1. Fractures of the tibial diaphysis
Published: September 2013
Malcom Smith
AOT Basic Principles Course

2. Learning outcomes Outline the assessment of closed tibial fractures
Describe nonoperative and operative treatment options
Discuss how closed soft-tissue injuries should be managed
Teaching points:
Concentrate on closed fractures, but briefly refer to open fractures.

3. Tibial diaphyseal fractures
Problem
Most common long bone fracture
492,000 fractures/year
Most common open fracture
Significant cost
569,000 hospital days
Major cause of disability
Significant complications
50,000 nonunions/year

4. Clinical assessment Patient assessment History and energy of injury
Other associated injuries
Advanced Trauma Life Support (ATLS)

5. Clinical assessment Soft-tissue assessment Open/closed
Compartment syndrome
Nerve and vascular examination

6. Clinical assessment Bony assessment
Fracture site, severity, and stability
Classification and position

7. Specific assessment X-rays: A/P and lateral Special investigations
Pressure monitoring
Angiography
CAT scan (rare for diaphyseal fractures)

8. Clinical management General trauma patient management
Initial reduction and splintage
Soft-tissue protection
Preparation for definitive management

9. Soft-tissue injury
Complications and prognosis are directly related to the degree of soft-tissue injury

10. Tibial diaphyseal fracture classification

11. Tibial diaphyseal fracture classification

12. Tibial diaphyseal fracture classification

13. Tibial diaphyseal fracture classification

14. Tibial diaphyseal fracture classification

15. Nonoperative treatment
Nonoperative treatment does NOT mean no treatment
Closed reduction and plaster of Paris application can achieve good results
Nonoperative treatment requires close monitoring

16. Nonoperative treatment
Good casts can prevent lateral shift
Good casts can prevent angulation
Good casts can control rotation
No cast can prevent shortening

17. “A fracture in plaster of Paris will not displace
more than its previous maximal displacement”
Augusto Sarmiento

18. Nonoperative treatment of tibial shaft fractures
Relative stability leads to healing by callus

19. Nonoperative treatment
Children
Undisplaced fractures
“Stable” reduced fractures
Contraindication for surgery:
Patient
Health care team

20. Operative treatment—nailing
Indirect reduction that preserves soft-tissue attachments
Allows movement at fracture site which results in early union with callus formation
Anatomical reduction is rare but restoration of length, axis, and rotation is common

21. Nailing—mechanics Nails function as internal splints
Nails can withstand heavy loads
Nails can be mobilized with early weight bearing

22. Intramedullary (IM) nailing
Indications
Closed diaphyseal fractures
Open diaphyseal fractures
Segmental fractures
Floating knee
Nonunions
Treatment of choice for the vast majority of fractures

23. Insertion principles
Starting point
Proximal
Central
Anterior

24. Locking principles
In the vast majority of cases static locking is carried out
Locking
None
Static
Dynamic
Indications
Length
Rotation
Alignment

25. Problems nailing proximal and distal fractures
Malalignment
Instability
Failure
Malunion
Nonunion
To avoid this, fractures must be reduced and held during nail insertion!

26. Reamed or unreamed nails?—closed tibial fractures
Union
15.4 weeks
22.8 weeks
Nonunion 0%
20%
Malunion
16%
Screw breakage 4%
52%
Nail breakage
Reference:
Court-Brown CM, Will E, Christie J, et al (1996) Reamed or unreamed nailing for closed tibial fractures. A prospective study in Tscherne C1 fractures. J Bone Joint Surg Br; 78(4):580–583.
This study showed a very marked advantage for reamed nails over unreamed nails.
“Reamed nails mechanically and biologically superior.” Court-Brown CM, et al

27. Reamed and unreamed IM nailing
Randomized controlled trial of 1,226 adult tibial shaft fractures followed for 1 year
57 (4.6%) nonunions
105 reamed versus 114 unreamed nailing group experienced “problem event”
Possible benefit for reamed nailing in closed fractures
No benefit of reaming with open fractures
Delaying reoperation for nonunion for at least 6 months may substantially decrease the need for reoperation
This metaanalysis did show a slight advantage for reamed over unreamed nails in closed tibial fractures. The study did not confirm the dramatic findings of CM Court-Brown, et al.
References:
Bhandari M, Guyatt G, Tornetta P 3rd, et al. Randomized trial of reamed and unreamed intramedullary nailing of tibial shaft fractures. J Bone Joint Surg Am Dec;90(12):

28. Anterior knee pain—complication of nailing
Incidence varies from series to series
0–40%
Related to surgical approach—may be more common in patella tendon splitting approaches
Centre of tibial head is just medial to patellar tendon

29. Operative treatment—compression plating
18 months
Direct reduction can destroy soft-tissue attachments
Needs maximal periosteal preservation
Rigid fixation will result in slow union without callus formation
Anatomical reduction
Technique needs to be perfect

30. Compression plating—indications
Simple metaphyseal fractures
Corrective osteotomy for malunion
Plating for hypertrophic nonunion
Often done percutaneously (MIPO)

31. Operative treatment—external fixator
Useful in severe soft- tissue damage
Rarely used as definitive treatment

32. Compartment syndrome Devastating complication Incidence: 1–7%
Occurs in both reamed and unreamed nailing
High index of suspicion will lead to diagnosis
Presents with pain
Clinical suspicion important
Beware of patients with reduced sensation
Definitive diagnosis: compartment pressure < 30 mm below diastolic = compartment syndrome
References:
McQueen MM, Gaston P, Court-Brown CM. Acute compartment syndrome. Who is at risk? J Bone Joint Surg Br Mar;82(2):200-3.

33. Take-home messages Assessment of the injury
Nonoperative and operative options
Choice of implants—their advantages and disadvantages
Surgical technique
Importance of the closed soft-tissue injury