-9%
- can occur in both closed and open tibia shaft fxs
- diagnosis
- high index of clinical suspicion
- pain out of proportion
- pain with passive stretch
- compartment pressure within 30mm Hg of diastolic BP is most sensitive diagnostic test
- treatment
- emergent four compartment fasciotomy
- outcome
- failure to recognize and treat compartment syndrome is most common reason for successful malpractice litigation against orthopaedic surgeons
- prevention
- increased compartment pressure found with
- traction (calcaneal)
- leg positioning
- Nerve injury
- LISS plate application without opening for distal screw fixation near plate holes 11-13 put superficial peroneal nerve at risk of injury due to close proximity
- saphenous nerve can be injured during placement of locking screws
- transient peroneal nerve palsy can be seen after closed nailing
- EHL weakness and 1st dorsal webspace decreased sensation
- treated nonoperatively; variable recovery is expected
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