Fractures of the tibial shaft are
common. Due to the subcutaneous nature of the distal part of the anterior
shaft, these fractures are often open.
Management: Shaft fractures
Tibial fractures are often due to high velocity trauma. Remember
to look for other injuries, including chest and abdominal trauma.
Check for other fractures and dislocations, especially of the ipsilateral
knee and hip.
Closed Fractures
Conservative Treatment
Stable and minimally displaced fractures can be treated conservatively
by reduction and an above knee cast. If the fracture is minimally
displaced a general anesthetic may not be necessary. Use a general
anesthetic if there is overlapping of bones, or difficulty is expected.
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The below knee portion can be completed first.
Hang the leg over the end of the table. An assistant can pull
downwards on the ankle to maintain the reduction |
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How to apply Above Knee plaster
- 15 degrees flexion at knee
- Ankle at 90 deg.
- Extend proximally to groin
- Ends distally at MP joints
Take a check X Ray to confirm your reduction. Keep the patient overnight,
or instruct him to return for a circulation check the following day.
The next follow up can be at one or two weeks. Here the plaster is
checked. X rays are taken in the cast. If there is angulation wedging
can be done of the cast. If there is unacceptable loss of length this
method will fail and a remanipulation or possibly open reduction and
internal fixation is required.
Wedging a plaster.
Measure the angulation on the x ray (leg still in plaster). Extend
a line at right angles to the shaft at both sides of the fracture
onto the image of the plaster. This will be equivalent to the gap
to open. The plaster is sawed open at eh fracture level - keep a intact
hinge open at the opposite side. hinge the limb into alignment by
opening the gap in he plaster and holding it with a wooden block.
Check X rays are taken. Once the desired result is achieved repair
the defect with plaster bandage.
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X rays show acceptable length , but valgus angulation
of the distal tibia. The wedge has been marked out. The cut will
be made so that an opening wedge can be made on the lateral side
of the plaster. |
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Deepening the cut. A hinge of intact plaster
can be left at the (medial) apex |
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Once the plaster gap has been opened; retain
it with a wooden block. Now take a follow-up x ray. If satisfactory
alignment is obtained, repair the plaster with more pop bandages |
Once the doctor is satisfied with alignment, the patient is followed
up as an outpatient. Once the fracture starts stabilising after the
initial few weeks he is seen monthly. The plaster cast is kept on
with only replacements when seen at the clinic. At this stage X rays
can be taken out of plaster, as callus formation is better assessed
on X ray without a cast.
For mid shaft or lower fractures a patellar bearing cast often speeds
up union.
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The PTB cast is well mould ed between
the gastrocnemeus heads, (to prevent rotation) and applies load
to the patellar tendon area. A walking heel on the sole allows
weight bearing |
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Open Reduction
Indications for Open reduction and internal fixation - Tibial
Shaft
- Inability to obtain a reduction
- Inability to maintain a reduction
- Vascular complications
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IM Pin |
Recently there has been a swing towards intramedullary pinning of
the tibia. The procedure has a low sepsis rate and pin breakages are
rare. Any closed unstable fracture of the shaft (large butterfly segment
or comminution) can be considered candidate for this method. It is
difficult to successfully plate a tibia shaft as there is a high rate
of sepsis due to its poor distal blood supply, and the proximity of
the skin to the bone lets in sepsis.
Open Fractures
Tibial fractures are often open due to most of the anterior border
of the shaft being subcutaneous. The wound must be inspected in the
trauma ward and then covered with a sterile dressing. A broad spectrum
antibiotic is given (first generation cephalosporin plus amiloglycocide
if very contaminated) Prophylaxis against tetanus is also necessary.
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Curetting out the medullary cavity. The bone
may have become contaminated when it embedded in the ground |
In theater the leg
is scrubbed before it is draped. The wound is incised to a larger
size if it is too small for access. All dead tissue is excised. Viable
muscle will bleed, and should contract if pinched with a forceps -
if it does not it needs excision. Preserve nerve tissue and suture
if transected. Vessels may need repair at his stage. Lose pieces of
bone ( no muscle attachments) are discarded. Leave the wound open
for secondary suture later. take tissue and pus swabs for areobic
and anaerobic culture) The wound needs irrigation with copious water
(10 litres or more). A pulsed lavage system is invaluable in getting
fine contaminants out of the tissue. If there is a large soft (Gustillo
3b type or more ) tissue defect consult a plastic surgeon regarding
a primary flap to close the defect. The limb is stablised - use an
exfix if the wound is large
or will need attention later (skin graft etc.) If the wound is small
and easily closable a paster cast may be necessary. Open reduction
is not recommended at this primary debridement. It may be done at
a later stage (48 hr.+) in the less contaminated fracture (below Gustillo
3B).
A second debridement at 48 hours is recommended in all contaminated
cases. Here further non viable tissue is identified and removed. Wounds
may be sutured at this stage if the wounds appear clean.
Delayed and Non Union
The tibia should begin to show signs of callus formation on X rays
from six weeks onwards. The fracture becomes less mobile when stressed
and the pain diminishes. If the tibia does not show signs of union
or does not progress as expected delayed union may be diagnosed.
Make sure there are not causes such as sepsis, medical conditions
such as diabetes etc. Smoking inhibits fracture union and should be
discouraged. Non union has occurred when there is no progress towards
union and the fracture is pain free.
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Established nonunion. This
man had fractured his tibia 20 years previously. He only had minimal
pain. Note the hypertrophy of the fibula. |
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Treatment of delayed union needs to address the cause. Conservative
treatment such as a dynamic cast (patellar tendon bearing cast) may
stimulate union. If this fails, surgical measures are necessary. If
sepsis is the cause a sequestrectomy of the fracture area is needed.
If there is abundant callus but none bridges the gap (hypertrophic delayed
union -"Elephant's foot" type) more stability is called for.
An open reduction and internal fixation may be needed. Hypotrophic
delayed unions ( where there is little callus) are due to vascular reasons
(e.g.severe stripping of soft tissue in an open fracture) Here a bone
graft as well as further stabilisation (ORIF or Exfix) will be needed.
Mal alignment is a potent cause of non or delayed union, as there are
shear and angulatory forces tearing apart all attempts by capillaries
to bridge the fracture gap. In this case a realignment procedure with
fixation by exfix, or intramedullary pin is called for. |
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