Tibia Fracture 1

Tibia Fracture
References
R&G

Summary
- AMPLE, pre problem, neuro s/s, smoker, other
- JAB, NV exam, C/S, ABI, open # management, ancef, gent (1mg/kg), pen (1mill/u), cipro/ceftaz for water injuries,
Td 0.5cc, TTIG 250, 500 really dirty, remove gross contamination, compress dressing
- monitored bed, realign limb, re check all, re xray, splint, pain Rx
- trauma bloods, x match, serial exams, consent for all
- open tibia and C/S cat 2: consent, abx, supine, radiolucent table, full I&D of open # to bleeding edges, fasciotomy
if CS or warm ischemia over 6 hours (really bad and no tib fxn consider amputation), 2 incision technique, ex fix
and align #, PACU checks, repeat check and I&D 48 hrs while continuing Abx, get coverage of bone with muscle
flap and skin with STSG early, gastroc for prox 1/3, soleus for mid and free for distal (may need plastics ), keep ex
fix, keep abx until 48hrs after last OR, plan to exchange ex fix for nail when tissues calm by 2 weeks post ex fix
application, patellar tendon splitting, lock prox and distal, alignment, length and rotation checks on fluoro, PACU
check all, watch on floor, check wounds, serial f/u, early ROM knee and ankle, NWB w/ crutches, follow wounds
closely as well as grafts, watch Cr and for myoglobinuria on floor, hydrate IV well, int med assistance
- bone loss: ICBG at 6 wks post ST coverage for 3 cm or less, do bone transport with nail if good coverage, be sure
to shorten/osteotomize fibula at same time, done over nail, if anterior coverage poor and ST compromised, consider
PL graft b/t PL and FHL along IOM w/ ICBG
- if no tib fxn, ST extremely poor and really dirty, warm ischemia over 6 hrs, amputate limb
- comp: nonunion (r/o infection as usual, remove HW, frozen section, gram stain and cultures, I&D to bleeding and
remove all necrotic, ex fix, Abx beads, ID consult, IV Abx, PICC, f/u esr/crp, when normal, do revision fixation and
ICBG 2 wks after that), non infected non union (exchange nail and ICBG), malunion is osteotomy to correct
alignment and rotation, fix w/ ex fix or nail

1. History
a. ATLS – ABCDEs, AMPLE
b. Age/Sex
c. Onset of pain
i. MOI
ii. Previous Injury
d. P osition
e. Q uality/Quantity
f. R adiation
g. S ymptoms associated
i. Neurologic
ii. Mechanical
1. able to ambulate
2. able to move arm/leg/back
iii. Local
h. Timing
i. When injury occurred (important for ischemia time)
i. PSHX, PMHX, Meds, Allergies
j. Social Hx (EtOH, tobacco), prev problems with
k. Handedness, Occupation, Sports
l. ROS
m. Last Meal

2. Physical Exam
a. General
b. JAB
c. Look
i. Gait
ii. S welling
iii. E rythema
Tibia Fracture 2

iv. A trophy
v. D eformity
vi. S kin changes
d. Feel
e. Move
f. NV Exam
g. COMPARTMENTS
h. Classifications, OPEN
i. Gustillo
1. Grade 1= <1cm
2. Grade 2= >1cm without extensive soft tissue damage
3. Grade 3
a. A = adequate coverage
b. B = bone exposed requiring coverage
c. C = vascular injury requiring repair
ii. Tscherne
1. C0 = little soft tissue injury
2. C1 = moderate fracture with superficial abrasions
3. C2 = moderate # with deep contamination and local skin or muscle contusion
4. C3 = extensive soft tissue crushing or muscle destruction
5. C4 = compartment syndrome
iii. AO tibia
1. 42
2. A
a. 1 simple spiral
b. 2 simple oblique
c. 3 simple transverse
3. B
a. 1 torsion wedge
b. 2 bending wedge
c. 3 multiple butterfly
4. C
a. 1 comminuted torsion
b. 2 segmental
c. 3 crush

3. Imaging
a. X-rays AP, lateral tibia, JAB
i. Morphology of bone
ii. Morphology of fracture
iii. Secondary fracture line
iv. Gas in soft tissues
v. Extension into joint
b. Contralateral x-rays for templating
c. X-rays of other injuries
d. ATLS required x-rays

4. Diagnosis or DDx
a. Tibia Fracture
b. ? Open
c. ? Vascular injury

5. Acute Rx and work-up

a. Antibiotics
i. ancef for grade 1
ii. ancef + gent for grade 2-3
iii. ancef+gent + pen G for clostridium possibility
Tibia Fracture 3

iv. cipro or 3rd gen cephalo for water injury (vibrio, gram negs)
b. Tetanus prophylaxis
i. Tetanus immune
1. Clean = Tetanus toxoid (0.5 cc) only if last booster > 10 years ago
2. Dirty = Tetanus toxoid (0.5 cc) only if last booster > 5 years ago
ii. Tetanus immune status unknown or bad
1. Clean = Tetanus toxoid (0.5 cc IM)
2. Dirty = Tetanus toxoid + Immunoglobulin (250 microgram IM)
c. Clean obvious dirt, apply occlusive dressing and splint
d. Compartment pressures
i. If unconscious
ii. Within 30 of diastolic is indication for fasciotomy
iii. Most common finding is elevated compartment pressure in deep posterior compartment
followed by anterior compartment
iv. Measure close to fracture
1. At least 5 cm
e. No cultures in ER
f. trauma bloods
g. Ask for serial exams to be done to monitor for compartment syndrome

6. Treatment plan
a. Goals
b. Non-operative Rx
i. Acceptable Reduction
1. 5 degrees varus/valgus
2. 10 degrees anterior/posterior angulation
3. 10 degrees rotational
a. ER better than IR
4. < 1 cm shortening
5. < 5 mm distraction
6. 50% cortical contact
ii. Technique
1. Long leg cast
a. 0-5 degrees flexion
b. PWB X 2 weeks then WBAT
2. Once swelling subsides can change to patella bearing cast or fracture brace
c. Operative Rx
i. IM Nail
ii. Ex Fix
iii. Fasciotomy
iv. ST coverage
d. Consent
i. Outcome
ii. Risks
1. Immediate
a. Infection, blood loss, NV injury, Anaes
2. Late
a. Osteomyelitis, nonunion, malunion, knee pain
e. Pre-op
i. Labs (x-match), tests (ECK, CXR), old OR reports, consults
f. Post the case
i. Category 2 (open, compartment syndrome)
ii. Radiolucent table
iii. Supine
iv. Irrigation + debridement, +IM nail locked and reamed vs ex-fix +/- fasciotomy +/-
vascular repair +/- angiography
v. Fluoroscopy
Tibia Fracture 4

vi. Consent
vii. May need vascular surgeon

7. Technique
a. Nail if > 5cm from plafond
b. Medial parapatellar / patellar spllitting approach unless proximal fracture
c. Beware of valgus and procurvatum (extension) with proximal fracture
i. Use lateral entry point, poller screws, triangle
ii. Unicortical plate
d. Limited reaming
e. Fasciotomy two-incision technique
i. See Compartment Syndrome Scenario
f. Vascular injury
i. Anterior tibial artery injury is most common,
1. may cause loss of anterior compartment muscle.
2. Lower leg can survive loss of peroneal or tib post arteries.
ii. Get vascular surgery consult +/- real angio vs on table OR angio.
iii. If minimal warm ischemia time
1. Can stabilize bony injury first with ex-fix vs IM nailing followed by vascular
repair.
2. If grey zone, or warm ischemia time > 6hrs should
a. Do vascular repair, after ex fix
b. Some advocate doing vascular shunt, then bony stabilization, then
definitive vascular repair.
iv. Prophylactic fasciotomy if warm ischemia > 6 hrs due to reperfusion injury (watch
Cr for renal failure and CK levels for myoglobinuria).
v. Prep and drape opposite leg for harvest of saphenous vein graft
g. Wound closure
i. Primary
ii. Delayed primary with interim VAC treatment
iii. Pie crusting
1. Multiple 5 – 10 mm incisions placed in 1 cm wide rows parallel to wound.
Incisions are staggered
a. I I I I I
b. I I I I
c. I I I I I
d. Within 3 weeks the relaxing incisions heal by contraction
iv. Split thickness skin grafts require a vascular tissue bed and will not take over exposed
bone stripped of periosteum or tendon.
v. Wound VAC treatment can be used for 1 – 2 weeks to close tissue defects, or at least
minimize the size of defect requiring a smaller flap
vi. Local random fasciocutaneous flaps
vii. Local muscle flaps
1. Gastrocs
a. Consider angio to make sure sural arteries are intact.
b. Each head of gastroc is supplied by sural arteries which branch off
popliteal artery.
c. Medial head for defect over proximal third of tibia (anterior and medial
defects) or anterior knee
i. Incision from plateau to 10 cm above ankle paralleling
posterior border of tibia.
ii. Saphenous vein left intact
iii. Gastroc is separated from overlying subQ tissue.
iv. Avascular plane developed b/w medial head of gastroc and
soleus.
v. Median raphe s is identified.
Tibia Fracture 5

vi. Proximally, sural nerve traverses midline b/w the 2 heads,

and passes into lateral raphe distally.
vii. Based on sural artery proximally
viii. Release medial head distally with small portion of Achilles
ix. After Achilles attachment is released, NV pedicle is isolated –
based on sural artery.
x. Pedicle can be dissected to its origin and muscle’s femoral
attachments divided.
d. Lateral head for lateral defects around knee and proximal tibia
i. Longitudinal incision 3cm posterior to fibula. Peroneal nerve
identified at neck of fibula.
ii. Flap shorter in length.
iii. Based on sural artery identified after distal attachment.
2. Soleus for middle third of tibia
a. Blood supply unpredictable in tibial fracture.
b. Proximal is peroneal artery, popliteal artery
c. Distal is posterior tibial artery
d. With ligation of distal tib post perforators,
i. proximal pedicle is most reliably based on popliteal vessels,
e. can also be based on posterior tibial and peroneal arteries.
f. Can raise as hemisoleus
i. which leaves little functional deficit
ii. if do not transect intermuscular artery and take it with flap.
iii. Soleus is split longitudinally just lateral to the midline to
ensure that intermuscular artery is not transected.
iv. The posterior neurovascular bundle is identified.
v. Superficial and deep surfaces are cleared of soft tissues.
g. Attached to Achilles anteriorly and distally
h. Incision
i. medial tibial plateau to medial malleolus
i. Separate soleus from gastrocs at midpoint, and
j. Separate deep surface attachment of soleus from FDL.
k. Distally separate from Achilles leaving a portion of the tendon
attached.
l. Ligate distal perforators from posterior tibial artery for proximally
based flap.
m. Look for distal flap necrosis after distal perforators are ligated and
excise necrosed muscle.
3. Free flap for distal third vs dorsalis pedis fasciocutaneous flap, tibialis
anterior flap
a. Choices for free flap donor graft include
i. rectus abdominus flap
ii. latissimus dorsi flap
iii. gracillis flap
iv. dorsalis pedis fasciocutaneous flap.
4. Cover within 72 hours
h. Bone loss
i. Type 1
1. < 50% diameter – usually heals, exchange nail
ii. Type 2
1. >50% < 2cm – bone graft at 6weeks
iii. Type 3
1. missing bone segment – debridement, ilzarov or vasc fibula
iv. Ilizarov for > 4cm bone loss
v. Consider acute shortening then lengthening
1. may have less complications than nonunion
vi. Time to healing
Tibia Fracture 6

1. usual tibial fracture = 4 months

2. + 1.5 months per cm of bone defect.
vii. Complications
1. nearly all pts require at least 1 extra OR.
2. Nonunion
3. infection
4. pin site problems
5. abx toxicity
6. n/v injury
7. malalignment
8. weakness
9. dysfunctional limb
10. psychologic problems.
viii. Treatment Approach
1. < 1 cm defect
a. shortening
2. 1 -3 cm
a. cancellous bone graft
3. 2 – 10 cm
a. bone transport +/- free vascularized fibula
4. 10 – 30 cm
a. amputation +/- bone transport
ix. Acute limb shortening.
1. Short treatment time with fewest complications,
2. some loss of limb function.
x. Iliac crest bone graft with initial bone fixation with ex-fix, plate, IM nail preserving
bone length.
1. Bone graft at 6 weeks b/c if soft tissue coverage was used it is now
epithelialized and bacterial counts are decreased.
2. Even if soft tissue grafting was not done, 6 week delay allows healing of
traumatized tissues.
3. Generally applicable, but slow treatment time, donor site morbidity, applicable
to smaller defects.
4. Technique
a. Avascular tissue debrided
b. IM canal is reamed
c. Cortical ends are overlapped by at least 1 cm proximally and distally
d. Posterolateral graft avoids often traumatized anteromedial soft tissue.
e. Pt is prone for access to posterior iliac crest and tibia
f. If flap in place anastamosed
i. to posterior tibial artery
1. Approach should be anterolateral
ii. to anterior tibial artery.
1. Approach should be posteromedial.
xi. Posterolateral graft to create synostosis above and below fracture.
xii. Fibula pro tibia
1. Through posterolateral approach
2. double osteotomy of fibula above and below fracture with transfer of fibula to
posterolateral surface of tibia
3. OR placement within tibial shaft and secured with screws proximal and distal.
4. Can augment with graft.
xiii. Free fibula graft from contralateral leg.
1. Lateral decub
2. Distal fibula cut 10 cm above fibular tip
3. Tourniquet
4. Lateral incision through skin, lateral fascia.
5. Peroneals reflected off fibula, periosteum left intact.
Tibia Fracture 7

6. 1 -2 mm layer of muscle is left on fibula – marbling effect

7. Anterior and posterior fascia is cut with a knife.
8. Posteriorly the fascia is cut on the bone. There are no anterior feeding vessels, so
there is no danger in this manoever.
9. Anteriorly, the interosseous membrane is visible.
a. The fascial layer is cut with a knife.
b. Posteriorly after the fascial cut the FHL is visible.
c. Pedicle is directly under FHL,
i. so it is released with care.
ii. Using metz, the FHL muscle fibers are spread, and cut taking
care to cauterize muscle perforators.
10. Pedicle is visualized deep to FHL.
11. Protecting the posterior tibial bundle with 2 mallealble ribbon retractors deep to
the fibula, a gigli saw is used to cut the fibula, care is taken to hold the fibula
during the second cut.
12. Distal wound pedicle is dissected free and medium hemoclips are used.
13. Dissection through membrane is carried out taking care to cauterize or clip
perforators.
14. Nerve to FHL may be carried with pedicle, but sacrifice does not affect
outcome.
15. Pedicle is exposed at proximal bifurcation. 5 cm is ideal length of pedicle before
placing 2 large hemoclips.
16. Fibular graft is freed.
17. Wound is packed to control bleeding.
18. Deep fascia is not closed and subQ tissue and skin closed over a drain.
19. Length of fibular graft is 4cm longer than defect, with 2 cm overlap at both
proximal and distal ends.
20. 7 cm of proximal fibula is left at donor site to prevent knee and peroneal
problems.
21. Time to union is 3 – 6 months with 90% union rate.
22. Donor site morbidity in 19% of patients, with fracture of graft in 25%, esp if
graft hypertrophy does not occur.
xiv. Bone transport techniques
xv. Distraction histiogenesis
1. Ilizarov technique is good for large defects of 30 cm or more.
2. Fracture with bone defect is left alone
3. Proximal osteotomy is made at metaphyseal-diaphyseal junction.
4. Ilizarov fixator half-pins with ring are placed proximal and distal to osteotomy
site, and proximal and distal to fracture
5. Latency period of 14 days for adults followed by distraction of 1mm per day, or
0.25mm q 6 hrs.
6. Gradual distraction allows N/V bundle to stretch safely.
7. Less distraction may lead to premature consolidation, and more distraction over-
extends the bone regeneration process.
8. Keep central radiolucency b/w 2mm and 8mm.
9. “docking site” is fracture site where proximal fragment will eventually meet
distal fragment once distraction is finished.
10. Often need to bone graft docking site.
11. Ex-fix is kept until callus becomes mature
12. Treatment is 1.5 months per mm lengthened
13. After lengthening is complete, consolidation until mature callus is present lasts
2x as long as lengthening in kids, and 3 – 4x as long in adults.
14. Alternatively consider acute shortening with lengthening later.
15. Useful for closure of soft tissue defects. Useful if fibular comminution present.
If massive defect there is too much soft tissue redundancy with shortening.
xvi. Induced Membrane Technique (Masquelet)
Tibia Fracture 8

1.Thorough and efficacious débridement must be performed to limit the risk of

subsequent infection
2. fixation construct should be stable enough to allow the soft tissues to heal before
the second stage of the procedure. Can use internal or external fixation
3. First stage: a polymethyl methacrylate spacer is placed in the defect to produce a
bioactive membrane, which appears to mature biochemically and physically 4 to
8 weeks after spacer placement.
a. Cement should be placed into the defect during later stages of
polymerization to allow proper sizing and shaping of the spacer while
limiting interdigitation with cancellous bone
b. spacer should overlap the outer cortical ends of the remaining bone to
ensure that the graft has sufficient room to heal
c. If the condition of the soft tissue allows, the spacer should be larger
than the original defect to permit placement of enough bone graft for
reconstruction of the defect
d. recommend temporary removal of the cement spacer during the final
stages of polymerization, if possible, because the exothermic reaction
of PMMA curing can be significant and may lead to heat necrosis in the
surrounding bone and soft tissue. When spacer removal is not possible,
judicious use of saline can limit any sequelae of heat necrosis.
e. Definitive soft-tissue coverage and spacer placement should be
performed during the same surgical procedure
4. Second stage: cancellous autograft is placed within this membrane and, via
elution of several growth factors, the membrane appears to prevent graft
resorption and promote revascularization and consolidation of new bone.
a. use of an osteotome and mallet typically is required to remove the
PMMA in a piecemeal fashion
b. If an IM nail is used for fixation, a second membrane forms between
the cement spacer and the nail; this membrane should also be
maintained to maximize healing and promote corticalization of the graft
c. No need to remove the nail in the 2nd stage as it provides stability
d. recommend the Reamer-Irrigator-Aspirator (RIA) for femoral bone
graft harvest because the biologic content of this graft has been shown
to be equivalent or superior to that of iliac crest graft, with volumes of
≤80 mL obtainable from each femur
e. Allograft extender volume of ≤25% of the final graft composition can
be used
5. Excellent clinical results have been reported, with successful reconstruction of
segmental bone defects >20 cm
6. increased incidence of delayed stress fractures has been reported with use of
external fixation for definitive bony stabilization compared with fixation with
IM nails or plate-and-screw constructs
xvii. Amputation
1. shortest treatment time, but complete loss of limb function

8. Post-op
a. follow wound
b. serial NV checks (compartments)
c. Physio
i. WBAT for A type
ii. Partial for others
iii. Start ROM immediately

9. Disposition and Follow-up

a. Remember to book second look for RE I&D, ABX post op x 48 hrs
b. coverage
i. may need plastics consult
Tibia Fracture 9

c. exchange ex-fix to nail before 2 weeks even with pin tract leakage
i. clean ex-fix pin sites daily with tooth brush

10. Complications
a. Compartment syndrome
i. 4%
ii. anterior compartment always involved
b. NV injury
i. Claw toes
ii. pre and post-op peroneal nerve lesion improve in 80%
c. Infection
i. Osteomyelitis – see actual template
d. Infected nonunion
i. <2weeks abx
ii. >2weeks, abx, ream membrane and exchange nail
iii. chronic
1. may need to remove hw
2. antibiotic beads and debridement, repeat if necessary
3. bone + gallium + indium scan, ESR, CRP
4. reconstruction, consider ilizarov
iv. FOR INFECTED NONUNION –
1. adequate blood supply, CBC, ESR, CRP back to baseline, normal host with
good nutrition consider PAPINEAU TECHNIQUE
a. repeat irrigation and debridement until granulation tissue layer has
formed (usually at 2 weeks)
b. autologous cancellous bone graft is compressed into the defect. – this
step is repeated until graft incorporated
c. Once graft incorporated soft tissue coverage may be needed.
2. Posterolateral bone grafting (?Hartman?)
a. can be used for infected nonunion without disturbing anterior
traumatized soft tissues.
b. Can also be used for non-infected nonunions.
c. Average time to union is 5 months following grafting.
d. Relative contraindications include
i. proximal 1/3 grafting due to risk of N/V injury
1. do posteromedial graft
ii. previous fibulectomy which would compromise synostosis
iii. drainage from front of leg is not a contraindication as long as
fibrous barrier across # is undisturbed.
e. Technique
i. Lateral decub
ii. Incision just posterior to fibula to allow 5 cm of exposure
above and below fracture.
iii. POSTEROLATERAL APPROACH to tibia
iv. Protect cutaneous branch of peroneal nerve
v. Interval b/w peroneals and gastroc
1. Follow interosseus membrane to posterior tibia.
vi. Peroneals retract anterior
vii. Soleus, gastroc, FHL, tib post retract posterior. Follow
membrane to tibia
viii. Pack bone graft.
ix. If bone loss can span with tricortical ICBG after roughening
tibia above and below fracture
f. With massive bone loss can use ipsilateral fibula as tibial bone graft.
i. Iliac crest graft is then added.
g. Patients should be warned about ankle problems following synostosis
h. At closure, deep fascia is not closed
Tibia Fracture 10

3. Technique
a. Debridement
i. Irrigate & Debride nonviable, necrotic tissues including skin,
soft tissues, and bone.
ii. Continue until punctuate bleeding is seen. Send for C&S.
iii. Mycobacteria and fungal cultures are taken in
immunocompromised patients.
iv. Send for pathology, esp sinus tracts to r/o malignant
transformation.
b. Skeletal stabilization
i. If fracture is healed all hardware is removed
c. If IM nail & # healed,
i. remove nail and ream canal to remove membrane.
d. If # not healed exchange nail.
e. If IM nail with IM abscess,
i. remove nail and ream canal.
ii. Ex-fix fracture.
iii. Leave abx beads pouch.
iv. Leave ex-fix on for 2 weeks then re-ream canal & IM nail.
v. Prepare ex-fix pin sites by drilling.
vi. IV abx x 6 weeks.
f. Hardware not providing stability is removed and fracture ex-fixed.
g. Local abx with PMMA abx bead pouch
i. Dead space filled with PMMA abx cement beads.
ii. Per 40g of PMMA
1. 2.4 – 4.8g tobramycin,
2. 2 – 4 g vancomycin.
iii. Occlusive dressing placed over beads is kept until soft tissue
coverage is performed
1. usually after serial debridements
h. Culture specific Systemic abx culture specific IV
i. Wound management with repeat I&D and coverage of soft tissue defect
when bed is clean of infection
i. Delayed vs primary closure depending on “clean wound”
ii. May require repeat debridements.
iii. Reconstruction ladder includes
1. VAC
2. gastroc flaps for prox tibia
3. soleus for middle tibia defects
4. free flap in distal 1/3 tibia defects.
5. Usually performed as 2nd stage 5 – 7 days post initial
debridement when wound bed in clean.
j. Bone graft at 6 weeks, infection negative
k. Reconstruction for bone defects at 6-8 weeks
i. Autologous iliac crest bone graft for defects up to 4 – 6 cm
long.
ii. Bone grafting is done when soft tissue envelope has healed,
flap viability is determined, and infection controlled (usually 6
– 8 weeks) after muscle transfer.
4. Imaging studies (CT, MRI, bone scan) reviewed to assess status of bone healing
and location and extent of cortical and medullary bone involvement.
5. Evaluate soft tissues (abscess, sinus tracts) to determine extent of debridement
necessary.
6. N/V and functional status of extremity to aid in determining final outcome goal
a. nerve injury, compartment sx, deformed foot
7. Co-morbidity
a. Stop smoking, nutritional support.
Tibia Fracture 11

v. common infecting organism is

1. s. aureus
2. second most common is pseudomonas aureginosa.
3. Osteo is most commonly polymicrobial.
e. Nonunion
i. 9 months or 3 months without progression of healing
ii. Hypervascular (hypertrophic, pseudarthrosis) vs. hypovascular (atrophic, oligotrophic,
torsion wedge) vs Infected (CBC, ESR, CRP, bone/gallium/indium scans + needle
aspiration of nonunion)
iii. 2% with nails
iv. smoking
v. HW failure
1. Usually locking bolts
vi. Non-op
1. functional bracing ± fibular osteotomy (fibulectomy should be performed at a
site other than that of the nonunion)
2. extracorporeal shock wave therapy: shown to be as effective as surgical
management in patients with stable hypertrophic nonunion
a. patients with fracture gaps >5 mm wide, defects measuring >5 mm, and
fractures that could not be immobilized adequately did not respond to
ESWT
3. Low-intensity Pulsed Ultrasound
a. 20 minutes/day
4. Electrical Stimulation
vii. Operative Options
1. Consider fibular osteotomy (1-2cm resection) with dynamization
2. Exchange nailing with overreaming
3. Anterolateral bone graft
a. proximity to possible damaged anterior soft tissues, + small amount of
bone graft can be applied.
4. Prophylactic bone grafting at 6weeks
5. Posterolateal bone grafting (97% union)
a. Elevate shavings from posterior tibia, put ICBG corticocancellous strip
along membrane to tibia
6. Proximal 1/3 of tibia use posteromedial graft placement
7. Use plate when correcting a tibial malalignment
a. put plate of tension side of bone.
b. If varus malalignment put plate lateral
c. if valgus put plate medial.
d. Expose bone only on side of plate application.
e. If no significant malalignment put plate lateral under tib ant.
f. Interfrag lag screw.
g. 4.5mm titanium LCDCP or locking LCDCP
8. Fixations Options
a. IM nail
b. Plate
c. ex-fix
d. hybrid ex-fix
9. DON’T TAKE DOWN NONUNION unless
a. unacceptable malalignment that can’t be corrected without take-down
b. infected nonunions
c. pseudoarthrosis
f. Malunion
i. REDUCTION
1. 5 degrees of varus/valgus angular, 10 deg of ant/post angulation or rotatory and
1cm shortening
ii. OPERATION (need patient symptoms first)
Tibia Fracture 12

1. > 10 valgus
2. > 6 – 10 varus
3. ER 15 – 20 deg
4. IR 10 – 15 deg
5. shortening > 2cm
iii. Treat with
1. osteotomy of tibia + fibula + plate/IM nail/ex-fix through posterolateral
approach.
2. If malunion has large degree of shortening consider Ilizarov distraction
osteogenesis with potential for deformity correction
iv. Consider need for Achilles lengthening in procurvatum
g. Amputation
i. 21-85% after grade IIIC
ii. indications
1. PT nerve transaction
2. severe crushes
3. warm ischemia more than 6 hours
iii. MESS score
1. Soft tissue
a. 1 = low energy
b. 2 = medium
c. 3 = high
d. 4 = high + contamination
2. Limb ischemia
a. 0 = normal pulse
b. 1 = abn pulse but perfusion ok
c. 2 = pulseless with decreased cap refill
d. 3 = cool and numb
e. THIS SCORE DOUBLE FOR WARM ISCHEMIA > 6 hrs
3. Shock
a. BP > 90mmHg = 0
b. transiently < 90 = 1
c. persistently < 90 = 2
4. Age
a. < 30 = 0
b. 30 – 50 = 1
c. > 50 = 2
5. Initially thought that score > or = to 7 was 100% predictive of amputation
6. Bosse et al showed that
a. low scores predict good survivorship,
b. high scores have poor predictive value for amputation vs limb-salvage.
7. BKA
a. bone length should be 12 – 17 cm from medial joint line.
b. If stump is < 9 cm consider removing entire fibula with muscle bulk.
c. If stump < 5 cm convert to knee disartic or AKA
h. Knee pain
i. Tx by nail removal
i. RSD
i. Associated with acute localized osteoporosis
Tibia Fracture 13
Tibia Fracture 14

Figure 1:Algorithm for removing or retaining infected hardware in patients with chronic osteomyelitis of the
tibia
Tibia Fracture 15

Previous OSCEs:

Case 2013: 17 y.o. kid with fall and injury to lower extremity. Guy with accident- Metaphyeal/Diaphyseal jx tibia
fx.
How to treat? Nail

Problems with nail at Met/Dia jx? Valgus

How to prevent this? Open, Clamp, alter starting point slightly lateral, verify proper alignment with flouro, poller
blocking screws

OK. Your partner does it and kid is in valgus. What amount of alignment is acceptable?
< 5 degrees varus-valgus angulation
< 10 degrees anterior/posterior angulation
> 50% cortical apposition
< 1 cm shortening
< 10 degrees rotational alignment

Some time passes and kid comes back because of pain- malalignment. What do you recommend? Correction of
fracture fixation.

Why? Prevents biomechanical future problems- specifically early arthritis of knee and/or ankle.