Chapter 57: Tibia and Fibula Shaft Fractures

Christina Boulton, Robert V. O’Toole

Chapter Outline

Introduction

Fractures of the tibia and fibula are relatively common and have been recognized as serious and debilitating injuries for centuries. Descriptions of the treatment of tibial fractures are included in the Edwin Smith Papyrus, an ancient Egyptian medical text dating back to at least 1500 to 1600 BC.33 
Tibial fractures are associated with a wide range of injury mechanisms and severities. Although most fractures are closed open fractures of the tibia are more commonly seen than in many other bones because of its subcutaneous location. The management of tibia and fibular fractures is influenced greatly by the associated soft tissue injury. Severe open fractures of the tibia are associated with high complication rates and poor long term outcomes. Prior to the modern era of antibiotics and sterile surgical techniques open tibial fractures not infrequently resulted in amputation or death. It is estimated that in the Crimean War (1853 to 1856) the survival rate after tibial gunshot injuries was less than 20%. Even in World War I one in five battle injuries involved unstable fractures of the lower leg, the majority of which were open. At that time, combat-related tibial fractures were associated with a mortality rate of about 10% and an amputation rate of over 20%.36 
For many years the tibia was the most frequently fractured long bone98 and in many countries this remains the case. However, it is not a fragility fracture and in developed countries the increase in fragility fractures and periprosthetic fractures has meant that the incidence of femoral diaphyseal fractures has increased so that the incidence of femoral and tibial diaphyseal fractures is now very similar (see Table 3-3). Compared to fractures elsewhere in the body, tibial fractures have relatively high rates of nonunion and malunion.188 The tibial diaphysis is the most common site of fracture in the tibia and about 80% of these injuries have associated fibular fractures. Published data suggest an incidence of 17 per 100,000 person-years,5,254 although more recent data indicate that the incidence may be declining (see Table 3-3). 

Assessment

Mechanisms of Injury for Tibia and Fibula Shaft Fractures

Tibial fractures have a bimodal distribution with low-energy spiral patterns being more common in patients over 50 years of age and high-energy transverse and comminuted fractures being more common in patients under 30 years of age. Among Medicare patients aged ≥65 years tibial fractures are almost three times more common in women than in men.42 However, high-energy tibial fractures in younger patients are approximately twice as common in males than females.50 There is no significant racial disparity.42 
The most common causes of low-energy tibial fractures are falls from a standing height and sporting injuries (see Table 3-39). The associated sporting activities vary depending on the population studied with soccer injuries accounting for as many as 80% of sports-related fractures in British studies.55 High rates of ski-related injuries have been reported in Swiss studies.89 
High-energy tibial diaphyseal fractures are most commonly associated with vehicular trauma. Court-Brown and McBirnie55 showed that in 1988 to 1995 vehicular trauma accounted for 37.5% of tibial diaphyseal fractures with pedestrians being struck the most common mechanism (59.2% of vehicular injuries), followed by motorcycle crashes (22.4%) and motor vehicle crashes (17.3%). In a study focusing on pedestrian injuries, Burgess et al.36 found that 30% of pedestrian tibial fractures were bilateral and 65% of patients had Gustilo type III92,93 open fractures. Other high-energy mechanisms include assaults (4.5%), most commonly a direct blow or a gunshot wound, and falls from a height (6.2%). 
Because of its subcutaneous location open fractures of the tibia are common with reported rates varying between 12% and 47% depending on the patient population and type of treatment center.220,254 Open fractures are even more common with high-energy mechanisms with rates as high as 63% being reported following motorcycle crashes.55 When open fractures occur in the tibia they are more commonly type IIIB requiring flap coverage than for other sites of injury.55 Perhaps, more so than for any other bone, treatment and outcomes for fractures of the tibial diaphysis are governed primarily by the extent of the associated soft tissue injury. 

Associated Injuries with Tibia and Fibula Shaft Fractures

Compartment Syndrome

Tibial diaphyseal fractures have a risk of developing compartment syndrome. This is discussed later in this chapter and in Chapter 29. Compartment syndrome has been reported to occur in 1.5% to 11% of tibial fractures.153,154,176 Since a missed compartment syndrome can have devastating consequences on limb function or may even cause renal failure through rhabdomyolysis, clinicians should be aware of the possibility of compartment syndrome in every patient with a tibial fracture. The pathophysiology, diagnosis, and treatment of compartment syndrome are discussed in Chapter 29

Ankle Injuries

Ankle injuries occur in association with approximately one-fifth of tibial diaphyseal fractures and can include lateral ligamentous complex disruptions as well as fractures of the lateral, medial, and posterior malleoli.223 Specific surgical treatment of the associated ankle injury is not necessarily recommended in all cases. CT evaluation of the ankle can be helpful to identify undisplaced medial or posterior malleolar fractures prior to surgery to assess the need for clamping or fixation to prevent displacement of these fractures during intramedullary (IM) nailing. Posterior malleolar fractures are reported in association with 8% to 9% of tibial diaphyseal fractures,103,212 and there is a high correlation with spiral fractures of the distal third of the tibia (25% to 39%).29,129. The detection rate of these injuries is significantly increased when a protocol is in place for preoperative CT scanning of distal tibial fractures.190 

Floating Knee Injuries

Ipsilateral femoral and tibial fractures are referred to as floating knee injuries. Type I injuries involve fractures of the femoral and tibial diaphyses, type IIA fractures involve the knee joint, and type IIB involve the hip and/or ankle. These combined injury patterns are typically due to high-energy mechanisms. Reported rates of associated vascular injury (21%) and open fracture (62%) are higher than expected based on the rates for the two isolated injuries combined.1 Knee ligamentous instability has also been reported in almost one-third of cases.245 Historically reported outcomes have been quite poor,1,14 but good to excellent results can be achieved when both fractures are treated with internal fixation.65 Risk factors for poor outcome include intra-articular involvement of the knee (type IIA) or severe open tibial fracture.65,261 

Fracture Extension into Tibial Plateau

Occult proximal extension of tibial diaphyseal fractures into the tibial plateau is rarer than the extension into the tibial plafond or malleoli described above, but is equally important. Preoperative CT scanning of the knee in all proximal one-third tibia fractures is recommended to rule out an associated plateau injury. It is important to recognize intra-articular knee involvement preoperatively as it may influence the choice of implant. A central undisplaced plateau fracture can become widely displaced during IM nail placement and should be stabilized with a clamp or screws prior to IM nailing being undertaken. Alternatively, a lateral plate can be used to avoid intra-operative fracture displacement. 

Knee Ligamentous Injury

Case reports have been published describing ipsilateral knee ligamentous injury, and even knee dislocation, in patients with tibial diaphyseal fractures.12,105 In a prospective study using examination under anesthesia, 22% of patients with tibial diaphyseal fractures were found to have sustained an injury to at least one knee ligament.227 Although knee ligamentous injuries are more commonly seen in association with femoral diaphyseal fractures and floating knees than with tibial diaphyseal fractures alone,226,245 some authors advocate routine knee ligament examination in all patients presenting with tibial diaphyseal fractures.105 However, it is difficult to evaluate the knee ligaments in a patient with an unstable tibia fracture and therefore these injuries are likely to be underdiagnosed on initial presentation. Examination of knee ligament stability is more straightforward after tibial fixation, but a postoperative diagnosis prevents the surgeon from altering the type or position of the implant to facilitate early ligamentous reconstruction.43 

Proximal Tibiofibular Joint Dislocation

Dislocation of the proximal tibiofibular joint can occur in isolation and is associated with lateral ligamentous instability and peroneal nerve injury.114 In rare cases, proximal tibiofibular joint dislocation can occur in association with a tibial diaphyseal fracture, usually when the fibula is intact.9,114 Widening of the joint can best be visualized on an internal rotation X-ray following tibial stabilization. Because of the rarity of this combined injury little data are available to guide treatment or predict outcomes. 

Signs and Symptoms of Tibia and Fibula Shaft Fractures

History and Physical Examination

A thorough history and physical examination should be undertaken in patients presenting with fractures of the tibia and/or fibula. The history should focus on the timing and mechanism of injury, location and quality of pain, and any additional presenting symptoms such as numbness or tingling. A prior history of injury, infection, tumor, or surgery in the affected limb should be obtained. The patient should be questioned about pre-existing conditions that may affect normal function of the limb such as diabetic neuropathy, spinal radiculopathy, or peripheral vascular disease. As with all multiply injured patients, a comprehensive understanding of the nature and severity of associated injuries to vital organ systems is critical. In the absence of polytrauma the examination should focus on the injured leg and the adjacent knee and ankle joints. Particular attention should be paid to the following factors to identify and treat any associated injuries and complications. 

Compromised Skin

Skin compromise can occur in association with both open and closed fractures of the tibia and fibula. Any areas of skin tenting or puckering should be relieved by restoration of the normal anatomic alignment and splinting once the initial limb assessment is completed. In some cases, reproduction of the injury displacement is necessary to relieve skin puckering related to the incarceration of subcutaneous tissue or periosteum at the fracture site. The significance of skin tenting or puckering should not be underappreciated. If skin compromise is not addressed promptly irreversible full thickness skin necrosis can occur within hours and in severe cases this may result in subsequent soft tissue reconstructive procedures.80 It is also possible for bone to perforate through threatened or necrotic skin resulting in a previously closed fracture becoming an open fracture. If this occurs under a splint or cast, the conversion to an open injury may be unrecognized and treatment delayed thus increasing the infection risk. Postsplinting radiographs should be obtained to make sure the fracture displacement causing the initial skin compromise has been corrected, and areas of initially threatened skin should be checked after the limb is reduced. Inability to adequately relieve skin compromise following closed reduction is an indication for early operative bony stabilization. 

Wounds

A wound present on any fractured limb should be assumed to be associated with an open fracture until proven otherwise. This is especially true for a wound associated with tibial diaphyseal fracture as the thin anteromedial soft tissue envelope results in a relatively high incidence of open fractures. Surgeons should remember that the displacement of the limb at the time of injury can cause open fracture wounds to be located at some distance from the fracture. Open lateral and posterolateral leg wounds are often associated with the fibular fracture which may be at a different anatomic level to the associated tibial fracture. The wounds should be examined and any obvious contaminants removed. Preliminary wound irrigation using sterile saline should be followed promptly by the application of a moist sterile dressing, fracture reduction, and splint application. Exposed bone and articular cartilage should be reduced inside the soft tissue envelope whenever possible or covered with a moist dressing to prevent desiccation. Removal of this dressing and multiple inspections of the open wound should be avoided. Documentation of the size, location, and degree of contamination of any open wounds on the leg is of great importance as it predicts outcome and some clinicians use this information to determine the urgency of the timing of surgical debridement. The use of photographic documentation of the wounds can prevent the need for multiple examinations, aid in communication with other physicians, and provide additional information for the medical record. 

Vascular

A comprehensive distal vascular examination should be performed both before and after restoration of length and alignment of the limb. Some patients with significantly displaced tibial and fibular fractures will have diminished or absent pulses distal to the injury because of kinking of the arteries of the leg. In most of these cases, palpable pulses will return once normal anatomic alignment is restored. If the pulses do not return to normal after bony reduction then further investigations such as angiography, CT angiography, or arterial Doppler studies should be performed to rule out a vascular injury. Attention should also be paid to swelling, pallor, capillary refill, temperature, and venous congestion during the vascular examination of the limb. 

Motor

The evaluation of motor function in a patient with a tibia and fibular fracture should include strength grading of all of the muscles in the injured leg (Table 57-1). However, in the vast majority of cases, pain and limb instability will limit the degree to which a patient can participate in rigorous motor strength testing. In all cases documentation should be as detailed and specific as possible under the circumstances. For example “tibialis anterior muscle strength 3/5, limited by pain” or “patient displayed spontaneous ankle plantar flexion on presentation but unable to follow commands for formal testing” are both more useful and correct than “wiggles toes” or “peroneal nerve motor intact.” It is important to keep in mind that motor function can be altered for multiple reasons including pain, muscle or tendon rupture, nerve injury, limb ischemia, compartment syndrome, spinal cord or brain injury, or any combination of these. In severely displaced fractures a motor examination should be performed both before and after fracture reduction as results can vary significantly. 
Table 57-1
The Four Compartments of the Leg with the Muscles, Arteries, and Nerves Contained Within Them
Compartment Muscles Arteries and Nerves
Anterior Tibialis anterior
Extensor hallucis longus
Extensor digitorum longus
Peroneus tertius
Anterior tibial artery
Deep peroneal nerve
Lateral Peroneus longus
Peroneus brevis
Superficial peroneal nerve
Superficial posterior Gastrocnemius
Soleus
Plantaris
Deep posterior Tibialis posterior
Flexor hallucis longus
Flexor digitorum longus
Popliteus
Posterior tibial artery
Peroneal artery
Tibial nerve
X

Sensory

Patients with tibial diaphyseal fractures should have a distal sensory examination of the ipsilateral foot performed including the territories of the deep peroneal nerve (first dorsal interspace), the superficial peroneal nerve (the dorsum of the foot), the sural nerve (lateral ankle and heel), the saphenous nerve (medial ankle and heel), and the tibial nerve (plantar aspect of foot). Although detailed testing of temperature, proprioception, and two-point discrimination are rarely indicated for patients with an acute tibial or fibular fracture, care should be taken to determine whether sensation is present in each zone and whether it is normal or diminished. It has been our clinical experience that the sensory examination is most reliable when the patient receives no visual cues. We therefore ask the patient to cover their eyes for that portion of the evaluation. 

Evaluation of Compartment Syndrome

The possibility of compartment syndrome, either primary or because of reperfusion of an ischemic limb, should always be considered when evaluating patients with fractures of the tibia and fibula. Care should be taken to evaluate signs of compartment syndrome and to clearly document the findings. Patients with a borderline initial examination should be followed with serial examinations to allow prompt diagnosis and treatment if a compartment syndrome develops. Physical examination findings indicating compartment syndrome include pain out of proportion to injury severity, pain on passive stretch of the relevant compartment musculature, paresthesiae, paralysis of the muscles in the affected compartments, severely swollen or indurated compartments, and in rare cases, pulselessness. It is important to realize that pulselessness is an unusual finding in compartment syndrome and indicates severe compartment syndrome as the pressure in the compartment must approach the systolic blood pressure to occlude arterial flow. Compartment syndrome is discussed in detail in Chapter 29
The diagnosis of compartment syndrome by physical examination can be particularly difficult when a patient is sedated, obtunded, or has an exaggerated pain response such as those with long-term narcotic addiction. Under these circumstances compartment pressure monitoring can be used to diagnose compartment syndrome. This is discussed in detail in Chapter 29. Untreated compartment syndrome can result in significant long-term disability, neuropathic pain, and necessitate multiple reconstructive procedures. Lawsuits involving compartment syndrome are more often successful and involve higher average settlements when compared with other lawsuits brought against orthopedic surgeons.25 For all of these reasons, particular care must be taken to investigate and diagnose compartment syndrome in all patients who present with an acute tibial diaphyseal fracture. 

Imaging and Other Diagnostic Studies for Tibia and Fibula Shaft Fractures

The initial radiographic evaluation of all fractures of the tibia and fibula diaphyses should involve anteroposterior (AP) and lateral orthogonal radiographs centered on the midtibia (Figs. 57-1A and 57-2A). Ideally, these standard views should include the entire length of both the tibia and fibula. However, this is sometimes difficult to achieve in tall patients. Standard views of the ipsilateral knee (AP and lateral) and ankle (AP, lateral, and mortise) should also be obtained. These additional radiographs may show involvement of the proximal or distal tibial articular surfaces, the lateral and medial malleoli, the proximal or distal tibiofibular joints, and adjacent bones such as the talus, distal femur, and patella. The presence of a knee effusion containing separate layers of fat and blood is highly suggestive of fracture or internal knee derangement. Therefore, subtle radiographic findings, such as a lipohemarthrosis on a lateral radiograph of the knee, may prompt further imaging with CT or MRI. In some specific fracture patterns, additional CT imaging of an adjacent joint is routinely ordered to exclude commonly associated fractures. The most common example of this is a spiral fracture of the distal third of the tibia which is associated with a high prevalence of posterior malleolar fractures, many of which are not visible on plain radiographs of the ankle (Fig. 57-3).103,190 
Figure 57-1
 
A: AP and lateral radiographs showing a distal diaphyseal tibial fracture in adequate alignment. B: The alignment was maintained after the application of a cast.
A: AP and lateral radiographs showing a distal diaphyseal tibial fracture in adequate alignment. B: The alignment was maintained after the application of a cast.
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Figure 57-1
A: AP and lateral radiographs showing a distal diaphyseal tibial fracture in adequate alignment. B: The alignment was maintained after the application of a cast.
A: AP and lateral radiographs showing a distal diaphyseal tibial fracture in adequate alignment. B: The alignment was maintained after the application of a cast.
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Figure 57-2
A: AP and lateral radiographs of an open tibia fracture treated with debridement and immediate nailing.
 
The fracture demonstrated fracture callus by 7 weeks from injury (B) and more callus at 11 weeks (C) without the need for bone grafting. The appearance of the healed fracture at 14 months is typical (D).
The fracture demonstrated fracture callus by 7 weeks from injury (B) and more callus at 11 weeks (C) without the need for bone grafting. The appearance of the healed fracture at 14 months is typical (D).
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Figure 57-2
A: AP and lateral radiographs of an open tibia fracture treated with debridement and immediate nailing.
The fracture demonstrated fracture callus by 7 weeks from injury (B) and more callus at 11 weeks (C) without the need for bone grafting. The appearance of the healed fracture at 14 months is typical (D).
The fracture demonstrated fracture callus by 7 weeks from injury (B) and more callus at 11 weeks (C) without the need for bone grafting. The appearance of the healed fracture at 14 months is typical (D).
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Figure 57-3
 
A: Sagittal CT scan of a distal tibia diaphyseal fracture demonstrating a coronal fracture line entering the joint that was not apparent on plain radiographs. B: The fracture was stabilized with a screw prior to intramedullary nailing.
A: Sagittal CT scan of a distal tibia diaphyseal fracture demonstrating a coronal fracture line entering the joint that was not apparent on plain radiographs. B: The fracture was stabilized with a screw prior to intramedullary nailing.
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Figure 57-3
A: Sagittal CT scan of a distal tibia diaphyseal fracture demonstrating a coronal fracture line entering the joint that was not apparent on plain radiographs. B: The fracture was stabilized with a screw prior to intramedullary nailing.
A: Sagittal CT scan of a distal tibia diaphyseal fracture demonstrating a coronal fracture line entering the joint that was not apparent on plain radiographs. B: The fracture was stabilized with a screw prior to intramedullary nailing.
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Supplemental imaging with CT, MRI, or both modalities is also indicated when there is concern about a possible pathologic bone lesion either at the fracture site or within the zone of planned instrumentation. Causes for concern can include a minimal energy mechanism, a history of malignancy, antecedent pain, or an irregular appearance of the bone on x-ray. Although malignant bone lesions are rare, IM reaming or fixation through an unrecognized malignant bone tumor can have profound effects on disease spread and patient survival. Therefore, if a pathologic bone process is suspected further workup including additional imaging should be obtained prior to surgical treatment, and consultation with an orthopedic oncologist should be considered. 

Classification of Tibia and Fibula Shaft Fractures

The most commonly used classification system for fractures of the tibia and fibula is the AO/OTA classification which separates fractures into three basic types, these being simple fractures (type A), wedge fractures (type B), and complex fractures (type C).149 Each fracture type is divided into three groups which denote increasing severity of injury (Fig. 57-4 and Table 57-2). Further subgroups and qualifications also exist and can be helpful in classifying fractures for research purposes although they less useful in clinical practice. In clinical practice we find the AO/OTA149 classification system for tibial diaphyseal fractures to be less useful than for other fractures. 
Figure 57-4
The AO/OTA classification of tibial diaphyseal fractures.
 
For an explanation of the different types, groups, and subgroups see Table 57-2.
For an explanation of the different types, groups, and subgroups see Table 57-2.
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For an explanation of the different types, groups, and subgroups see Table 57-2.
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For an explanation of the different types, groups, and subgroups see Table 57-2.
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Figure 57-4
The AO/OTA classification of tibial diaphyseal fractures.
For an explanation of the different types, groups, and subgroups see Table 57-2.
For an explanation of the different types, groups, and subgroups see Table 57-2.
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For an explanation of the different types, groups, and subgroups see Table 57-2.
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For an explanation of the different types, groups, and subgroups see Table 57-2.
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Table 57-2
AO/OTA Classification of Tibial Diaphyseal Fractures
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Table 57-2
AO/OTA Classification of Tibial Diaphyseal Fractures
Type A: Unifocal Fractures
Group A1 Spiral Fractures
Subgroups A1.1 Intact fibula
A1.2 Tibia and fibula fractures at different level
A1.3 Tibia and fibula fractures at same level
Group A2 Oblique Fractures (fracture line >30 degrees)
Subgroups A2.1 Intact fibula
A2.2 Tibia and fibula fractures at different level
A2.3 Tibia and fibula fractures at same level
Group A3 Transverse Fractures (fracture line <30 degrees)
Subgroups A3.1 Intact fibula
A3.2 Tibia and fibula fractures at different level
A3.3 Tibia and fibula fractures at same level
Type B: Wedge Fractures
Group B1 Intact Spiral Wedge Fractures
Subgroups B1.1 Intact fibula
B1.2 Tibia and fibula fractures at different level
B1.3 Tibia and fibula fractures at same level
Group B2 Intact Bending Wedge Fractures
Subgroups B2.1 Intact fibula
B2.2 Tibia and fibula fractures at different level
B2.3 Tibia and fibula fractures at same level
Group B3 Comminuted Wedge Fractures
Subgroups B3.1 Intact fibula
B3.2 Tibia and fibula fractures at different level
B3.3 Tibia and fibula fractures at same level
Type C: Complex Fractures (multifragmentary, segmental, or comminuted fractures)
Group C1 Spiral Wedge Fractures
Subgroups C1.1 Two intermediate fragments
C1.2 Three intermediate fragments
C1.3 More than three intermediate fragments
Group C2 Segmental Fractures
Subgroups C2.1 One segmental fragment
C2.2 Segmental fragment and additional wedge fragment
C2.3 Two segmental fragments
Group C3 Comminuted Fractures
Subgroups C3.1 Two or three intermediate fragments
C3.2 Limited comminution (<4 cm)
C3.3 Extensive comminution (>4 cm)
X
As mentioned above, the management of tibia diaphyseal fractures is influenced most significantly by the state of the soft tissues. Therefore, in clinical practice tibial fracture classification is meaningless without a classification of the associated soft tissue injury. The Tscherne classification235 is used to classify closed fractures (Fig. 57-5) and the Gustilo classification92,93 is used to classify open fractures (Table 57-3). These classification systems are mainly used to describe the soft tissue injuries associated with closed and open fractures respectively. Whereas the AO/OTA149 classification system for tibial diaphyseal fractures has been shown to be a poor predictor of functional outcomes81,225 the Tscherne classification235 has been shown to correlate with the time to return to walking and sporting activities.81 An open fracture of any type is predictive of increased risk of nonunion, malunion, and reoperation.81 
Figure 57-5
The Tscherne classification of closed fractures.
 
C0, simple fracture configuration with little or no soft tissue injury; C1, superficial abrasion, mild to moderately severe fracture configuration; C2, deep contamination with local skin or muscle contusion, moderately severe fracture configuration; C3, extensive contusion or crushing of skin or destruction of muscle, severe fracture.
C0, simple fracture configuration with little or no soft tissue injury; C1, superficial abrasion, mild to moderately severe fracture configuration; C2, deep contamination with local skin or muscle contusion, moderately severe fracture configuration; C3, extensive contusion or crushing of skin or destruction of muscle, severe fracture.
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Figure 57-5
The Tscherne classification of closed fractures.
C0, simple fracture configuration with little or no soft tissue injury; C1, superficial abrasion, mild to moderately severe fracture configuration; C2, deep contamination with local skin or muscle contusion, moderately severe fracture configuration; C3, extensive contusion or crushing of skin or destruction of muscle, severe fracture.
C0, simple fracture configuration with little or no soft tissue injury; C1, superficial abrasion, mild to moderately severe fracture configuration; C2, deep contamination with local skin or muscle contusion, moderately severe fracture configuration; C3, extensive contusion or crushing of skin or destruction of muscle, severe fracture.
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Table 57-3
Gustilo Classification of Open Fractures
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Table 57-3
Gustilo Classification of Open Fractures
Type I Clean wound of less than 1 cm in length
Type II Wound larger than 1 cm in length without extensive soft tissue damage
Type III Wound associated with extensive soft tissue damage; usually longer than 5 cm
Open segmental fracture
Traumatic amputation
Gunshot injuries
Farmyard injuries
Fractures associated with vascular repair
Fractures more than 8 hours old
Subtype IIIA Adequate periosteal cover
Subtype IIIB Presence of significant periosteal stripping
Subtype IIIC Vascular repair required to revascularize leg
X

Outcome Measures for Tibia and Fibula Shaft Fractures

To our knowledge there are no outcome scores in widespread use that are specifically designed for tibia and fibula diaphyseal fractures. Scores that predict the viability of limb salvage in severe open tibia fractures exist, as do general outcome scores, knee scores, and foot and ankle scores that are also used for injuries to these regions. Classification systems of tibial diaphyseal fractures do not predict outcomes such as union, the requirement for secondary surgery, or infection, nor do they correlate with functional outcomes.225 Busse et al.38 have recently published a new instrument called the Somatic Pre-Occupation and Coping (SPOC) questionnaire which has good correlation with SF-36 scores and is a better predictor of functional recovery after tibia fracture than age, gender, fracture type, smoking status, or polytrauma.38 This tool may prove helpful in the future but, as yet, it has not been used widely. 

Lower Extremity Trauma Scores

Severe open fractures of the tibia and fibula, usually Gustilo Type IIIB and IIIC fractures, can be associated with severe lower extremity injuries that make limb salvage difficult or impossible. Salvage of these complex injuries is extremely challenging and often requires multiple surgical procedures, prolonged hospitalization, long-term narcotic pain medication, and high medical bills. These issues need to be weighed against the psychological and functional effects of amputation and the costs of lifelong prostheses. Several lower extremity injury severity scores have been developed in an attempt to predict which injuries are best treated with limb salvage and which with amputation. 
The Mangled Extremity Severity Score (MESS) is the most commonly used system and grades injuries on a scale from 2 to 11 based on energy of injury, limb ischemia, the presence of shock, and patient age. The MESS score is doubled for limb ischemia greater than 6 hours. A MESS score greater than 7 is the recommended threshold for amputation. 
In a recent meta-analysis of publications on limb salvage scores, Fodor et al. reported that the range of published salvage rates for limbs with MESS > 7 was from 0% to 93%.68,74,130 The MESS score correlated well with amputation outcome in only one quarter of publications and seemed to be more useful as a predictive tool in combat-related injuries than in civilian injuries. Bosse et al.30 prospectively investigated the clinical utility of five lower extremity injury scores (MESS; Limb Salvage Index [LSI]; Predictive Salvage Index [PSI]; Nerve Injury, Ischemia, Soft Tissue Injury, Skeletal Injury, Shock, and Age of Patient Score [NISSSA]; Hannover Fracture Scale-97 [HFS-97]) in 556 patients and found that whereas low scores could be used to predict high limb salvage potential, high scores were not valid predictors of amputation.30 Because of this these scores are much less commonly used to predict viability of limb salvage after severe open tibial diaphyseal fractures. 

General

SF-36 & SF-12: The Medical Outcomes Study Short Form Health Survey (SF-36) is a 36-item questionnaire used to assess functional status and well-being. It is commonly used to assess general outcome after fracture. Scores range from 0 to 100, with higher scores indicating a more favorable state of health. Population norms are available for several countries allowing comparisons of the health status of the patient groups with the general population. The SF-12 is a validated subset measure of the SF-36. 
SMFA: The Short Muscculoskeletal Form Assessment is a common outcome measure for patients with fractures of the lower extremity. 

Knee Scores

WOMAC: The Western Ontario and McMaster Universities (WOMAC) osteoarthritis index is widely used for conditions that affect the knee and hip and is well validated.198 It is a 24-item instrument, which assesses functional impairment, pain, and stiffness, in which higher scores indicate poorer results. However, it was developed for the elderly with osteoarthritis and is not therefore the most appropriate instrument to assess the knee in younger individuals and athletes. 
LYSHOLM: The Lysholm Knee Score is a validated, patient-reported outcome measure looking at eight categories—limp, support devices, locking, instability, pain, swelling, stairs, and squatting. Scores range from 0 to 100 with 100 representing a fully functional, asymptomatic knee.147 
CINCINNATI: The modified Cincinnati Knee Rating System is another validated patient-reported outcome measure looking at eight categories–pain intensity, swelling, giving way, overall activity, walking, stairs, running, and jumping/twisting. Scores range from 0 to 100. Results >80 are considered excellent, 55 to 79 are good, 30 to 54 are fair, and <30 are poor.171 

Foot and Ankle Scores

AOFAS: The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale is the most commonly used ankle scoring system. It assesses pain, function, and alignment. The maximum score is 100 with higher scores indicating better outcome. However, compared with other instruments it has poorer validity, consistency, and responsiveness.71 
Foot Function Index (FFI): The FFI is a 17-question validated region-specific instrument for measuring outcomes in patients with foot and ankle disorders. Scores range from 0 to 100 with higher scores indicating more severe functional limitation. It correlates well with the SF-36. However, as it was first developed for use in the elderly it is best suited for the evaluation of lower functioning patients.2,71 

Pathoanatomy and Applied Anatomy

Osteology

The tibial diaphysis is triangular in cross section with very thick cortices and is extremely strong. Cortical thickness tends to decrease with age predisposing the tibia to lower energy injury mechanisms. The tibia is the main weight-bearing bone in the leg, carrying greater than 80% of load.88,135 The fibula lies posterior and lateral to the tibia throughout the leg and the two bones are connected by a thick interosseus membrane. Compared to the tibial diaphysis, the distal and proximal metaphyseal bones are relatively weaker. 
The distal tibial articular surface is externally rotated approximately 20 degrees (mean 21.6 ± 7.6; range 4.8 to 39.5 degrees) compared with the proximal articular surface. This is a normal anatomic phenomenon known as tibial torsion.165,222 Therefore, a standard AP view of the ankle cannot typically be obtained on the same radiograph as a standard AP view of the knee. The mechanical axis of the lower extremity runs from the center of the femoral head to the center of the distal tibia at the ankle and should pass just medial to the center of the knee. The normal proximal and distal tibial articular surfaces are not quite parallel. The distal articular surface is perpendicular to the mechanical axis of the tibia (lateral distal tibial angle [LDTA] = 90 degrees), whereas the proximal articular surface is tilted slightly medial (medial proximal tibial angle [MPTA] = 87 degrees). These values are not of significant importance in the management of routine tibial fractures but can be helpful in planning the correction of multiplanar congenital or posttraumatic deformities. 

Vascularity

Osseous vascularity is of key importance in bone healing after fracture. The adult tibia has both a medullary and a periosteal blood supply. It is estimated that the outer 25% to 30% of the tibial cortex derives its oxygenation primarily from the periosteal system, whereas the rest of the bone is predominantly supplied by the medullary system.194,221 The main nutrient artery to the tibia is a branch of the posterior tibial artery and enters the bone in its proximal one-third supplying a rich network of medullary vessels. The periosteal blood supply is supplied by branches of the arterial supply to the surrounding soft tissues and can be disrupted when soft tissue stripping occurs at the time of injury. After soft tissue stripping outer cortical viability is maintained by centrifugal flow directed outward from the medullary system via anastomoses.221 Reaming has been shown to temporarily decrease medullary blood supply in animal studies,213 raising concern about reamed nailing in open fractures with periosteal stripping. However, animal studies have also shown that loss of the medullary arterial system results in stimulation of the periosteal system and reversal of the normal direction of blood flow through the anastomoses between the two vascular systems.192,221 

Compartments and Musculature

The musculature of the leg is divided into four compartments (Fig. 57-6). The contents of each compartment are listed in Table 57-1. There is very little anatomic variation in compartment anatomy from person to person. The anterior compartment musculature originates predominantly from the anterolateral aspect of the proximal tibia (Fig. 57-7) and includes the main dorsiflexors of the ankle and toes. The anterior compartment also contains the deep peroneal nerve and anterior tibial artery which supply the muscles in the compartment. The anterior compartment structures are dissected off the tibial surface and retracted laterally during an anterolateral surgical approach to the tibia, this being required for plate osteosynthesis. 
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Figure 57-6
The four compartments of the leg.
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Figure 57-7
The (A) anterior and (B) posterior anatomy of the leg, illustrating the origins and insertions of the muscles.
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The lateral compartment muscles evert the foot and take origin from the lateral and posterior aspects of the fibula diaphysis (Fig. 57-7). The lateral compartment also contains the superficial peroneal nerve which exits the fascia approximately 10 to 12cm proximal to the tip of the distal fibula. The superficial peroneal nerve is at risk during lateral fasciotomy, distal fibular fixation, and placement of distal screws during percutaneous plating of the tibia. 
There are two posterior leg compartments—superficial and deep (Fig. 57-6). The superficial posterior compartment contains the gastrocnemius soleus muscle complex, which is the primary ankle plantarflexor, and the plantaris muscle. The posterior deep compartment is bordered anteriorly by the posterior surface of the tibia and the interosseus membrane. It contains tibialis posterior which inverts the foot, flexor hallucis longus and flexor digitorum longus, which plantarflex the toes, in addition to popliteus, and the peroneal artery, posterior tibial artery, and tibial nerve. The posterior deep compartment can be difficult to assess for compartment syndrome by clinical examination and it is the compartment most often incompletely released during fasciotomy. The posterolateral surgical approach to the distal tibia utilizes the plane between muscles of the lateral and deep posterior compartments. 

Treatment Options

Nonoperative Treatment of Tibia and Fibula Shaft Fractures

Indications/Contraindications

Nonoperative treatment of tibial diaphyseal fractures has fallen out of favor over time. Although the preferred method of surgical fixation varies geographically and by surgeon age and training,19 the vast majority of adult tibial fractures are treated operatively in the modern developed world. A survey of Canadian orthopedic surgeons published in 2008 showed that only 20% of surgeons routinely managed closed tibial diaphyseal fractures nonoperatively40 compared with 30% of surgeons surveyed at the Orthopaedic Trauma Association Meeting in 1997.123 Multiple studies have demonstrated that nonoperative management is associated with poorer results when compared to IM nails with reference to nonunion, malunion, return to work, outcome scores, or time to union.5,28,101,118 
Despite this there is still a role for nonoperative management in treating adults with tibial diaphyseal fractures. Current indications include patients with very high anesthetic risk or fractures with excellent initial alignment that will require little or no reduction to obtain adequate alignment (Fig. 57-1). Relative contraindications for closed treatment include anything that prevents effective cast or fracture brace application or any factor that requires operative treatment. Closed treatment requires frequent follow-up to check for displacement, so noncompliant patients are less well suited for nonoperative treatment. Displaced tibial fractures without a fibular fracture are prone to fall into varus with nonoperative treatment, so these require particular caution and close monitoring when treated closed. Very proximal or distal fractures that approach the metaphysis can be difficult to maintain in acceptable alignment with closed means, so these patterns are also a relative contraindication. Patients at risk of compartment syndrome, particularly ICU patients who cannot provide pain information or participate in the physical examination, should be considered carefully as casts and splints can limit access to the limb to evaluate swelling of the leg compartments. A list of indications and contraindications for the use of nonoperative management is given in Table 57-4
Table 57-4
The Indications and Relative Contraindications for Nonoperative Management
Indications Relative Contraindications
Adequate alignment, length, and rotation in a splint or cast Inadequate alignment, length, and rotation after application of splint or cast
Soft tissue cannot tolerate cast Open fracture
Significant anesthetic risk Arterial injury
Patient refuses operative treatment Displaced proximal or distal fracture
Compartment syndrome or high risk of compartment syndrome
Soft tissues will not tolerate a splint, cast, or brace
Patient unable to comply with nonoperative protocol
Ipsilateral femoral diaphyseal fracture
High-energy mechanism or soft tissue injury
Ipsilateral injury preventing weight bearing
X
Tibial diaphyseal fractures should only be treated nonoperatively if adequate alignment can be obtained with closed reduction (Table 57-5). However, there is very little evidence to say how much malalignment is too much.160 Instead, what we have is a general consensus on threshold values for closed treatment of a tibial diaphyseal fractures. These values are based largely on the criteria used in a series of 1,000 fractures treated with functional bracing,211 discussed below, that demonstrated positive outcomes including a nonunion rate of only 1.1% with only 2.4% failing this treatment because of progressive angulation. 
 
Table 57-5
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Table 57-5
Acceptable Malalignment in Tibial Diaphyseal Fracturesa
Alignment Parameter Acceptable Malalignment
Varus <5 degrees
Valgus <5 degrees
Apex anterior/Posterior <5–10 degrees
Rotation <0–10 degrees
Shortening <10–12 mm
X
Because of the orientation of the knee and ankle joints varus or valgus malalignment is thought to be more detrimental than apex anterior or posterior alignment as the knee and ankle can compensate for some degree of sagittal plane deformity. Despite the commonly held belief that malaligment of the tibia will lead to long-term arthritis, no relationship was shown in a long-term follow-up study.160 Similarly, there is thought to be little threshold for rotational malalignment as this would cause a mismatch between the axis of the knee and ankle and impede ambulation. However, humans may compensate for rotational lower limb deformities better than previously thought.229 
There is significant variability in published standards for acceptable angulation, shortening, and rotation of tibial diaphyseal fractures and therefore there is no consistent definition of tibial malunion in the literature. This can make comparisons between studies misleading and interpretation of study results challenging. Parameters for acceptable alignment of a tibial diaphyseal fracture have not been rigorously tested, nor are the effects of malalignment on long-term function well studied. Limited animal and cadaveric data suggest that tibial varus or valgus malalignment of <10 degrees does not result in significantly abnormal cartilage contact pressures or cartilage degeneration in the ankle or knee.144,152,208 Although several authors have proposed that even small angular deformities of the tibia can result in significant functional losses114,168,251 this has not been well borne out in the literature. Merchant and Dietz157 have reported data showing no correlation between tibial malunion and subsequent radiographic osteoarthritis or functional change at the knee or ankle. Recent level II evidence has shown no significant intermediate-term functional impact secondary to tibial malrotation over 10 degrees.229 

Techniques—Closed Treatment of Tibial Diaphyseal Fractures

The initial closed treatment of tibial diaphyseal fractures involves the use of closed reduction maneuvers as required and then the application of a long leg splint or cast (Fig. 57-9). Some surgeons perform this procedure under conscious sedation or even full general anesthesia to promote patient comfort and improve the chances of obtaining the best fracture reduction possible. A long leg splint is initially used to control rotation. Soft material that has some capacity to expand, such as web roll surrounded by plaster, or bivalving of a fiberglass cast is preferred as these injuries are associated with significant swelling, and compartment syndrome may occur. Casts, splints, and any circumferential dressing can increase intracompartmental pressure, so these should be removed immediately in any patient suspected of developing compartment syndrome. 
Figure 57-9
A: A well padded long leg cast has been used for the definitive treatment of a minimally displaced tibia diaphyseal fracture.
 
To correct loss of alignment the cast can be split (B) and a wedge inserted to maintain the new alignment (C).
To correct loss of alignment the cast can be split (B) and a wedge inserted to maintain the new alignment (C).
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Figure 57-9
A: A well padded long leg cast has been used for the definitive treatment of a minimally displaced tibia diaphyseal fracture.
To correct loss of alignment the cast can be split (B) and a wedge inserted to maintain the new alignment (C).
To correct loss of alignment the cast can be split (B) and a wedge inserted to maintain the new alignment (C).
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Failure to achieve an adequate initial reduction, as defined in Table 57-5, is an indication for operative treatment or further attempts at closed reduction. However, unlike nonoperative treatment of humeral diaphyseal fractures, tibial diaphyseal fracture alignment does not tend to improve during nonoperative treatment. Therefore, if the initial alignment is not adequate, nonoperative treatment should be abandoned in favor of operative treatment. 
Nonoperative treatment of tibial diaphyseal fractures is typically performed with either cast immobilization or functional bracing. Both treatment methods involve initial stabilization in a long leg cast or a well-moulded splint for 2 to 4 weeks until the soft tissue swelling reduces and callus formation begins.204,209 The long leg cast or splint is then changed to a short leg patellar tendon-bearing (PTB) cast (Fig. 57-8) or a fabricated functional brace.204 The advantage of a functional brace over a PTB cast is that it allows ankle motion in addition to knee motion. 
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Figure 57-8
A patellar tendon-bearing cast.
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The theory behind how bracing and cast immobilization maintain tibial alignment centers around the hydraulic pressure exerted on the fracture by circumferential forces on the noncompressible fluid-based tissues of the leg.204 Therefore, a tight, well-contoured fit is required for the successful maintenance of fracture reduction. Appropriate moulding is employed at the time of initial cast or brace application and subsequent adjustments can be made by reforming the brace or wedging the cast to correct fracture alignment (Fig. 57-9). Cast wedging involves making a transverse cut through the cast at the level of the fracture, improving the reduction by applying an appropriate angular force to the fracture and placing “wedges” on one side of the cast to help hold the new reduction. The wedges are typically something like fragments of a tongue depressor. The wedges are then overwrapped with fiberglass at the site of fracture. Although this technique can help realign the fracture, some clinicians believe that once you start wedging the cast closed treatment is failing. 
A central theory in the nonoperative treatment of tibia fractures is that stimulation of fracture healing occurs through functional activity of the limb.204 Therefore, early weight bearing is encouraged and ipsilateral injuries that prevent weight bearing are a relative contraindication to nonoperative treatment of the tibia with functional bracing.204,209 

Outcomes

Although nonoperative treatment of tibial diaphyseal fractures may be less popular today, Sarmiento has published extensively on the nonoperative treatment of tibial diaphyseal fractures with his initial descriptions of the technique dating back to the 1960s.203205,211 In the largest series published,211 a retrospective analysis of 1,000 closed tibial diaphyseal fractures treated conservatively, Sarmiento reported a nonunion rate of 1.1% with 95% of fractures healing with ≤12 mm of shortening and 90% with ≤6 degrees of angulation. Average final shortening (4.3 mm) correlated strongly with average initial shortening (2.5 mm) demonstrating that for closed, diaphyseal tibial fractures initial shortening is not increased through functional bracing and weight bearing. Similarly, this correlation also suggested that improvement in initial shortening achieved by closed reduction was not maintained through bracing, and therefore unacceptable initial shortening should be viewed as a contraindication to conservative treatment. The study was limited by its retrospective nature and a lack of validated outcome scores. However, this study gives the impression that nonoperative treatment is reasonable and should be considered as a viable treatment option. 
Fracture types found to correlate with poorer results following conservative treatment include open fractures, fractures with initial shortening >12 mm, and tibial fractures with an intact fibula because of an increased risk of late angular deformity.211 However, acceptable shortening, angulation, and healing times have also been reported with conservative treatment of segmental tibial fractures.210 
It should be noted that other authors have not been able to reproduce the positive outcomes of Sarmiento’s work. Limitations in ankle and subtalar motion,64 and nonunion rates of up to 40% have been reported63 with nonoperative treatment. A systematic review of the literature reported 32% malunion rates with only 4.1% nonunion with closed treatment.47 However, many of the other published reports on conservative management describe the technique used in more heterogeneous populations including patients with Gustilo type II and III open fractures.28,113,187 Axially unstable fractures with unacceptable initial shortening will typically return to the initial shortening when braced even when acceptable length is initially gained by traction and manipulation, and therefore should not be routinely treated nonoperatively.204 Several authors have also recommended operative treatment for spiral fractures with initial displacement >50%.32,167 However, data from Toivanen et al.231 have shown that a cut off of 30% initial displacement is more appropriate. 
Although Sarmiento has shown successful treatment of grade I open tibia fractures with functional bracing,204,211 the vast majority of the literature does not support the routine use of conservative treatment for open fractures of the tibia.8,113,143,187 When compared to operative treatment it has been associated with a longer time to union,8 higher rates of nonunion (9.9% to 21%),63,143,188 malunion (4.3%),63,188 and soft tissue complications such as skin necrosis and infection (15%).113 In addition, the effectiveness of the cast or brace may be hindered by an inability to apply it with sufficient circumferential compression because of soft tissue damage, and application of a cast or brace makes regular monitoring of the soft tissues very difficult.208 
The most compelling outcome data against closed treatment of tibial fractures comes from studies comparing closed treatment to IM nail fixation. A retrospective cohort study28 and several randomized controlled trials (RCTs) comparing the outcomes of nonoperative treatment versus IM nail fixation5,101,118 favored nail fixation over closed treatment in terms of outcome. In 1998 Littenberg et al. published a meta-analysis comparing conservative treatment to plating and IM nail fixation for closed tibial diaphyseal fractures. Reported rates of nonunion with nonoperative treatment (0% to 13%) were comparable to those for operative treatment, but the most significant difference found was an odds ratio of 0.21 for time to union >20 weeks when nonoperative treatment was compared to surgical fixation.143 Operative treatment had a higher risk of superficial infection and pooling of data from multiple studies did not allow comparison of malunion rates or functional outcomes. 
A systematic review of the literature analyzing 13 RCTs demonstrated that closed treatment had higher rates of nonunion, malunion, and infection than operative treatment with plates or nails.48 However, it should be noted that reoperation rates with operative treatment ranged from 4.7% to 23.1% depending on the study.48 An economic analysis39 suggests that closed treatment offered no advantages over nail fixation in terms of cost to a single payer or from a societal perspective. The societal costs are driven by the longer time off from work that are associated with nonoperative treatment. However, the most important fact that surgeons should remember is that no randomized study has favored nonoperative management over IM nailing. 

Operative Treatment of Tibia and Fibula Shaft Fractures

Indications/Contraindications

Indications for operative treatment are discussed in the previous section, but include failure to obtain adequate closed reduction, open fractures, vascular injury, a soft tissue envelope which precludes cast application, a patient who is too unreliable for closed treatment, and patient preference to not have a cast. The appeal of immediate knee and ankle motion with less frequent follow-up, often coupled with immediately being allowed to weight bear makes tibial nailing desirable to many patients and clinicians particularly as the outcomes of RCTs have favored operative fixation over closed treatment in terms of nonunion, malunion, complications, and time to return to work.48 Operative treatment is currently the preferred treatment for most displaced tibial diaphyseal fractures, with intramedullary nailing being the most common surgical procedure.19 

Open Fractures of the Tibia

Open fractures of the tibial diaphysis are the most common lower extremity open fracture.50,103 Thirty-three percent of the 1,248 tibia fractures in the Study to Prospectively evaluate Reamed Intramedullary Nails in Tibial fractures (SPRINT) trial220 were open indicating how commonly these injuries occur. A detailed discussion of the management of open fractures is given in Chapters 10, 11, and 12, but the topic is of particular interest in the tibia where the limited anteromedial soft tissue envelope makes open fractures more common than in other locations. Infection and nonunion are more common with open tibia fractures and controversy exists regarding how, or if, definitive treatment algorithms should change in the face of an open fracture.18 
Particular issues related to open fractures include the use of antibiotics,181183 the timing of the initial debridement,68,166,186,218,255 the use of local antibiotic delivery devices,174 the type of irrigation solution,7,73 and the type and timing of wound closure.27,44,193 There are a host of other issues that are of particular interest in open tibial diaphyseal fractures and continue to attract research projects. Avoidance of infection and promotion of fracture union remain challenges to the clinician in open tibial diaphyseal fractures. In a survey of surgeons disagreement regarding preferred treatment did not occur until higher grade open fractures were considered with 68% using a nail for type IIIA fractures and only 48% for type IIIB fractures. External fixation is more popular for higher grade open fractures although North American surgeons still tend to prefer reamed nails even in these cases.19 
Particular controversy continues regarding the ideal treatment of the most severe open tibia fractures (Fig. 57-10). Although closed and low grade open diaphyseal fractures are typically treated with internal fixation, with nails being used for diaphyseal fractures and plates or nails for periarticular fractures, controversy continues regarding the best treatment of the high-grade injuries that are rarely seen in civilian trauma and more commonly observed in military trauma (Fig. 57-11).19 Some reports have advocated modern ring fixators for type IIIB or IIIC injuries in both civilian108 and military settings122 to avoid metal at the fracture site. The ideal treatment of more severe open tibial fractures is not yet resolved and requires further study. 
Figure 57-10
A motorcyclist sustained a Gustilo type IIIB fracture after being struck by oncoming traffic while turning a corner at low speed.
 
This injury was completely circumferential with gross disruption of all of the medial-sided tendons and the Achilles tendon. The zone of injury extended from the foot to the proximal third of the tibia with degloved skin, devitalized muscle, and a complete loss of bone from the midtibia to 1 cm above the plafond. This injury eventually resulted in a below-knee amputation.
This injury was completely circumferential with gross disruption of all of the medial-sided tendons and the Achilles tendon. The zone of injury extended from the foot to the proximal third of the tibia with degloved skin, devitalized muscle, and a complete loss of bone from the midtibia to 1 cm above the plafond. This injury eventually resulted in a below-knee amputation.
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Figure 57-10
A motorcyclist sustained a Gustilo type IIIB fracture after being struck by oncoming traffic while turning a corner at low speed.
This injury was completely circumferential with gross disruption of all of the medial-sided tendons and the Achilles tendon. The zone of injury extended from the foot to the proximal third of the tibia with degloved skin, devitalized muscle, and a complete loss of bone from the midtibia to 1 cm above the plafond. This injury eventually resulted in a below-knee amputation.
This injury was completely circumferential with gross disruption of all of the medial-sided tendons and the Achilles tendon. The zone of injury extended from the foot to the proximal third of the tibia with degloved skin, devitalized muscle, and a complete loss of bone from the midtibia to 1 cm above the plafond. This injury eventually resulted in a below-knee amputation.
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Figure 57-11
A: Gustilo IIIB tibial diaphyseal fracture with a large open wound and a segmental defect.
 
This was initially treated with irrigation and debridement and an intramedullary nail. B: An antibiotic-impregnated spacer (C) was also used. Massive bone grafting was performed 6 weeks later when the spacer was removed.
This was initially treated with irrigation and debridement and an intramedullary nail. B: An antibiotic-impregnated spacer (C) was also used. Massive bone grafting was performed 6 weeks later when the spacer was removed.
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Figure 57-11
A: Gustilo IIIB tibial diaphyseal fracture with a large open wound and a segmental defect.
This was initially treated with irrigation and debridement and an intramedullary nail. B: An antibiotic-impregnated spacer (C) was also used. Massive bone grafting was performed 6 weeks later when the spacer was removed.
This was initially treated with irrigation and debridement and an intramedullary nail. B: An antibiotic-impregnated spacer (C) was also used. Massive bone grafting was performed 6 weeks later when the spacer was removed.
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Open Tibia Fracture Outcomes

Since open tibial fractures often occur in patients with high-energy mechanisms, high injury severity scores, and other significant musculoskeletal injuries58 it is not surprising that open fractures are also associated with poorer outcomes than closed fractures including longer time to union, longer hospital stay, higher reoperation rate, and higher incidence of infection when compared with closed fractures.55,58,81 In a 2012 analysis of outcomes in 323 open tibial diaphyseal fractures there was an infection rate of 20.7%. More severe fractures (Type IIIB and IIIC) required more operations and a longer hospital stay and an exponential increase in treatment cost occurred with higher Gustilo fracture grades.46 

Intramedullary Nail

IM nailing is the most common treatment of tibial diaphyseal fractures. An international survey indicated that surgeons preferred nail fixation for 96% of closed fractures and lower grade open fractures.19 This practice trend is supported by multiple prospective randomized trials and a systematic review of the literature that supports the outcome of nail fixation over closed treatment.5,48,101,118 

Open Fractures

The literature supports irrigation and debridement followed by immediate nailing of lower grade open tibial fractures116 with an overall infection rate of 3% and union of 89% without further surgery. The large prospective SPRINT trial220 also showed a low infection rate for primary nailing of open tibial fractures and demonstrated that reaming appears to be safe in these patients. 
The outcomes of tibial nailing in studies with predominantly higher grade (“severe IIIA,” IIIB, and IIIC) open fractures have not been as positive. The large multicenter prospective Lower Extremity Assessment Project (LEAP) study investigated these injuries and found an infection rate of 16% and that complication rates ranged from 33% to 57%.31 However, other studies have found lower infection rates with a 9% infection rate being recorded in type IIIB fractures.179 Controversy continues as to the ideal treatment of these mangled extremity patients, but acute tibial nailing is still commonly performed in North America for these injuries.19 
Preoperative Planning.
The main preoperative planning step unique to tibial nailing is determining whether the fracture pattern is amenable to fixation with a nail. Adequate imaging must be obtained to determine that the fracture is not too proximal or distal to nail. Often, this requires a CT scan in addition to x-rays. Simple fracture lines that enter the knee or ankle joint may not preclude nailing, but the surgeon should know of this beforehand so that the surgery can be modified as required to address this component of the fracture. 
Some surgeons routinely perform CT scans of fractures in the distal one-fourth of the tibia as intra-articular fractures have been observed in up to 43% of the cases (Fig. 57-3), with coronal shear fractures into the posterior malleolus being the most common fracture pattern.190 Undisplaced fractures can be difficult to appreciate on plain radiographs and 14% of articular involvement is missed.190 It is advantageous to know about these articular fractures prior to surgery so that clamp placement or screw fixation can be performed to avoid displacing the fracture during nailing (Fig. 57-3). 
Further preoperative considerations include the surgeon ensuring that the canal is not too small for the sizes of nail available. Companies will differ in the size of their smallest nail and rare sizes may not be stocked in your hospital. Typical smaller nail diameters are 9 mm or 8.5 mm. Similarly, patients who are significantly shorter or taller than population norms may also require nail lengths not routinely kept in stock. Finally, the surgeon should make sure there are no other factors that might make nailing difficult such as pre-existing knee stiffness, a previous tibial fracture that might have caused a significant tibial deformity or obliterated the medullary canal, a total knee arthroplasty, or a large contaminated knee wound. A preoperative planning checklist is presented in Table 57-6 and a list of appropriate surgical steps is given in Table 57-7
 
Table 57-6
Intramedullary Nailing: Preoperative Planning Checklist
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Table 57-6
Intramedullary Nailing: Preoperative Planning Checklist
  •  
    Is the preoperative imaging adequate?
    •  
      Does the fracture involve the knee or ankle joint?
    •  
      Is the fracture too proximal or distal to nail?
  •  
    Is the patient appropriate for nailing?
    •  
      Is there enough knee range of motion to place a nail?
    •  
      Is the canal clear (no TKA, other implants, previous fracture)?
  •  
    Operating table. Allows imaging from knee to ankle
  •  
    Position/positioning aids. Supine with bump, radiolucent triangle
  •  
    Fluoroscopy location. Contralateral (ipsilateral is also possible)
  •  
    Equipment. Standard nail set
    •  
      Is the tibia too small for the smallest nail diameter you have?
    •  
      Do you have nail lengths appropriate for the patient?
  •  
    Tourniquet (sterile/nonsterile). Not used if reaming is planned
  •  
    Possible reduction aids available. Large bone clamps, femoral distractor or external fixator, Schanz pins
X
 
Table 57-7
Intramedullary Nailing: Surgical Steps
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Table 57-7
Intramedullary Nailing: Surgical Steps
  •  
    Approach (see text)
  •  
    Place guidewire at appropriate starting point (Figs. 57-17 and 57-18)
  •  
    Advance guidewire down into diaphysis
  •  
    Place opening reamer over guidewire
  •  
    Remove guidewire
  •  
    Reduce fracture
  •  
    Pass guidewire to center-center position in ankle
  •  
    Ream to 1.5 mm greater than nail while keeping fracture reduced
  •  
    Lock distally and proximally through the nail
  •  
    Confirm interlocking screws are through the nail
  •  
    Close wounds
  •  
    Postoperative radiographs to confirm alignment
X
Positioning.
Tibial nailing is typically performed on a table that allows imaging from the knee to the ankle (Fig. 57-12). The patient is placed supine with a bump under the ipsilateral hip to help prevent the natural tendency of the limb to externally rotate at the hip. A radiolucent triangle is helpful and is placed under the knee. Triangle position can be changed during the procedure to allow different degrees of knee flexion. 
Figure 57-12
A typical setup for intramedullary nailing of the tibia with the limb placed over a radiolucent triangle.
 
The C-arm is opposite the affected limb and the monitor is at the foot of the bed for ease of viewing by the surgeon.
The C-arm is opposite the affected limb and the monitor is at the foot of the bed for ease of viewing by the surgeon.
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Figure 57-12
A typical setup for intramedullary nailing of the tibia with the limb placed over a radiolucent triangle.
The C-arm is opposite the affected limb and the monitor is at the foot of the bed for ease of viewing by the surgeon.
The C-arm is opposite the affected limb and the monitor is at the foot of the bed for ease of viewing by the surgeon.
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Tibial nailing also can be performed effectively on a fracture table.151 In this setup the knee is hyperflexed over a bump, and a traction pin can even be used distally to help reduce the fracture. This technique is effective but has become less popular as some studies raised concerns regarding an increased risk of compartment syndrome secondary to elevated intracompartmental pressures during nailing with traction. This effect is thought to be related to either traction itself or compression of venous outflow with the knee flexed over a bolster.153,230,233 The clinical significance of this increase in pressure during nailing is less clear.151 
IM nailing of the tibia uses fluoroscopy throughout the case. The C-arm is typically placed opposite the limb (Fig. 57-12), but some surgeons prefer to place the C-arm ipsilaterally to move the base of the machine away from the medial side of the leg where the surgeon typically stands to place the medial to lateral interlocking screws. This is an option that should be kept in mind particularly if the contralateral upper extremity is being operated on at the same time. 
Tourniquets are typically not used by North American surgeons for procedures that involve reaming for fear of thermal necrosis, although this has only been described in case reports.15,139,180 Although the evidence for the association between tourniquet use and thermal necrosis is not strong and thermal necrosis probably occurs as a result of reaming small IM canals up to a much larger size,86 most North American surgeons do not typically use tourniquets when reaming the tibia.22 If a tourniquet is needed for debridement of an open fracture, the tourniquet can be placed in the sterile field and lower on the thigh so as to reduce the risk of the surgeon forgetting that the tourniquet is inflated when it is time to ream the tibia. 
Surgical Approaches.
Parapatellar. Medial parapatellar approaches are commonly used.22 A lateral parapatellar approach is used by some surgeons for proximal fractures or in patients in whom preoperative fluoroscopy indicates that the ideal starting point appears to be more easily accessed through this approach. The skin incision is typically centered over the knee or 1 cm medial for a medial parapatellar approach (Fig. 57-13). The incision starts at the midpoint of the patella and runs distally about the same length as the patella. Dissection is continued to identify the medial border of the patella and a longitudinal incision is made along its course. The approach should not go into the knee joint, but rather remain in the fat pad. 
Figure 57-13
A midline incision is made centered over the inferior pole of the patella (A).
 
An incision is then made medial to the patellar tendon (B) and a guidewire is inserted (C).
An incision is then made medial to the patellar tendon (B) and a guidewire is inserted (C).
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Figure 57-13
A midline incision is made centered over the inferior pole of the patella (A).
An incision is then made medial to the patellar tendon (B) and a guidewire is inserted (C).
An incision is then made medial to the patellar tendon (B) and a guidewire is inserted (C).
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The typical difficulty with the medial parapatellar approach is obtaining a starting point that is sufficiently lateral as the patella and patellar tendon tend to push the starting wire too medial. An overly medial starting point can result in a valgus deformity for proximal tibia fractures (Fig. 57-14). Some patients also have anatomy that makes obtaining the ideal starting point through this approach difficult. One advantage of the limited medial parapatellar approach is that it can be extended up to a full medial parapatellar approach used, which is commonly used for operations such as total knee arthroplasty. This is usually not required but it allows for complete subluxation of the patella and straightforward placement of the starting point regardless of the patient anatomy. 
Figure 57-14
 
A: If the starting point is too medial reaming creates an oblique proximal channel in the bone that induces a valgus deformity once the nail is placed (B). Subsequent placement of a blocking screw and reaming a correct path corrects the deformity (C).
A: If the starting point is too medial reaming creates an oblique proximal channel in the bone that induces a valgus deformity once the nail is placed (B). Subsequent placement of a blocking screw and reaming a correct path corrects the deformity (C).
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Figure 57-14
A: If the starting point is too medial reaming creates an oblique proximal channel in the bone that induces a valgus deformity once the nail is placed (B). Subsequent placement of a blocking screw and reaming a correct path corrects the deformity (C).
A: If the starting point is too medial reaming creates an oblique proximal channel in the bone that induces a valgus deformity once the nail is placed (B). Subsequent placement of a blocking screw and reaming a correct path corrects the deformity (C).
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Patellar Tendon Split. An approach that eliminates the difficulty of placing the guidewire far enough lateral with the medial parapatellar tendon approach is the patellar tendon split. The incision is brought down to the tendon and a longitudinal split is made in the tendon. Care is taken to protect the tendon at all times during the surgery. Some surgeons object to the possible damage that splitting the patellar tendon might cause whereas others argue that it is of no clinical consequence. 
This patellar tendon split approach does present some difficulty in obtaining the ideal starting angle that is most important in proximal tibia fractures as it is not possible to sublux the patella away from the starting wire as the wire is passing through the patellar tendon. This can make the starting wire tend to angle posteriorly (Fig. 57-15). This is of less consequence in distal fractures but can produce an apex anterior deformity in proximal fractures. 
Figure 57-15
 
If the starting guidewire is angled too far posteriorly (A) the initial reamer can be passed for a short distance (B) and the angle corrected using a curved hand reamer (C and D).
If the starting guidewire is angled too far posteriorly (A) the initial reamer can be passed for a short distance (B) and the angle corrected using a curved hand reamer (C and D).
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If the starting guidewire is angled too far posteriorly (A) the initial reamer can be passed for a short distance (B) and the angle corrected using a curved hand reamer (C and D).
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Figure 57-15
If the starting guidewire is angled too far posteriorly (A) the initial reamer can be passed for a short distance (B) and the angle corrected using a curved hand reamer (C and D).
If the starting guidewire is angled too far posteriorly (A) the initial reamer can be passed for a short distance (B) and the angle corrected using a curved hand reamer (C and D).
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If the starting guidewire is angled too far posteriorly (A) the initial reamer can be passed for a short distance (B) and the angle corrected using a curved hand reamer (C and D).
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Suprapatellar. Suprapatellar approaches for tibial nailing have gained significant interest recently with several studies being published on the topic.82,112,128 The proposed advantages of the approach are the technical ease in obtaining the starting point, the ease of obtaining anteroposterior fluoroscopic images with the knee less flexed, and the relative ease of obtaining fracture reduction. These are all of particular benefit in proximal fractures. Theoretical concerns involve damage to the patellofemoral joint and converting a procedure that was outside the knee joint into one that traverses the knee joint and therefore may be at increased risk of a surgical site infection becoming septic arthritis. Studies are underway to address these issues, but the technique is currently gaining popularity because of the ease of obtaining a staring point for proximal fractures for which it was initially proposed.82,112,128 
The incision is made more proximally than for the other starting points beginning midline at the superior pole of the patella and proceeding 5 cm proximally (Fig. 57-16). The quadriceps tendon is split longitudinally and the knee joint is entered from above. Specialized trocars are used that protect the patellofemoral joint from the guidewires, reamers, and nail insertion, so this technique is currently only done with nailing systems that have these specialized instruments. 
Figure 57-16
The suprapatellar starting point.
 
A small incision above the patella is used and the quadriceps tendon is split (A). Special cannulae are needed to protect the patella from the reamers (B).
A small incision above the patella is used and the quadriceps tendon is split (A). Special cannulae are needed to protect the patella from the reamers (B).
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Figure 57-16
The suprapatellar starting point.
A small incision above the patella is used and the quadriceps tendon is split (A). Special cannulae are needed to protect the patella from the reamers (B).
A small incision above the patella is used and the quadriceps tendon is split (A). Special cannulae are needed to protect the patella from the reamers (B).
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Technique.
The patient is positioned supine and one of the three approaches described above are chosen. A starting guidewire is placed at the starting point. The ideal starting point is just medial to the lateral tibial spine (Figs. 57-17 and 57-18). Care should be taken that this is determined from a true AP radiograph as the amount of tibial rotation has been shown to affect the appearance of the guidewire location by as much as 15 mm (Fig. 57-19).249 Therefore, it is important that a “true” AP of the knee is used to determine the starting point. This view should be obtained by ensuring that the fibula is bisected by the lateral aspect of the tibia at the joint.249 Modern nails have a proximal bend such that the ideal starting point is located between the joint line and the tibial tubercle (Figs. 57-17 and 57-18). Care should be taken not to place the starting point too proximal where it risks damage to the menisci or too distal where the tibial tubercle could be reamed away. 
Figure 57-17
 
A: A diagram demonstrating that the correct starting point for a tibial nail is medial to the lateral tibial spine on the AP radiograph and just anterior to the lateral surface on the lateral radiograph. B: The correct nail starting point is anterior to the important structures in the knee.
A: A diagram demonstrating that the correct starting point for a tibial nail is medial to the lateral tibial spine on the AP radiograph and just anterior to the lateral surface on the lateral radiograph. B: The correct nail starting point is anterior to the important structures in the knee.
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Figure 57-17
A: A diagram demonstrating that the correct starting point for a tibial nail is medial to the lateral tibial spine on the AP radiograph and just anterior to the lateral surface on the lateral radiograph. B: The correct nail starting point is anterior to the important structures in the knee.
A: A diagram demonstrating that the correct starting point for a tibial nail is medial to the lateral tibial spine on the AP radiograph and just anterior to the lateral surface on the lateral radiograph. B: The correct nail starting point is anterior to the important structures in the knee.
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Figure 57-18
AP (A) and lateral (B) radiographs of the knee demonstrating the placement of a starting wire.
 
The starting wire should be just medial to the lateral spine on a true AP radiograph of the knee as demonstrated by the lateral border of the tibial plateau bisecting the fibular diaphysis. The lateral starting point is just off the articular surface and should parallel the anterior surface of the tibia. This wire placement is aimed slightly posterior and would be acceptable for distal fracture patterns but might be less ideal for a very proximal pattern.
The starting wire should be just medial to the lateral spine on a true AP radiograph of the knee as demonstrated by the lateral border of the tibial plateau bisecting the fibular diaphysis. The lateral starting point is just off the articular surface and should parallel the anterior surface of the tibia. This wire placement is aimed slightly posterior and would be acceptable for distal fracture patterns but might be less ideal for a very proximal pattern.
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Figure 57-18
AP (A) and lateral (B) radiographs of the knee demonstrating the placement of a starting wire.
The starting wire should be just medial to the lateral spine on a true AP radiograph of the knee as demonstrated by the lateral border of the tibial plateau bisecting the fibular diaphysis. The lateral starting point is just off the articular surface and should parallel the anterior surface of the tibia. This wire placement is aimed slightly posterior and would be acceptable for distal fracture patterns but might be less ideal for a very proximal pattern.
The starting wire should be just medial to the lateral spine on a true AP radiograph of the knee as demonstrated by the lateral border of the tibial plateau bisecting the fibular diaphysis. The lateral starting point is just off the articular surface and should parallel the anterior surface of the tibia. This wire placement is aimed slightly posterior and would be acceptable for distal fracture patterns but might be less ideal for a very proximal pattern.
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Figure 57-19
These three images (A, B, and C) are all taken with the guidewire in exactly the same position and orientation.
 
However, the C-arm was rotated differently in each image to give different-angled views of the knee. This demonstrates the importance of obtaining a true AP radiograph to determine the proper starting point. The leg often lies in external rotation at the hip, causing the starting point to appear more lateral than it actually is.
However, the C-arm was rotated differently in each image to give different-angled views of the knee. This demonstrates the importance of obtaining a true AP radiograph to determine the proper starting point. The leg often lies in external rotation at the hip, causing the starting point to appear more lateral than it actually is.
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Figure 57-19
These three images (A, B, and C) are all taken with the guidewire in exactly the same position and orientation.
However, the C-arm was rotated differently in each image to give different-angled views of the knee. This demonstrates the importance of obtaining a true AP radiograph to determine the proper starting point. The leg often lies in external rotation at the hip, causing the starting point to appear more lateral than it actually is.
However, the C-arm was rotated differently in each image to give different-angled views of the knee. This demonstrates the importance of obtaining a true AP radiograph to determine the proper starting point. The leg often lies in external rotation at the hip, causing the starting point to appear more lateral than it actually is.
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Once the starting point is correctly placed the starting wire must be advanced in the appropriate direction. In the AP plane this is in line with the longitudinal axis and in the lateral plane it is in line with the anterior cortex (Fig. 57-18). Once the starting wire has been placed in the correct position and alignment, a reamer is used to open a path through the proximal tibial metaphysis. Care must be taken to protect the patellar tendon during this step using a soft tissue protector or retractors. There is a tendency for the starting wire to be too far posterior (except if using the suprapatellar approach) because the patella tends to make it difficult to keep the guidewire in line with the anterior cortex (Fig. 57-15). If the fracture is in the diaphysis this may be less important, but for proximal fractures this will induce an apex anterior deformity once the nail is passed into the tibia. 
After the initial reamer has been passed into the IM canal, a ball-tipped guidewire is placed into the canal. Typically, a small bend is placed in the distal few centimeters of the guidewire using pliers or a similar instrument. Larger bends will allow for more control to position of the wire and will facilitate the passage of the wire across the fracture site, but they can make it more difficult to get the wire out of the nail. 
The guidewire is passed from proximal to the fracture to distal to the fracture. This step is usually trivial in open fractures as the surgeon has direct access to the fracture, but it can be more challenging in closed fractures. There are a number of techniques to facilitate closed reduction of the fracture to allow passage of the wire. By rotating the guidewire, the direction of its advancement can be controlled because of the bend in the distal guidewire. Once the wire has passed across the fracture site, it is placed distally at about the level of the physeal scar and centered on both the AP and lateral views (Fig. 57-20). Once the wire is in place, the nail length can be measured. A nail length shorter than the measured length is selected. 
Figure 57-20
The guidewire should be centered on both the AP (A) and lateral views (B).
 
This is particularly important for distal fractures to prevent angulation once the nail is passed (C and D).
This is particularly important for distal fractures to prevent angulation once the nail is passed (C and D).
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Figure 57-20
The guidewire should be centered on both the AP (A) and lateral views (B).
This is particularly important for distal fractures to prevent angulation once the nail is passed (C and D).
This is particularly important for distal fractures to prevent angulation once the nail is passed (C and D).
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Reaming of the IM canal is typically used for closed fractures as it allows the insertion of a larger nail and promotes healing21,79,220,259 without adding much time to the procedure. There has historically been a concern with reaming open fractures as the reaming temporarily damages the endosteal blood supply and the periosteal blood supply may have also been damaged as a result of the open fracture. A large prospective RCT on this issue has shown little difference between the outcomes of these two techniques with a slight edge toward reamed nailing.220 Our center reams all nails regardless of open or closed status but there is variation between surgeons.22 
The reamers are passed over the guidewire, typically starting at 9.5 mm and progressing in increments of 0.5 mm or 1 mm. The reaming progresses to 1.5 mm greater than the nail size. Once some “chatter” is noted, reaming is adequate. It is important to know what diameter nails are available for the system you are using, as well as how the size of the interlocking bolts is affected by nail diameter. Most systems have nail diameters down to 8.5 or 9 mm, and humeral nails exist that are even smaller and have a contour that can be used reasonably in the tibia, although of course these nails are not designed for this application. The nail will follow the path you reamed for it, so care should be taken while reaming to keep the fracture well reduced to avoid eccentric reaming that leads to malalignment once the nail is passed. Techniques for reduction of proximal and distal fractures are outlined in Table 57-8. After reaming, the nail is passed into the tibia over the guidewire. 
Proximal interlocking screws are placed through a guide arm, typically from medial to lateral. Remember to remove the guidewire before attempting to place the interlocking screws as this will prevent screw placement. More proximal fracture patterns should have multiple interlocking screws placed to prevent loss of reduction and improve mechanical stability77,133,257 with at least three being ideal for the most proximal patterns.96 Some modern nails do not use medial and lateral interlocking screws but instead use obliquely placed screws. If this is the case any anteromedial to posterolateral screw should be placed with care as damage to the common peroneal nerve, as it passes around the proximal fibula, is possible. 
Distal interlocking screws are placed with a free hand technique that utilizes a C-arm and the so called “perfect circles” technique (Fig. 57-21). Recently, a nail system has emerged that uses a computer-guided technique for distal interlocking without fluoroscopy but this system awaits validation. Care should be taken to make sure that rotation is correct as this can only be determined by physical examination and not radiographically. Distal fracture patterns should have two or more interlocking screws to increase stability and decrease the risk of loss of reduction or nonunion.163 
Figure 57-21
 
“Perfect circles” refers to obtaining a true lateral of the distal screw hole through the nail such that the image appears as a circle (A). The drill tip is placed in the center of the circle (B) and drilled along the path of the beam of the C-arm. After one cortex is drilled, the location is checked (C). If the tip is not well centered, such as in image C where the tip is slightly posterior and distal, the drill can be angled toward the center of the hole (D) and tapped with a mallet through the nail (E). The second cortex is drilled and the interlocking screw is placed this being confirmed with fluoroscopy (F).
“Perfect circles” refers to obtaining a true lateral of the distal screw hole through the nail such that the image appears as a circle (A). The drill tip is placed in the center of the circle (B) and drilled along the path of the beam of the C-arm. After one cortex is drilled, the location is checked (C). If the tip is not well centered, such as in image C where the tip is slightly posterior and distal, the drill can be angled toward the center of the hole (D) and tapped with a mallet through the nail (E). The second cortex is drilled and the interlocking screw is placed this being confirmed with fluoroscopy (F).
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“Perfect circles” refers to obtaining a true lateral of the distal screw hole through the nail such that the image appears as a circle (A). The drill tip is placed in the center of the circle (B) and drilled along the path of the beam of the C-arm. After one cortex is drilled, the location is checked (C). If the tip is not well centered, such as in image C where the tip is slightly posterior and distal, the drill can be angled toward the center of the hole (D) and tapped with a mallet through the nail (E). The second cortex is drilled and the interlocking screw is placed this being confirmed with fluoroscopy (F).
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Figure 57-21
“Perfect circles” refers to obtaining a true lateral of the distal screw hole through the nail such that the image appears as a circle (A). The drill tip is placed in the center of the circle (B) and drilled along the path of the beam of the C-arm. After one cortex is drilled, the location is checked (C). If the tip is not well centered, such as in image C where the tip is slightly posterior and distal, the drill can be angled toward the center of the hole (D) and tapped with a mallet through the nail (E). The second cortex is drilled and the interlocking screw is placed this being confirmed with fluoroscopy (F).
“Perfect circles” refers to obtaining a true lateral of the distal screw hole through the nail such that the image appears as a circle (A). The drill tip is placed in the center of the circle (B) and drilled along the path of the beam of the C-arm. After one cortex is drilled, the location is checked (C). If the tip is not well centered, such as in image C where the tip is slightly posterior and distal, the drill can be angled toward the center of the hole (D) and tapped with a mallet through the nail (E). The second cortex is drilled and the interlocking screw is placed this being confirmed with fluoroscopy (F).
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“Perfect circles” refers to obtaining a true lateral of the distal screw hole through the nail such that the image appears as a circle (A). The drill tip is placed in the center of the circle (B) and drilled along the path of the beam of the C-arm. After one cortex is drilled, the location is checked (C). If the tip is not well centered, such as in image C where the tip is slightly posterior and distal, the drill can be angled toward the center of the hole (D) and tapped with a mallet through the nail (E). The second cortex is drilled and the interlocking screw is placed this being confirmed with fluoroscopy (F).
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Unlike femoral nailing where only static locking is used, there is some controversy regarding whether dynamic locking may be advantageous in tibial nailing. Fluoroscopy should be used to confirm that all interlocking screws are properly through the nail, particularly those interlocking screws that have been placed with a free hand technique. There is some recent biomechanical evidence in nails for “angle stable” interlocking90,228,247 for proximal or distal fractures that are more difficult to maintain reduction, but this technique has yet to be verified clinically. 
Distraction at the fracture site is undesirable because it is thought to lead to increased risk of nonunion.202 In axially stable fracture patterns, compression can be obtained at the fracture site by locking the nail distally first and then “back slapping” the nail to compress the fracture site before locking proximally. Some nail systems also have an internal compression device for this same purpose. Once the hardware is in place, sterile radiographs of the entire length of the tibia can be obtained while closing to make sure the alignment is adequate. The wounds are then closed in a standard fashion. 
Postoperative Care.
There is variation in postoperative care. There is an argument to place patients in a postoperative splint with the ankle in a neutral position to minimize swelling and to prevent the development of ankle equinus in patients who will have delayed weight bearing. Splinting may also keep the ankle in a near neutral position which may reduce intracompartmental pressures253 and therefore lessen the likelihood of compartment syndrome. Many surgeons do not use postoperative splints or braces, but if they are used patients are converted from the splint into a removable boot somewhere between the first postoperative day and the first follow-up visit. The boot is generally discarded once weight bearing has started. Exercises to encourage knee and ankle range of motion should be initiated as soon as possible. 
Weight bearing is determined by the axial stability of the fracture pattern. If there is good axial stability as seen in noncomminuted diaphyseal fracture patterns then immediate weight bearing as tolerated is usually instituted. Weight bearing is often limited to partial weight bearing or non–weight-bearing for 6 weeks for highly comminuted patterns, or for fractures that are very proximal or distal where the nail has less mechanical advantage in controlling loss of reduction. 
Patients are typically seen at 2, 6, 12, 26, and 52 weeks from the time of surgery. Radiographs are obtained at each visit after the initial visit. Patients with very proximal or distal fracture patterns may benefit from radiographs at the 2-week mark or more frequent early follow-up as these fracture patterns can lose reduction in the early healing phase. 
Closed fractures can be expected to demonstrate radiographic and clinical evidence of healing in the 3- to 6-month time frame. An analysis of clinical union as it related to the Tscherne classification of closed fractures (Fig. 57-5) showed that Tscherne C0 fractures united in 12.5 weeks on average compared with 23.7 weeks for C3 fractures.52 The healing time is delayed in patients with open fractures, compartment syndrome or diabetes and in smokers. Patients who demonstrate no evidence of healing early on are candidates for bone grafting often using a posterolateral approach. Fractures typically heal with fracture callus regardless of fracture pattern (Fig. 57-2). 
Some patients will have symptomatic hardware typically over the interlocking screws. Care should be taken to avoid screws that are too long, particularly over the medial aspect of the proximal tibia as these are often symptomatic. Proximal interlocking screws are usually placed medial to lateral to minimize medial soft tissue irritation by the screw tip, but the head of the screw can also be symptomatic. Hardware is typically not removed until there is good radiographic and clinical evidence of healing; however, isolated symptomatic interlocking screws can be removed earlier if this does not destabilize the construct. 
Potential Pitfalls and Preventative Measures.
A list of potential pitfalls and preventative measures for IM nailing of the tibia is given in Table 57-8
 
Table 57-8
Intramedullary Nailing: Potential Pitfalls and Preventions
Pitfalls Preventions
Pitfall no. 1: Proximal fracture malalignment: Valgus and apex anterior Correct starting point and direction of initial reaming
Blocking screws
Semiextended nailing
Clamp the fracture
Provisional plating
Temporary external fixation
Suprapatellar starting point
Pitfall no. 2: Distal fracture malalignment Center-center position of guidewire
Blocking screws
Clamp the fracture
Temporary external fixation
Plate a coexisting distal fibular fracture first
Pitfall no. 3: Starting wire too posterior Use curved hand reamer or awl to correct trajectory
Pitfall no. 4: Postoperative knee pain Unavoidable to some extent
Blocking screws
Correct starting point
Bury nail proximally
Correct interlocking screw length
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Pitfall no. 1: Proximal Fracture Malalignment: Valgus and Apex Anterior 
It is notoriously difficult to obtain adequate alignment using a tibial nail in proximal tibial fractures. Initial reports on the topic demonstrated malreduction rates of 55% and 85%.76,134,237 The high rate of malreduction has led some surgeons to recommend percutaneous plating for its relative technical ease in comparison to proximal nailing, and outcomes for plating and nailing of proximal fractures appear to be similar.142 
The typical deformity present is valgus and apex anterior (procurvatum). The valgus is typically created by using too lateral a starting point that creates an initial reaming pathway which runs from too medial to lateral. Once the nail is placed, this tips the fracture into valgus (Fig. 57-14). Similarly, the apex anterior deformity is created by the pull of the extensor mechanism and is worsened by an initial reaming path that is angled too far posterior which produces the deformity once the nail is introduced. 
Several reports describe techniques to overcome this tendency to malreduce proximal tibia fractures with a nail and have demonstrated relatively low malreduction rates.95,100,142,145,170,232,246 The use of an ideal starting point and starting wire direction is particularly important for proximal fractures as is reducing the fracture before reaming. The surgeon cannot rely on the nail to reduce the fracture as it is introduced. It is difficult to obtain the ideal proximal reaming path because of interference with the patella, which is what leads to the typically incorrect starting point which is too medial and too posterior. One technique to obtain the ideal starting point and reaming path is to extend the incision into a more extensive medial parapatellar arthrotomy and dislocate the patella. 
Recently, there has been interest in the use of the suprapatellar starting point for proximal fracture patterns.82,112,128 This is thought to be beneficial because the ideal starting point and reaming path are not blocked by the patella as they are in more traditional approaches. Further, nailing can be performed in a more extended position where the pull of the extensor mechanism is less of a deforming force (Fig. 57-22).128,232 
Figure 57-22
Anteroposterior (A) and lateral (B) radiographs of a segmental tibia fracture nailed through a suprapatellar starting point.
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Other techniques to prevent malreduction include the use of percutaneous clamps (Fig. 57-23)75 or threaded guidewires. Provisional plating with unicortical screws has also been described. The use of a femoral distractor or an external fixator can be helpful to hold the fracture in a reduced position while nailing (Fig. 57-24).258 The proximal pin is placed posterior in the tibia to avoid the nail’s proximal entry path, and the distal pin can be placed in the distal tibia, talus, or calcaneus. 
Figure 57-23
 
The insertion of a clamp through small percutaneous incisions can facilitate fracture reduction and hold the fracture reduced during reaming and nail insertion. Care must be taken to make sure the clamp does not place undue pressure on the skin (A and B). This technique is particularly useful for simple oblique fracture lines (C and D).
The insertion of a clamp through small percutaneous incisions can facilitate fracture reduction and hold the fracture reduced during reaming and nail insertion. Care must be taken to make sure the clamp does not place undue pressure on the skin (A and B). This technique is particularly useful for simple oblique fracture lines (C and D).
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Figure 57-23
The insertion of a clamp through small percutaneous incisions can facilitate fracture reduction and hold the fracture reduced during reaming and nail insertion. Care must be taken to make sure the clamp does not place undue pressure on the skin (A and B). This technique is particularly useful for simple oblique fracture lines (C and D).
The insertion of a clamp through small percutaneous incisions can facilitate fracture reduction and hold the fracture reduced during reaming and nail insertion. Care must be taken to make sure the clamp does not place undue pressure on the skin (A and B). This technique is particularly useful for simple oblique fracture lines (C and D).
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Figure 57-24
A temporary external fixator (A) can be used to maintain fracture reduction when nailing a tibial diaphyseal fracture (B).
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Blocking or “Poller” screws are a particularly useful technique to help guide the nail correctly.125,127 This technique involves placing a blocking screw, drill bit, or k-wire to force the reamer and then the nail into the proper path (Fig. 57-25). The screw can be left in place to increase stability125,127 which may be particularly useful in geriatric fractures with wider tibiae and poorer bone quality. The screw is typically placed on the concave side of the fracture or where you want to prevent the nail from being located. For a typical deformity in the proximal tibia a screw to prevent valgus would be positioned in the distal–lateral aspect of the proximal fragment to prevent a nail path that passes too laterally. A screw to prevent apex anterior deformity would be placed in the distal–posterior portion to prevent an excessively posterior entry path. The interlocking screws from the nail set can be used for this purpose and should be placed under fluoroscopic guidance. 
Figure 57-25
A: Varus malalignment of a distal tibial fracture after the passage of a nail despite the use of a clamp.
 
This is because of eccentric reaming. To correct this deformity, the nail is removed and an AP blocking screw is placed (B) and reaming is performed again with the blocking screw in place (C). Adequate alignment is obtained after nail placement (D) and the blocking screw is left in place for added stability.
This is because of eccentric reaming. To correct this deformity, the nail is removed and an AP blocking screw is placed (B) and reaming is performed again with the blocking screw in place (C). Adequate alignment is obtained after nail placement (D) and the blocking screw is left in place for added stability.
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Figure 57-25
A: Varus malalignment of a distal tibial fracture after the passage of a nail despite the use of a clamp.
This is because of eccentric reaming. To correct this deformity, the nail is removed and an AP blocking screw is placed (B) and reaming is performed again with the blocking screw in place (C). Adequate alignment is obtained after nail placement (D) and the blocking screw is left in place for added stability.
This is because of eccentric reaming. To correct this deformity, the nail is removed and an AP blocking screw is placed (B) and reaming is performed again with the blocking screw in place (C). Adequate alignment is obtained after nail placement (D) and the blocking screw is left in place for added stability.
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The above techniques are all useful to avoid malreduction. Once the error has been made and a nail pathway has been established with a nail in place, the deformity can be difficult to correct. Often, removal of the nail and insertion of blocking screws with subsequent reaming of a new pathway is the most straightforward technique to create the correct pathway for reinsertion of the nail. 
Pitfall no. 2: Distal Fracture Malalignment 
Distal fractures are also prone to malalignment because the metaphysis is much wider than the diameter of the nail and care must be taken to avoid malunion as this may lead to a worse functional outcome.66,109,131,141,170,197,242 The keys to avoiding malalignment distally are ensuring the guidewire is placed centrally on both the AP and lateral images (the “center-center position”) (Fig. 57-20) and keeping the fracture well aligned during reaming and nail insertion. The techniques described in the section on proximal fracture malalignment, including percutaneous clamps, temporary external fixator placement, and blocking screws, can also be very useful for this fracture pattern. 
For distal tibia fractures that also have a fibula fracture, plating of the fibula fracture before nailing of the tibia can help provide alignment and length.66,170 This is particularly useful for simple fibular fracture patterns and very distal tibial fracture patterns. Care should be taken to reduce the fibula as malreduction of the fibula will prevent accurate reduction of the tibia. After the fibula is plated, care should be taken to make sure the tibia is not malaligned in varus as the fibular plating will keep the tibia out to length laterally, but will typically not prevent varus collapse. One report has indicated that fibular plating in combination with tibial nailing had an eightfold increased risk of nonunion compared to tibial nailing alone,11 so further studies on the clinical efficacy of this technique are needed. 
Pitfall no. 3: Staring Wire too Posterior 
The proper starting point and reaming path are particularly important for proximal fractures. As the fracture location moves more distally, there is more tolerance for imperfection as the fit of the straight nail in the narrow diaphysis will tend to align the fracture and make up for imperfections in the starting pathway. For more proximal fracture patterns the starting pathway is critical as discussed in pitfall no. 1. 
If the starting point is adequate but the starting wire is angled too far posteriorly, a reamer can be advanced a shorter distance than usual, approximately 1 or 2 cm down the wire (Fig. 57-15). The wire is then removed and a curved hand reamer or a similar device can be used to correct the reamer path bringing it more in line with the anterior cortex. This technique is particularly useful if a patellar splitting approach is used as the patella often makes it difficult to obtain a starting wire that is angled anterior enough. 
Pitfall no. 4: Postoperative Knee Pain 
Postoperative knee pain after IM nailing has been reported in a high proportion of patients in many studies, with rates ranging from 31% to 73%.24,52,53,94,121,138,231 Nail removal in some series is as high as 26% to 50%.28,52,231 The etiology of this knee pain is unclear but possibilities include an intra-articular starting point that damages the meniscus, leaving the nail too proud proximally,24 and differences in the approaches as detailed above. Authors have argued that a correct starting point and burying the nail may reduce but not completely eliminate the rate of knee pain, although various studies have contradicted each other regarding the importance of nail prominence in knee pain.24,52,138 Pain over the proximal interlocking screws is also common and should be differentiated by physical examination from pain unrelated to the interlocking screw sites. Pain over the interlocking screws can typically be relieved by simply removing the screws without taking out the entire nail. Care should be taken to make sure the interlocking screws are not too long as this may increase the rate of symptomatic hardware. 
Treatment-Specific Outcomes.
Intramedullary Nailing Versus Nonoperative Treatment. One frequently cited study that supports the use of IM nails over nonoperative treatment is a level III retrospective cohort study of 99 patients undertaken by Bone et al.28 This study compared the outcomes of nonoperative treatment to IM nailing. The study found better outcomes in the nail group, with lower nonunion rates (2 vs. 10%), faster time to union (18 vs. 26 weeks), and better SF-36, knee, and ankle outcomes at a 4-year follow-up. The study should be interpreted with caution as it was not randomized; however, the authors state that the more displaced fractures tended to be treated with nails creating a selection bias that might favor outcomes in the nonoperative group, therefore validating their conclusions. It should be noted that the nail group had a greater than 50% (26/47) return to the operating room for nail removal. In Sarmiento’s opinion, the failure of this study and others to reproduce his previously published excellent nonoperative outcomes was most likely because of the use of a different treatment technique (casting vs. functional bracing) and less strict criteria for which fractures are amenable to conservative treatment.206,207 
The general findings of this study have been reproduced in multiple RCTs comparing nail fixation with nonoperative treatment.5,28,101,118 They typically show better outcomes in the nail groups in terms of time to return to work, time to union and knee function. For example, in one randomized prospective trial comparing conservative treatment and IM nailing for open and closed tibial diaphyseal fractures, Hooper et al.101 showed more rapid union (18.3 vs. 15.7 weeks), less shortening, less malunion, less time off work (23 vs. 13.5 weeks), and a faster return to full function in the IM nail group. There was a 27% rate of delayed or nonunion in their conservative treatment group, which was significantly higher than previously published results.204,209 This study also included a discussion of knee pain and the need for hardware removal as potential drawbacks to IM nailing, but did not quantify these as complications.101 It is interesting to observe that Hooper et al.101 planned a larger study but their study was discontinued because they felt that it was unethical to continue with nonoperative management given the proven benefits of IM nailing. 
A meta-analysis of 13 RCTs for the treatment of closed tibial fractures revealed that all treatment methods that were studied had significant complication rates. Malunion, nonunion, and delayed union were lower with operative treatment than nonoperative treatment irrespective of the surgical treatment method that was used, these being plate osteosynthesis, reamed nailing, and unreamed nailing. Among operative treatments, plating had lower rates of delayed union, nonunion, and malunion, but higher rates of infection when compared to nailing. Reoperation rates with operative treatment ranged from 4.7% to 23.1% depending on the study.48 
Historically, it was argued that the improved outcomes following IM nailing were not sufficient to justify its higher cost.204,209 However, a 2005 economic analysis comparing the cost of treatment favored reamed IM nailing for closed and open grade I tibial fractures over conservative treatment in a cast.39 
Reamed Versus Unreamed Nails. Significant controversy has existed regarding the superiority of reamed or unreamed tibial nailing. In a systematic review with a pooled analysis of earlier RCTs, Bhandari et al. reported that reamed IM nailing of lower-extremity long-bone fractures significantly reduced rates of nonunion and implant failure in comparison with nonreamed nailing.17,21 In a similar meta-analysis of seven randomized studies, Lam et al.134 showed a lower risk of nonunion after reamed nailing compared with unreamed nailing in patients with closed tibial diaphyseal fracture. Reaming has been shown not to significantly increase the operative time.59 It has also been shown that minimal reaming gives similar results to more extensive reaming.79 
Until 2008 randomized prospective data to address the question of reaming was lacking. Often referred to as the SPRINT trial, the 2008 Study to Prospectively evaluate Reamed Intramedullary Nails in Tibial fractures was a large (1,226 patients) multicenter randomized trial comparing reamed and unreamed nailing outcomes.220 The largest study of its kind in the field of orthopedic trauma, SPRINT rigorously examined closed and open (type I to IIIB) fractures with less than 1 cm fracture gap following IM nailing. The primary composite outcome was for reoperation, which included bone grafting, implant exchange, and dynamization. The outcome also included autodynamization from interlocking screw breakage without additional surgical intervention. 
SPRINT showed significantly fewer adverse outcomes when reamed nailing was used for the treatment of closed fractures. A similar benefit was not seen with reaming of open tibial fractures and depending on the interpretation of the subgroup analysis, a potential advantage may exist for unreamed nails in open fractures.220 One of the most important outcomes of this massive study is that fractures that many surgeons would have prophylactically bone grafted healed without surgery, indicating that at least some of these open fractures may heal on their own without bone grafting. 
Analysis of outcomes in the SPRINT study cohort revealed that predictors of reoperation within 1 year include high-energy mechanism, presence of a fracture gap, complex soft tissue reconstruction, and full weight bearing after surgery. No increase in negative outcome was detected with nonsteroidal anti-inflammatory drugs (NSAIDs), smoking, or late versus early surgical intervention.212 
Periarticular and Segmental Fractures. Fractures of the proximal or distal metaphysis of the tibia and segmental fractures are generally considered challenging to treat successfully with IM nailing. However, Kakar and Tornetta have shown good results using nonreamed nailing for the treatment of segmental tibial fractures. In their study, 91% achieved union with an average healing time of 138 days (approximately 19 weeks) for closed fractures and 178 days (approximately 27.5 weeks) for open fractures.116 
Nork et al.169 have shown that satisfactory radiographic alignment and union rates can be achieved for proximal one-third tibial fractures with nailing when strict attention is paid to obtaining a reduction prior to nail insertion and techniques such as blocking screws, a lateral starting point, the use of femoral distractor, the semiextended position, and unicortical plating are utilized. In a recent prospective randomized trial, Vallier et al. reported higher rates of malalignment >4 degrees when distal tibial metaphyseal fractures were treated with IM nailing compared to plate fixation, but there was no difference in functional outcomes scores.242,243 
Open Fractures. As with other trials, the largest prospective study of tibia fractures, the SPRINT study showed that open tibial diaphyseal fractures had poorer overall outcomes than closed injuries with the rate of reoperation or autodynamization within 1 year of injury being 26.5% in open fractures compared to 13.7% in closed fractures.220 The use and timing of IM nailing in severe open tibial fractures remains controversial but good results can be obtained (Fig. 57-11). In a prospective study, Kakar and Tornetta116 demonstrated high union (89%) and low infection (3%) rates with immediate unreamed IM nailing of open tibial fractures. Their protocol involved aggressive initial surgical irrigation and debridement followed by soft tissue coverage within 14 days. Keating et al.120 reported similar nonunion rates (9% to 12%) when reamed and unreamed IM nailing was used. However, both of these studies contained predominantly type I to IIIA open fractures, so these results may not apply to more severe type IIIB and IIIC injuries. 
Other authors have cautioned against immediate internal fixation for severe type IIIB and IIIC open tibia fractures because of high infection (27%) and complication (57%) rates for these high-energy injuries.31 Many recommend initial temporary stabilization with uniplanar external fixators for these injuries followed by conversion to definitive internal fixation when the soft tissue injury allows. 
A recently published meta-analysis does not provide evidence to support either external fixation or IM nailing in the treatment of severe open fractures.107 The main concern associated with IM nailing following temporary external fixation is infection related to canal colonization at the pin sites. In a meta-analysis of the relevant literature Bhandari et al. reported average infection rates of 9% and union rates of 90% with IM nailing following external fixation. The risk of subsequent infection was related to duration of external fixation and the authors recommended frame removal and definitive nailing within 14 days.23 

Long-Term Outcome

Little data regarding validated long-term outcomes after tibial diaphyseal fracture exist. In one study the SF-36 and SMFA functional outcome scores were not significantly different from population norms more than 12 years after IM nailing. However, persistent knee pain (73%) and leg swelling (33%) were common.138 

Plating

Open Reduction Internal Fixation

Plate fixation of extra-articular tibia fractures is still commonly employed for proximal and distal fractures as these are technically difficult to nail with adequate alignment and it can be difficult to achieve adequate mechanical stability. Mid-diaphyseal fractures are less commonly plated given the popularity of nails, but the technique can be useful in certain situations. These include cases where antegrade nailing is not possible such as a periprosthetic fracture associated with a total knee replacement (Fig. 57-26), a tibia that is too small for a nail, a canal that is not patent or is deformed because of a prior fracture or an ipsilateral tibial plateau fracture making nailing difficult. Some surgeons have argued that plating might be preferred for patients in whom rotational alignment is critical such as skiers and that plating might be better in these cases even for diaphyseal fractures. 
Figure 57-26
Anteroposterior (A) and lateral (B) radiographs of a fracture around a long-stemmed total knee arthroplasty.
This was treated by plating (C and D).
This was treated by plating (C and D).
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Open Fractures

Definitive plating of open tibia fractures is controversial. It is appealing because a significant exposure is required to debride the bone ends so that much of the exposure required to place the plate has already been performed. However, this approach has not become popular because of the risk of infection associated with the additional soft tissue stripping near the fracture site associated with plate fixation. 
A systematic review of the literature concluded that the deep infection rate is 11% for acute plating and recommended that it can be considered in certain circumstances.85 If plating is chosen for an open fracture, one approach is to initially treat the fracture with an external fixator and undertake definitive plating later when the condition of the soft tissues has improved (Fig. 57-27). 
Figure 57-27
 
Anteroposterior (A) and lateral (B) radiographs of an open distal tibia fracture which was initially debrided and closed and the fracture was kept out to length with a temporary external fixator. Posterior plating was performed 2 weeks after injury through a posterolateral approach. The fibula could have been fixed for additional stability through the same approach.
Anteroposterior (A) and lateral (B) radiographs of an open distal tibia fracture which was initially debrided and closed and the fracture was kept out to length with a temporary external fixator. Posterior plating was performed 2 weeks after injury through a posterolateral approach. The fibula could have been fixed for additional stability through the same approach.
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Figure 57-27
Anteroposterior (A) and lateral (B) radiographs of an open distal tibia fracture which was initially debrided and closed and the fracture was kept out to length with a temporary external fixator. Posterior plating was performed 2 weeks after injury through a posterolateral approach. The fibula could have been fixed for additional stability through the same approach.
Anteroposterior (A) and lateral (B) radiographs of an open distal tibia fracture which was initially debrided and closed and the fracture was kept out to length with a temporary external fixator. Posterior plating was performed 2 weeks after injury through a posterolateral approach. The fibula could have been fixed for additional stability through the same approach.
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Preoperative Planning.
Preoperative planning involves evaluation of the patient’s soft tissues to make sure that they are appropriate for plate fixation. Wounds, fracture blisters, and previous surgery or trauma may be relative contraindications to plate fixation. Surgical planning should include making sure that the appropriate plate is available. This can be determined by measuring the preoperative radiographs. Reduction aids such as clamps and a femoral distractor are often useful, as are plate benders even for precontoured plates that may not fit a particular patient’s anatomy. An appropriate table and fluoroscopy are both necessary. 
Some surgeons trace out the fracture and plan the exact location of the screws preoperatively using a template. More commonly, surgeons at least determine a strategy for fracture reduction and fixation. This involves deciding on the approach, to determine if a minimally invasive or more traditional open approach is required, and the type of fixation. Fixation strategies are detailed elsewhere, but the surgeon should decide preoperatively if the plan is to reduce all bone fragments perfectly (Fig. 57-26) to achieve primary bone healing, or simply to restore length and rotation with the goal being secondary bone healing (Figs. 57-27, 57-28, and 57-29). Caution should be exercised when attempting to achieve secondary bone healing with simple fracture patterns as these simple patterns are thought to be better treated with direct anatomic reduction of the fracture. A preoperative planning checklist is shown in Table 57-9
Figure 57-28
 
Anteroposterior (A) and lateral (B) radiographs of a distal tibial fracture treated by a medial plate inserted through through a percutaneous approach.
Anteroposterior (A) and lateral (B) radiographs of a distal tibial fracture treated by a medial plate inserted through through a percutaneous approach.
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Figure 57-28
Anteroposterior (A) and lateral (B) radiographs of a distal tibial fracture treated by a medial plate inserted through through a percutaneous approach.
Anteroposterior (A) and lateral (B) radiographs of a distal tibial fracture treated by a medial plate inserted through through a percutaneous approach.
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Figure 57-29
 
Anteroposterior radiographs of anterolateral plating used to treat a distal tibial fracture associated with lateral displacement on the initial radiograph (A). Tibial fixation can be performed with or without (B) fibular fixation.
Anteroposterior radiographs of anterolateral plating used to treat a distal tibial fracture associated with lateral displacement on the initial radiograph (A). Tibial fixation can be performed with or without (B) fibular fixation.
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Figure 57-29
Anteroposterior radiographs of anterolateral plating used to treat a distal tibial fracture associated with lateral displacement on the initial radiograph (A). Tibial fixation can be performed with or without (B) fibular fixation.
Anteroposterior radiographs of anterolateral plating used to treat a distal tibial fracture associated with lateral displacement on the initial radiograph (A). Tibial fixation can be performed with or without (B) fibular fixation.
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Table 57-9
Plating: Preoperative Planning Checklist
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Table 57-9
Plating: Preoperative Planning Checklist
  •  
    Physical examination. Are surgical sites appropriate for incisions?
  •  
    Surgical strategy
    •  
      Anatomic reduction for primary bone healing
    •  
      Restore length/alignment for secondary bone healing
  •  
    Operating table. Allows imaging from knee to ankle
  •  
    Position/positioning aids. Supine with bump
  •  
    Fluoroscopy location. Contralateral
  •  
    Equipment. Plate set of adequate length, typically 4.5 mm
  •  
    Plate bender if plate not precontoured for tibia
  •  
    Tourniquet (nonsterile)
  •  
    Possible reduction aids available. Large bone clamps, femoral distractor or external fixator set, Schanz pins
X
Positioning.
Open reduction and internal fixation of tibia fractures is typically performed using a setup that is similar to tibial nailing (Fig. 57-12), but without the radiolucent triangle. The patient is positioned supine with a bump under the contralateral hip on a table that allows imaging from the knee to the ankle. Soft bumps and a femoral distractor or external fixator should be available as these are helpful, particularly if the reduction is to be obtained through indirect means. A C-arm is typically placed on the contralateral side of the table. An unsterile tourniquet can be used. 
Surgical Approaches.
Preserving soft tissue attachments and therefore the vascular supply to the tibia is of particular importance when plating tibia fractures. Poor outcomes in some initial series have been attributed to approaches that stripped too much soft tissue and devitalized the bone. Inappropriate approaches with excessive soft tissue stripping are associated with a higher incidence of infection and nonunion. 
Modern plating techniques rely on more minimally invasive approaches, often using smaller skin incisions3,47,49,172,195,260 than those that were originally described,45,199 and are associated with better outcomes. Regardless of the size of the skin incision care should be taken to preserve soft tissue attachments, and periosteal stripping should be avoided whenever possible. Percutaneous techniques are now commonly employed for anterior approaches to the tibia where the plate is slid through relatively small incisions and screws are placed through small stab incisions (Fig. 57-30). Care should be taken when placing screws through lateral distal percutaneous incisions as the superficial peroneal nerve is at risk (Fig. 57-31).62 Open approaches to the fracture with direct visualization and reduction of simple fracture configurations are still used, but particular care must still be made to preserve soft tissue attachments. 
Figure 57-30
Percutaneous plate fixation of an extra-articular proximal tibial fracture.
 
A femoral distractor and a percutaneous clamp can help reduce the fracture (A). A small lateral incision and small percutaneous incisions are used for plate and screw insertion (B and C). A larger distal incision must be used if the plate approaches the level of the superficial peroneal nerve. Postoperative radiographs demonstrate good bone length and alignment (D and E).
A femoral distractor and a percutaneous clamp can help reduce the fracture (A). A small lateral incision and small percutaneous incisions are used for plate and screw insertion (B and C). A larger distal incision must be used if the plate approaches the level of the superficial peroneal nerve. Postoperative radiographs demonstrate good bone length and alignment (D and E).
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Figure 57-30
Percutaneous plate fixation of an extra-articular proximal tibial fracture.
A femoral distractor and a percutaneous clamp can help reduce the fracture (A). A small lateral incision and small percutaneous incisions are used for plate and screw insertion (B and C). A larger distal incision must be used if the plate approaches the level of the superficial peroneal nerve. Postoperative radiographs demonstrate good bone length and alignment (D and E).
A femoral distractor and a percutaneous clamp can help reduce the fracture (A). A small lateral incision and small percutaneous incisions are used for plate and screw insertion (B and C). A larger distal incision must be used if the plate approaches the level of the superficial peroneal nerve. Postoperative radiographs demonstrate good bone length and alignment (D and E).
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Figure 57-31
Longitudinal anatomy of neurovascular structures and their proximity to the distal holes.
Rockwood-ch057-image031.png
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Mid-diaphyseal and distal tibial fractures can be plated through three approaches, these being the medial (Figs. 57-28 and 57-32), anterolateral (Fig. 57-29), or posterior (Fig. 57-27) approaches. More proximal extra-articular tibia fractures are usually not approached posteriorly as this approach provides limited exposure because of the vascular anatomy. 
Figure 57-32
Percutaneous or open plating can be performed for mid-diaphyseal tibia fractures (A and B).
 
Plating in open tibial fractures is often associated with poor outcomes, but in this case plating was performed because intramedullary nailing was contraindicated because the patient developed fat embolism syndrome prior to the procedure.
Plating in open tibial fractures is often associated with poor outcomes, but in this case plating was performed because intramedullary nailing was contraindicated because the patient developed fat embolism syndrome prior to the procedure.
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Figure 57-32
Percutaneous or open plating can be performed for mid-diaphyseal tibia fractures (A and B).
Plating in open tibial fractures is often associated with poor outcomes, but in this case plating was performed because intramedullary nailing was contraindicated because the patient developed fat embolism syndrome prior to the procedure.
Plating in open tibial fractures is often associated with poor outcomes, but in this case plating was performed because intramedullary nailing was contraindicated because the patient developed fat embolism syndrome prior to the procedure.
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Medial approaches have the advantage of directly exposing the tibia without any risk of neurovascular damage, but problems can arise if there is wound breakdown as there is no deep, soft tissue cover on the medial tibia. Medial approaches are commonly used for distal fractures using a limited incision that is either directly in line with the tibia or a curvilinear incision to avoid plate exposure if the wound breaks down. 
Lateral approaches to the tibial diaphysis have the advantage of providing better soft tissue cover for the plate. If lateral wounds breakdown a skin graft might be possible instead of a muscle flap. Distal tibial fractures can be treated with a small anterior or anterolateral approach and then sliding the plate up percutaneously on the lateral side of the tibia. The proximal screws can be placed with a combination of a proximal lateral incision and small stab incisions. 
A third approach for tibial diaphyseal plating is the posterolateral approach (Fig. 57-27). This is typically performed with the patient prone, but can be done with the patient in a lateral position. It uses the interval between the peroneal muscles in the lateral compartment and flexor hallicus longus in the deep posterior compartment. Excellent exposure of the distal three-fourth of the tibia can be obtained, but proximal exposure is limited by the vasculature. This exposure provides an excellent soft tissue envelope over the plate and also allows for plating of the fibula through the same skin incision. This approach does not allow percutaneous insertion of the plate as this must be done with a full open exposure. 
Proximal fractures that are plated are typically approached through a limited anterolateral incision that is similar than that employed for lateral tibial plateau fractures (Fig. 57-30). This incision allows elevation of the anterior compartment muscles so that a submuscular plate may be slid percutaneously from the lateral side. Medial plating is also a possibility for proximal fractures but is less commonly used. As has already been discussed the posterior approach should not be used for proximal fractures. 
Technique.
Table 57-10 shows a list of surgical steps that should be used in plating a tibial fracture. 
 
Table 57-10
Plating: Surgical Steps
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Table 57-10
Plating: Surgical Steps
  •  
    Expose tibial diaphysis (see above)
  •  
    Take care to protect soft tissue attachments
  •  
    Reduce fracture either directly or indirectly
  •  
    Direct reduction. Use lag screw if fracture simple and of sufficient obliquity
  •  
    Indirect reduction. Consider femoral distractor to restore length and alignment
  •  
    Apply long plate with appropriate contour
  •  
    Provisional K-wires may be used
  •  
    Check reduction and plate placement with fluoroscopy
  •  
    Place screws into plate
  •  
    Radiographs to confirm alignment
  •  
    Close wound
X
As with plating of any fracture there are a number of decisions that the surgeon must make. The surgeon must choose one of the approaches that have been described in addition to the reduction goal whether it be anatomic reduction aimed at primary bone healing or relative reduction that restores length and alignment and is aimed at secondary bone healing. A decision must also be made as to whether reduction is to be direct or indirect and whether the plate is to be placed using an open or percutaneous technique, or a combination of the two. Further information about these principles is contained in Chapter 7
Plating is commonly employed for distal or proximal fracture patterns as these patterns are difficult to nail in good alignment and it is also difficult to obtain adequate fixation with a nail. Precontoured plates, often with an option for locking fixation, now exist to facilitate plating of these fractures. Comminuted fracture patterns are typically treated with a medial (Fig. 57-32) or anterolateral plate (Fig. 57-29), indirect reduction, and percutaneous plate insertion with no exposure of the fracture site. A femoral distractor or external fixator (Fig. 57-24) may be very useful in these cases to restore length and alignment. Screws can be placed percutaneously either using a guide-arm for some plate systems, or using fluoroscopy with a technique that is similar to free hand placement of interlocking bolts through a nail. 
Simple fracture patterns are more typically treated with direct reduction and lag screws, followed by plating through a larger skin incision since a larger incision is needed for the direct reduction of the fracture site. The fracture ends must be well cleared of hematoma and debris to allow an anatomic reduction that is typically facilitated with clamp application. After a lag screw is placed, a plate is placed to neutralize the torque around the lag screw. 
As with plating of other fractures, plates for the tibia now tend to be longer (Figs. 57-26, 57-27, and 57-30) and fewer screws are used than in previous studies. Proximal and distal fractures may employ locking screws in the metaphysis to provide resistance to angular collapse of the fracture. For healthy bone, nonlocking screws are adequate for the diaphysis but for poor bone locking screws should be considered. 
Postoperative Care.
Postoperatively, patients are usually placed in a splint with the ankle in a neutral position for mid-diaphyseal or distal fracture patterns to prevent an equinus contracture and perhaps to reduce compartment pressures,253 A splint or a knee brace may be employed for more proximal fractures. Management of the splint is similar to that for tibial nails as previously discussed. 
Weight bearing is often limited to non–weight-bearing or partial weight bearing for 6 to 12 weeks for highly comminuted patterns, or for fractures that are very proximal or distal. Weight bearing can be initiated earlier for simpler fracture patterns that are treated with anatomic reduction and rigid fixation. 
Patients are typically reviewed at 2, 6, 12, 26, and 52 weeks from the time of surgery. Radiographs are obtained at each review after the 2-week review. Patients with very proximal or distal fracture patterns may benefit from radiographs at 2 weeks or more frequent early follow-up as these fractures can lose reduction in the early healing phase. 
As with IM nails closed fractures can be expected to demonstrate radiographic and clinical evidence of healing in 3 to 6 months, although fracture callus may not appear in fractures treated with anatomic reduction aimed at primary bone healing. Fractures typically heal with callus if the bridge plating technique was used (Figs. 57-28, 57-29, and 57-32) or without callus if a strategy aimed at primary bone healing was used. As with tibial nails, expect the healing time to be delayed in patients with open fractures, compartment syndrome or diabetes, and in smokers. Patients who demonstrate no evidence of healing or who have defects associated with open fractures (Fig. 57-32) may require bone grafting. With the exception of proximal fractures this can usually be done through a posterolateral approach. 
Some patients will have symptoms of hardware irritation over the plate or tips of the screws. Care should be taken to avoid inserting screws that are too long, particularly over the medial aspect of the proximal tibia as these are often symptomatic. Hardware should not be removed until there is good radiographic and clinical evidence of healing and usually not before at least a year as union is often slow. 
Potential Pitfalls and Preventative Measures.
Pitfalls and preventative measures associated with tibial plating are listed in Table 57-11
 
Table 57-11
Plating: Potential Pitfalls and Preventions
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Table 57-11
Plating: Potential Pitfalls and Preventions
Pitfalls Preventions
Pitfall no. 1: Devascularization of bone Appropriate soft tissue surgical approaches
Pitfall no. 2: Simple fracture pattern leads to nonunion Be cautious of indirect reduction combined with rigid locked plating
X
Pitfall no. 1: Devascularization of Bone from Approach Leads to Infection and Nonunion 
As has already been discussed extensive subperiosteal stripping of the tibial diaphysis has been implicated in poor outcomes related to open reduction and internal fixation. Circumferential stripping of the periosteum should be avoided. For direct reduction, the fracture hematoma and periosteum must be cleared back a millimeter or so from the end of the bones, but this step is not necessary for indirect reduction. In addition, there is no need to reduce each component of a comminuted fracture as this requires more extensive exposure and results in higher complications. 
Modern plating techniques emphasize preservation of the soft tissue envelope of the tibia. This helps maintain the blood supply that is crucial for fracture healing. Soft tissue preservation may involve a percutaneous approach with smaller surgical incisions and submuscular plate insertion (Fig. 57-30). However, these principles can also be applied if larger, more traditional incisions are used as long as care is taken to preserve the soft tissue attachments. 
Pitfall no. 2: Simple Fracture Pattern Leads to Nonunion 
Simple fracture patterns that are treated with a plate are often best treated with anatomic reduction using a lag screw and a neutralization plate. With the increased use of percutaneous plate insertion and indirect fracture reduction, attempts are sometimes made to treat simple oblique patterns with indirect reduction and stabilization with a locking plate. However, this should be avoided and a direct reduction performed if possible for this fracture pattern. 
Indirect reduction of simple fracture patterns does not usually result in anatomic reduction at the fracture site and bone gaps usually remain. This is acceptable for a comminuted fracture pattern, but in a simple fracture pattern there is strain concentration at the fracture site when a small gap is present.184 The rigid fixation associated with the use of a locking plate may prevent motion and formation of callus and therefore lead to an increased risk of nonunion. 
Treatment-Specific Outcomes.
Multiple studies comparing plating to conservative treatment have shown a shorter healing time and lower rates of nonunion and malunion in the plating group. However, the overall complication rates are higher with plating and poor results are typically obtained when plating is used in the treatment of open tibial fractures. A systematic review of the literature analyzed the results of plating for severe open tibial fractures85 and demonstrated that the pooled deep infection rate was 11%, but some series have observed much higher rates. 
In the first RCT comparing AO compression plating of the tibia to nonoperative management, the plating group had a shorter union time and a lower rate of malalignment but the overall complication rate was higher. The highest prevalence of complications was encountered when plating was used in open fractures leading the authors to recommend against the use of this technique in open injuries.244 A meta-analysis of six controlled trials published between 1966 to 1993 allowed comparison of plate fixation with cast treatment and yielded similar results. Pooled data revealed higher rates of superficial infection with plating as well as improved union by 20 weeks.143 In one of the studies analyzed, the discrepancy in healing time was so significant that patients were able to return to work 4 months after plating compared with 8 months after cast management. 
Similar results were reported by den Outer et al.63 when they compared functional bracing to plating in 170 patients. Plating was associated with a higher complication rate but conservative treatment resulted in higher rates of malunion and a longer time to healing. Jensen et al.113 published the results of 207 tibial diaphyseal fractures treated conservatively or with various plating techniques and reported lower malunion rates with plating (0-8% and 21%) but a high risk of complications including refracture after hardware removal (11%) and infection (11% of open fractures). Rates of nonunion were similar between groups, but as with other studies, were significantly higher for open fractures compared with closed fractures irrespective of the treatment method (6-8% in closed fractures and 21-24% in open fractures).113 A large retrospective study looking at 418 tibia fractures published by Ruedi et al.199 showed similar good results with plating of closed fractures (nonunion 1%, infection 1%), but poorer results when the technique was applied to open injuries (nonunion 5.3%, infection 11.6%). 
In a prospective, randomized trial Bach and Hansen13 reported the results of 59 Gustilo type II or III open tibial fractures treated with either plate osteosynthesis or definitive external fixation. Patients treated with plating had a significantly higher rate of osteomyelitis (19% vs. 3%) and wound infection (35% vs. 13%). 
Despite many studies reporting good results in closed tibial fractures,45,199,244 plating of the tibial diaphysis has fallen out of fashion in favor of IM nail fixation which is associated with better results. Although IM nail fixation is now widely considered the treatment of choice for tibial diaphyseal fractures plating is still preferred by many for the treatment of proximal or distal one-third fractures because of too high rates of malalignment when nailing is used to treat these particular fractures.243 A recent randomized prospective trial compared large-fragment nonlocking plate fixation to reamed IM nailing for the treatment of closed and open distal tibial metaphyseal fractures. The rates of deep infection, nonunion, and secondary procedures for hardware removal were similar between the two groups. However, IM nailing was associated with a significantly higher rate of malalignment compared to plating (23% vs. 8.3%, p = 0.02). Open fractures treated with either technique had higher rates of infection, nonunion, and malunion than closed fractures.242 A subsequent study looking at functional outcomes at a minimum of 12 months from injury showed that patients treated with a nail reported slightly higher rates of knee (31% vs. 22%) and ankle (40% vs. 32%) pain, but there was no difference between functional outcomes scores (FFI and MFA) between the groups. Regardless of treatment method, 95% of patients had returned to work but approximately one third reported modification of work duties secondary to injury243. Generally positive outcomes for plating of distal tibial fractures have also been shown in other studies3 Ricci et al have shown similar satisfactory results when minimally invasive locked plating techniques are applied to fractures of the proximal tibia 195

External Fixation

External fixation of tibial diaphyseal fractures has been used for over 100 years but there has been recent increased interest in the use of modern ring fixators,108,122,250 particularly for high-grade open fractures. Modern fixators can adjust fracture alignment over time and allow early weight bearing for most fracture patterns which was not true of unilateral frames that were used previously. Ring fixators are therefore thought to be less susceptible to the problems associated with malunion that were identified in the past when definitive treatment of tibial fractures was undertaken with unilateral frames and malunion rates of 39% to 48% were recorded.54,99 
The definitive use of external fixation for fracture fixation is associated with high rates of pin tract infection. These rates can be greater than 100% as some patients have more than one infection. Although most infections can be treated with oral antibiotics, intravenous antibiotics and removal of pins are sometimes necessary. In addition, frames require more intensive postoperative management than is required with internal fixation. However, recent frames that are simpler to apply than the Ilizarov frame may broaden the appeal of external fixation. 
Although external fixation is rarely used for the definitive fixation of closed tibial diaphyseal fractures, it can be used to allow soft tissue swelling resolution before plate fixation. The temporary external fixator is applied and removed later when the swelling and fracture blisters have resolved to allow definitive plate fixation. This technique may be particularly useful for open fractures that are to be plated as it allows the open wound to heal without exposing any hardware to potential wound breakdown (Fig. 57-27). Temporary external fixation is also used by some surgeons before nailing in patients who undergo multiple operative debridements. 
External fixation is also sometimes performed prior to tibial nailing in patients who require to be treated by a damage control approach after trauma and in whom it is contraindicated to use a temporary splint (Fig. 57-33). The damage control approach to polytrauma patients is less commonly used than in the femur as the tibia can be splinted in most cases. Damage control surgery is discussed further in Chapter 9. The length of time after which conversion of primary external fixation to secondary nailing is associated with an unacceptable infection rate is unknown,23 but many clinicians are unwilling to nail a tibia that has been treated with an external fixator for 2 weeks or more. At this point some surgeons will treat the patient definitively with a ring fixator, or simply remove the temporary external fixator to allow the pin sites to heal. They will then nail the tibia. 
Figure 57-33
A spanning external fixation frame used for the acute management of a type IIIB open proximal tibial shaft fracture.
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Open Fractures

The use of ring fixators for severe Gustilo type IIIA, IIIB, and IIIC open fractures, particularly if they have a bone defect, has some theoretical rationale as the infection rate with internal fixation is often relatively high.108,122,250 The argument for external fixation as definitive treatment of severe open tibial fractures is based on avoidance of metal at the fracture site. Surgery is typically associated with increased infection rates when metal is introduced because bacteria form a biofilm on any metallic surface and internal fixation used for severe open tibia fractures is no exception. 
The use of modern ring external fixators in open fractures associated with considerable bone loss is an option (Fig. 57-34).108 In these cases the bone defect can be filled with bone graft as it would be with internal fixation or, more commonly, the tibia is osteotomized at another level and distraction osteogenesis is used to fill in the defect. This technique may have the advantage of having a lower infection risk and it has the advantage of forming bone at a site distant to the traumatic wound. Further information about bone reconstruction techniques is contained in Chapters 10, 12 and 15
Figure 57-34
 
A complex patient who was not a candidate for a flap was treated with shortening of the limb with a ring fixator (A, B, and C) and then lengthening of the massive defect using distraction osteogenesis (D and E). The tibia united (F and G) and the patient was pain free and ambulating without aids 2 years after injury. This is an atypical outcome for an injury of this severity.
A complex patient who was not a candidate for a flap was treated with shortening of the limb with a ring fixator (A, B, and C) and then lengthening of the massive defect using distraction osteogenesis (D and E). The tibia united (F and G) and the patient was pain free and ambulating without aids 2 years after injury. This is an atypical outcome for an injury of this severity.
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A complex patient who was not a candidate for a flap was treated with shortening of the limb with a ring fixator (A, B, and C) and then lengthening of the massive defect using distraction osteogenesis (D and E). The tibia united (F and G) and the patient was pain free and ambulating without aids 2 years after injury. This is an atypical outcome for an injury of this severity.
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Figure 57-34
A complex patient who was not a candidate for a flap was treated with shortening of the limb with a ring fixator (A, B, and C) and then lengthening of the massive defect using distraction osteogenesis (D and E). The tibia united (F and G) and the patient was pain free and ambulating without aids 2 years after injury. This is an atypical outcome for an injury of this severity.
A complex patient who was not a candidate for a flap was treated with shortening of the limb with a ring fixator (A, B, and C) and then lengthening of the massive defect using distraction osteogenesis (D and E). The tibia united (F and G) and the patient was pain free and ambulating without aids 2 years after injury. This is an atypical outcome for an injury of this severity.
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A complex patient who was not a candidate for a flap was treated with shortening of the limb with a ring fixator (A, B, and C) and then lengthening of the massive defect using distraction osteogenesis (D and E). The tibia united (F and G) and the patient was pain free and ambulating without aids 2 years after injury. This is an atypical outcome for an injury of this severity.
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Preoperative Planning.
Most tibial fractures can be treated by external fixation, regardless of the fracture location or the state of the soft tissues. Very proximal or distal fracture locations may require spanning the ankle or knee to achieve adequate fixation. This is not a problem if the frame is temporary and definitive internal fixation is planned later. Another option for proximal or distal fractures is a fine wire circular frame, but of course this type of system must be available if this technique is to be used. Reduction aids such as clamps should also be available and fluoroscopy and a radiolucent table are required. A preoperative planning checklist is shown in Table 57-12
 
Table 57-12
External Fixation: Preoperative Planning Checklist
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Table 57-12
External Fixation: Preoperative Planning Checklist
  •  
    Operating table. Allows imaging from knee to ankle
  •  
    Position/positioning aids. Supine with bump, radiolucent triangle
  •  
    Fluoroscopy location. Contralateral (ipsilateral is also possible)
  •  
    Equipment. External fixation set
  •  
    Tourniquet. Not normally used
  •  
    Possible reduction aids available. Large bone clamps, Schanz pins
X
Positioning.
External fixation of tibia fractures is typically performed using a setup that is similar to tibial nailing (Fig. 57-12). The patient is positioned supine with a bump under the ipsilateral hip on a table that allows imaging from the knee to the ankle. Soft bumps should be available as these are helpful, particularly if the reduction is to be obtained through indirect means. A C-arm is typically on the contralateral side of the operating table. A tourniquet is not needed as the incisions are percutaneous. 
Surgical Approaches.
External fixator half pins or wires are placed through percutaneous stab incisions. Their insertion is discussed in Chapter 8. Although there is no standard approach the safe pathways for pin or wire placement must be familiar to the surgeon. For simple unilateral external fixators, that typically use half pins, the anteromedial aspect of the tibia provides safe access along its entire length. Only the saphenous vein and nerve are at risk. 
In ring fixators the pins are placed at 90 degrees to each other to provide the ideal biomechanical environment as discussed in Chapter 8. This could put local neurovascular structures at risk, so the treating surgeon must be aware of the anatomical structures that could be damaged. In particular, the course of the peroneal nerve and vascular structures should be avoided. Safe zones for pin placement have been well established and should be reviewed prior to placement of pins into areas other than the anteromedial tibia. 
Technique.
The techniques used to place unilateral and ring fixators are discussed at length in Chapter 8. This chapter will concentrate those topics that are of particular importance in external fixation of tibia diaphyseal fractures. 
Unilateral External Fixators. This technique can easily be employed in tibial diaphyseal fractures. As the fracture gets closer to the knee or ankle joint it becomes more difficult to obtain adequate fixation in the proximal or distal metaphyses. An additional option is to extend the fixation into the femur for proximal fractures or into the talus or calcaneus for distal fractures. This prevents motion in the knee or ankle joints and is likely to result in at least short-term stiffness if the frame is left on for a significant period. If this occurs a manipulation under anesthesia may be required at the time of frame removal. 
Simple unilateral frames can be placed with half pins above and below the fracture site. As with any external fixator, stability is enhanced by placing the bars closer to the bone, spreading the pins out and reducing the distance between the pins on each side of the fixator. Increasing the size of the bars has a significant effect on construct stiffness. Larger pins also increase stability so most systems use 5- or 6-mm pins. Supplementary bars and pins can also be used to increase stability. 
Pins are typically placed into the anteromedial surface of the tibia. Pin placement should avoid the joint capsule so pins should not be too close to the knee or ankle joints. Either pin–bar clamps are used which constrain the placement of the pins or the pins are placed with pins near the fracture and far from it in each segment to enhance stability. 
The fracture is reduced intraoperatively using fluoroscopic guidance and the external fixator is tightened in place. If the construct is not rigid enough, additional measures should be taken to increase construct stiffness (see below). Plain x-rays are obtained to demonstrate adequate alignment. 
Modern Ring Fixators. Modern ring fixators can be used for diaphyseal and metaphyseal tibial fractures because the frames can use tensioned wires at various angles that can control the metaphyseal segments if needed. Ring fixators have an advantage over simple unilateral frames in that they are thought to have improved mechanical properties and be less likely to result in late collapse and malunion. 
Ring fixators can be employed in the tibia in several ways. The first is a static frame in which alignment cannot be changed during the healing process. Another is an Ilizarov frame that has linear struts that can lengthen along a single axis. The most modern devices employ computerized software and struts in multiple planes that allow manipulation of the fracture fragments both initially and during the healing process (Fig. 57-34). This flexibility can be particularly useful to prevent late malalignment of the fracture as alignment can be adjusted during the healing process. 
Ideally the ring fixator should be built prior to surgery and sterilized. Measuring the tibial length, careful assessment of the fracture, and sizing the rings on the uninjured contralateral limb, when possible, will facilitate this process. Building the frame prior to surgery saves significant time in the operating room. Care should be taken to size the rings appropriately so as not to impinge on soft tissues. When this is done it should be remembered that there will be some swelling in the immediate postoperative period. The common error is to place the ring too close to the posterior leg but the majority of leg swelling will occur posteriorly and laterally as the anteromedial aspect of the leg has less soft tissues that can become swollen. 
A combination of half pins and wires can be used in the tibia. For diaphyseal fractures half pins alone can be used. For metaphyseal locations, fine wires are used and tensioned in place. Typically, three points of fixation are placed in the proximal and distal fracture segments that are being held by the frame. Single pins are sometimes used in intervening fragments. To improve the mechanical stability these wires or pins should not be in the same plane and maximum stability is achieved when pins are 90 degrees to each other. 
The sequence of events used to reduce the tibial fracture depends on the type of frame being used. For frames without distraction elements, the fractures must be reduced using fluoroscopy as part of the process of placing the frame. For frames that have struts that can be adjusted, the frame may be placed in position with the fracture malreduced, and the computer software can then determine how to adjust the struts to reduce the fracture in the operating room or slowly over time as an outpatient. The process is iterative and may be repeated multiple times until the desired alignment is obtained. 
Pin Placement Techniques. There are several techniques that may be used to place external fixator pins or wires. These are discussed in Chapter 8. External fixator pins and wires are prone to pin tract infections, and the techniques are focused on attempting to reduce this complication. Because pin tract problems are more common with larger soft tissue envelopes, pins in the tibia tend to have a lower infection rate than pins in the femur or pelvis. 
Pins may be placed in the tibia by first drilling a guide-hole or by placing self-drilling pins without predrilling. Predrilling is aimed at reducing thermal necrosis which can increase the risk of pin loosening and infection. The drill is also smaller than the self-drilling pin and therefore should produce less heat while creating the guide pathway for the pin. The counterargument is that self-drilling pins can be inserted on power in one step which reduces the chance of off-axis pin insertion or loosening because the pin is inserted in a path that may not align precisely with the predrilled path. Inserting pins on power has the theoretical advantage of reducing the wobble effect of hand insertion that is thought to lead to pin loosening and pin tract infection. 
Pin insertion technique is probably more important if the frame is to be on the tibia for a longer period of time. Therefore, if ring fixators or standard frames are used for definitive fixation surgeons will often use a predrilling insertion technique and hydroxyapatite (HA)-coated pins in an attempt to minimize pin loosening. 
The technique of fine wire placement is also aimed at decreasing thermal necrosis by only using sharp pins. Some authors advocate cooling the pins or wires with irrigation while inserting them, but this technique is of questionable clinical importance because if it has an effect it is only on the surface of the bone. 
Small stab incisions with subsequent spreading of the soft tissues and the use of a soft tissue protector for drilling and pin insertion are used to protect the underlying soft tissues from damage during pin insertion. There is little soft tissue on the anteromedial aspect of the tibia so this is less of a problem when applying a unilateral frame to the tibial diaphysis. The incisions should be small so as to facilitate skin adherence to the pin to provide a barrier. Some surgeons carry this technique further and make very small incisions or no incisions and use the sharpness of the pin or wire to penetrate the skin arguing that this optimizes skin–pin adherence. A list of surgical steps in external fixation of the tibia is given in Table 57-13
 
Table 57-13
External Fixation: Surgical Steps
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Table 57-13
External Fixation: Surgical Steps
  •  
    Place pins proximal and distal to fracture (Fig. 57-34)
  •  
    Reduce fracture
  •  
    Traditional frame. Reduction must be achieved in operating room
  •  
    Computer-assisted ring fixator. Reduction may be either adjusted in operating room or clinic using frame
  •  
    Radiographs to confirm alignment
X
Postoperative Care.
Early weight bearing is usually limited with unilateral frames but it can usually be allowed between 6 and 12 weeks with the decision being based on the radiologic appearance of the fracture and the patient’s clinical presentation. Ring fixators have greater mechanical stability, and immediate weight bearing as tolerated is often allowed unless there is a large segmental defect such as occurs sometimes in severe open fractures. 
Patients are typically seen at 2, 6, 12, 26, and 52 weeks from the time of surgery or at least until healing has occurred. Patients with a unilateral fixator may need to be seen more often, particularly in the early weeks, as the fractures are prone to lose reduction during healing and it is advantageous to notice this early so it can be corrected. Radiographs are obtained at each visit and should be carefully compared with the original postsurgical radiographs to determine if the initial reduction has been maintained. Closed fractures can be expected to demonstrate radiographic and clinical evidence of healing at 4 to 6 months. Fractures typically heal with callus. As with other tibial fractures, expect the healing time to be delayed in patients with open fractures, compartment syndrome, or diabetes, and in smokers. 
Frame Dynamization and Removal. Unilateral frames are routinely dynamized during the healing process. Dynamizing a frame requires removing some portions of the frame to reduce the mechanical stiffness and allow more of the load to be taken by the fracture. This more gradual reduction in stiffness is thought to improve healing compared with early removal of the external fixator. 
Ring fixators also can be dynamized by removing pins or rods. This is more straightforward with traditional Ilizarov frames than with ring fixators that use multiple adjustable struts. More recent frames based on struts are more difficult to dynamize as releasing one strut completely destabilizes the construct. One technique is to loosen a few struts and have the patient ambulate. More or all of the struts can be sequentially loosened to allow the patient to ambulate without the support of the frame. A radiograph taken a week later in the clinic can determine if the fracture is displacing. If it appears stable the entire frame can be removed. If it is unstable, the struts can be reattached as more time is needed for healing. 
External fixators can often be removed in clinic. However, pins that have been present for many months, particularly those with HA coating, can be quite painful to remove and the patient will often require better anesthesia such as that provided in the operating room. Removing a single pin to treat a pin tract infection is usually straightforward in the clinic as these pins are often loose. 
Potential Pitfalls and Preventative Measures.
A list of pitfalls and preventative measures for tibial external fixation is given in Table 57-14
 
Table 57-14
External Fixation: Potential Pitfalls and Preventions
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Table 57-14
External Fixation: Potential Pitfalls and Preventions
Pitfalls Preventions
Pitfall no. 1: Pin tract infection Good pin/wire insertion technique
Appropriate pin management techniques
Pitfall no. 2: Loss of fracture alignment Careful radiographic follow-up
Increased fixator stiffness
Pitfall no. 3: Nonunion Prophylactic bone grafting
Avoid combining with lag screw
X
Pitfall No. 1: Pin Tract Infection 
Pin tract infections are very commonly encountered when treating tibia diaphyseal fractures with an external fixator and occur even after using the most meticulous pin insertion technique. As discussed above, insertion techniques that minimize thermal necrosis are thought to minimize pin tract infections. HA-coated pins are also thought to minimize infection by increasing the pin–bone interface. Surgeons tend to have strong preferences regarding the dressings and cleaning solutions that should be used. These preferences range from complex mixtures such as hydrogen peroxide and saline and compressive dressings to doing nothing but showering with the frame. However, little data exist to guide the clinician as to best practice. 
Pin tract infections can be aggressively managed with antibiotics if diagnosed early and the infection may resolve. A course of oral antibiotics aimed at the most common pathogens in your medical system is ideal. Occasionally, admission to the hospital for a short course of intravenous antibiotics may be useful, particularly if removing the infected pin would significantly destabilize the frame. If oral antibiotics clear the infection but it returns once the antibiotics are stopped, it is likely that the infection will not resolve until the pin is removed. The infection can be suppressed with oral antibiotics until the frame or pin can be removed. If the removal of the pin compromises frame stability, a new pin should be placed in a new position. 
Pitfall No. 2: Loss of Fracture Alignment 
External fixators can fail to maintain alignment during the healing process. This was most notable with unilateral frames and led to a high prevalence of malunions and a move away from this technique. More rigid external fixators are likely to minimize malunion. Ring fixators are thought to provide improved stability, but even these frames can fail to maintain fracture alignment. Surgeons should be familiar with how to increase the stiffness of their construct. 
Early detection of the problem is a crucial step in the prevention of malunion. Frequent radiographic evaluation is needed and if malalignment develops beyond acceptable limits, adjustment of the frame should be performed. The more unstable the fracture pattern, and the less stiff the frame, the more vigilant the surgeon must be and frequent radiographs are required during the healing process. 
Pitfall No. 3: Nonunion 
Nonunion was a significant problem when unilateral external fixators were popular. 
Although the increased rigidity of modern frames may improve healing, the use of a lag screw in combination with an external fixator should be approached with caution. This technique has shown poor clinical results because, unlike a plate, the external fixator is removed after a relatively short time leaving nothing to neutralize the rotational forces around the lag screw. Further, some surgeons argue that this technique mixes surgical principles as it combines strategies aimed at producing primary and secondary bone healing. Regardless of the reason, the technique has produced poor outcomes to date and should be avoided. 
Treatment-Specific Outcomes.
External fixation is an appealing treatment method for open fractures as no metal is placed at the fracture site, therefore theoretically reducing the risk of infection. Several studies have yielded encouraging outcomes in higher grade open fracture types.108,250 A meta-analysis comparing external fixation and unreamed nailing in Gustilo type II fractures showed few differences.70 External fixation has been show to be favorable in comparison to plating in type II and III open tibial fractures with a 3% prevalence of osteomyelitis in fractures treated by external fixation compared with 19% for plated fractures. 13 An analysis of papers comparing IM nailing and external fixation in complex tibial fractures yielded only three studies that met the authors’ inclusion criteria. There was very little difference between the two techniques. The authors commented that delayed union and nonunion were more prevalent in the external fixation group but the results were not statistically significant.107 
Unilateral External Fixators. Definitive treatment of tibial diaphyseal fractures with unilateral external fixation has been plagued with relatively high rates of malunion. Malunion rates of 39% to 48% have been reported,54,99 with progressive collapse of the fracture demonstrated over time. Two retrospective reviews demonstrated worse outcomes of unilateral frames compared to IM nails.4,216 Alberts et al.4 showed that time to union and delayed union rates were higher with external fixation compared with nailed fractures while Shannon et al.216 demonstrated a delay to full weight bearing and more clinic visits with external fixation, although infection, nonunion, and time to union were similar. 
Ring Fixators. Reported results with ring external fixation for treatment of tibia fractures vary widely in the literature. Possible contributing factors may include differences in fixator constructs, surgeon experience, and severity of injury. When comparing reported outcomes of ring fixation to those of other treatment methods for tibial fractures, it is critical to remember that ring fixators are used almost exclusively for Gustilo IIIB and IIIC fractures. Therefore reported rates of infection, reoperation, nonunion, malunion, and other complications cannot be compared between treatment methods without correcting for injury severity. 
Tucker et al.236 reported a 5% infection rate and 20% malunion rate using Ilizarov frames for the treatment of civilian, high-energy open tibial fractures. However, Hutson et al.108 reported no osteomyelitis and <10% malunion for similar severe injuries. In combat-related blast injuries, Keeling et al.122 reported a deep infection rate of 8% and no malunions >5 degrees for type III open tibia fractures treated definitively with circular external fixation. However, the average time for healing in these extreme injuries was 220 days. Further data is needed to determine the best treatment method for severe open tibia fractures. To this end, a multicenter RCT is currently in progress comparing ring external fixation with internal fixation in the treatment of Gustilo type IIIA and type IIIB tibia fractures. 
A recent review of the literature revealed only one outcome study comparing IM nailing to ring external fixation.107 In this randomized study of 61 patients, the only difference reported was a 2-week faster healing time in the fixator group. This is of questionable clinical significance. 

Amputation

Detailed discussions of the treatment of the mangled extremity can be found in Chapter 12 and a detailed analysis of amputation is presented in Chapter 14. However, these topics have specific relevance to the treatment of severe open tibia fractures. In fact, an influential editorial in 1987 argued that attempts at limb salvage for the most severe open tibial fractures with vascular injuries, Gustilo IIIc fractures, were not indicated and leave the patients destitute and demoralized.97 
In these severe open type IIIB and IIIC fractures of the tibia the limb can be so damaged that salvage potential is questionable.41 The management of these complex injuries is challenging with little objective clinical data to guide treatment toward limb salvage or amputation despite a recent large meta-analysis.201 Multiple lower extremity injury scoring systems have been developed to try and guide treatment. However, studies have shown that these scores have no clinical validity30,60 and no correlation with long-term functional outcomes.60,146 Which severe open tibia fractures are best treated with amputation or reconstruction continues to be an area of interest in both civilian and military settings. 
Typical absolute indications for amputation of an open tibial fracture include a warm ischemia time of greater than 6 hours, a skin bridge only connecting the distal portion of the limb, or a situation where attempts at reconstruction place the patient’s life at risk. This last indication may seem obvious, but the treating surgeon should not underestimate the effect of the physiologic burden of dead muscle or multiple trips to the operating room in an attempt to salvage a mangled limb. Relative indications for amputation of an open tibial diaphyseal fracture are many and center on the likely ultimate function of the limb, the importance of avoiding complication, and the value of completing the treatment course in a timely fashion for that particular patient. 

Preoperative Planning, Positioning, Surgical Approaches

Technique.
The specific techniques for amputation are discussed in Chapter 14. In tibial fractures every effort should be made to undertake a below-knee amputation as these are associated with better function but severe proximal tibial fractures sometimes require an above-knee amputation. Amputations for open tibia fractures should not be closed primarily as they have high rates of infection. The zone of soft tissue injury in a mangled limb can also continue to evolve for days after injury and therefore early closure can mean that an incomplete debridement of dead tissue has been undertaken. Rather, the patient should return to the operating room for serial debridements until closure is warranted. The zone of injury and skin necrosis often evolves over time so the level of soft tissue viability for residual limb closure is often impossible to determine at the time of amputation. 
Unlike amputations for foot trauma or for peripheral vascular disease, amputations for severe open tibia fractures often require unconventional skin and muscle flap coverage of the bone. Traumatic wounds can take various shapes and evolving skin necrosis commonly requires the surgeon to use whatever skin is still viable to achieve closure. It is often wise to be cautious with skin resection at the time of initial amputation as it is often difficult to know which portions of the skin will become nonviable between that time and the time of definitive closure. 
Postoperative Care.
Postoperative care is detailed in Chapter 14. Surgeons should keep in mind that below-knee amputations are prone to develop stiffness as well as flexion contractures. Many surgeons initially splint, cast, or brace the limb in extension to prevent flexion contractures. Once the wound is healed, an aggressive protocol of knee range of motion is instituted. Treating knee contractures in amputees is particularly difficult so every effort should be made to avoid this situation. Weight bearing in a prosthesis is typically begun by 6 weeks from skin closure. 
Potential Pitfalls and Preventative Measures.
A list of pitfalls and preventative measures for amputations is given in Table 57-15
 
Table 57-15
Amputations: Potential Pitfalls and Preventions
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Table 57-15
Amputations: Potential Pitfalls and Preventions
Pitfalls Preventions
Pitfall no. 1: Surgical site infection or necrosis Do not close wound at time of initial amputation
Pitfall no. 2: Flexion contracture Splint in extension
Pitfall no. 3: Knee contracture Aggressive range of motion once wound heals
X
Treatment-Specific Outcomes.
The best outcome data to date on amputation after tibial fracture comes from the LEAP trial.31 LEAP was an eight-center prospective observational study whose primary question was if high-energy lower extremity trauma had better outcomes after reconstruction or amputation. The patient cohort included over 500 patients with many different severe open lower extremity injuries, but 55% of the patients had a severe open tibial fracture making the dataset of interest to the question of outcome of amputation after tibia fracture. All were thought to be limb-threatening lower extremity injuries. The study showed no difference in functional outcomes between limb salvage and amputation.148 
Prior to the LEAP study smaller retrospective studies had reported superior outcomes for amputation83 or limb salvage,60 but numbers were small and the studies did not use validated outcome scores. More recently, Giannoudis et al.84 stated that patients who had undergone limb salvage for open type IIIB tibial fractures reported worse pain and difficulty with activities of daily living at a 3-year follow up than those who had had an amputation. However, both had equal mobility issues. 
In the LEAP study, outcomes were poor regardless of the treatment method and in both reconstruction and amputation groups approximately half the patients reported long-term disability.148 Predictors of poor outcome included rehospitalization for complication, poverty, lack of private health insurance, nonwhite race, low self-esteem (low patient confidence in being able to resume life activities), smoking, involvement in disability-compensation litigation, a poor social support network, and low education level.31 Poor outcomes are consistent with previously published data showing that patients with severe lower extremity trauma had more long-term physical disability than those with chronic medical conditions such as chronic obstructive pulmonary disease, diabetes, cancer, angina, myocardial infarction, or low back pain.60 McCarthy et al.150 showed that psychological distress was also common (20%) even after 2 years from injury. 
Treatment-associated costs are significant and they differ between salvage and amputation. Projected lifetime health-related costs were three times higher for patients who had an amputation than those who underwent limb salvage because of prosthesis expense.148 Patient satisfaction after severe injuries of the lower extremity appears to be driven by the extent of both physical and emotional recovery and the ability to return to work.175 However, in a study that showed better functional outcomes after amputation, Dagum et al.60 reported that 92% of patients who underwent limb salvage preferred their salvaged legs over an amputation at any stage of treatment and that none would have preferred primary amputation. 
Outcome studies do not yet definitively answer the fundamental question regarding which patients with severe open tibia fractures are best treated with amputation. Ongoing multicenter trials with a similar study design to LEAP, except in the military population (the METALS study [military extremity trauma amputation/limb salvage study]) and in distal wounds that fared worse in the LEAP cohort (the OUTLET study [outcomes following severe distal tibia, ankle and/or foot trauma]) may shed further light on the outcomes after open tibial diaphyseal fractures treated with amputation. 
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Figure 57-35
Treatment algorithm.
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Management of Complications

A list of common complications associated with tibial diaphyseal fractures is given in Table 57-16
 
Table 57-16
Common Complications
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Table 57-16
Common Complications
Compartment syndrome
Knee pain
Symptomatic hardware
Malunion
Nonunion
Deep infection
X

Compartment Syndrome

Much of the literature on compartment syndrome involves fractures of the tibia as there is a relatively high rate of compartment syndrome associated with tibial diaphyseal fractures with rates of 1.5% to 11% being reported.153,155,176 Surgeons should have a high threshold for suspicion in patients with tibial fractures as a missed compartment syndrome can have devastating clinical consequences. Compartment syndrome also significantly increases the costs associated with managing tibial fractures.214 
Many surgeons rely on physical examination to diagnose compartment syndrome. However, this is impossible in intubated, intoxicated or demented patients, or other patients who are not able to comply with clinical examination. There remains considerable variation between clinicians regarding the diagnosis of compartment syndrome.176 The diagnosis and treatment of compartment syndrome in tibial diaphyseal fractures is covered in depth in Chapter 29
The clinical diagnosis of compartment syndrome was examined in detail by Ulmer.238 He pointed out that there was limited data in the literature but that the sensitivity of clinical findings for diagnosing compartment syndrome was only between 11% and 19%. In patients in whom physical examination is inappropriate or impossible, the current recommendation is to use a pressure differential of <30 mm Hg between the intracompartmental pressure and the diastolic blood pressure as diagnostic of acute compartment syndrome.154 McQueen and Court-Brown154 advocate continuous monitoring of all patients with tibial diaphyseal fractures arguing that it improves outcomes by minimizing the delay in diagnosis. However, continuous pressure monitoring is currently not commonly undertaken in North America where single stick pressure monitoring is more common. This is undertaken in patients in whom clinical examination is difficult or impossible or where there is concern that a compartment syndrome may be present. 
Independent risk factors for compartment syndrome are thought to be tibial fracture, male gender, younger age, proximal tibia fracture location, and low-energy athletic competition.155,256 It is important to note that compartment syndrome can also occur in open fractures.26 In addition, isolated ballistic tibial and fibular diaphyseal fractures, particularly those of the proximal third, have both been shown to have high rates of compartment syndrome.159 This is also true for isolated ballistic proximal fibula fractures.159 Tibial nailing is not thought to increase the risk of compartment syndrome.153,233 
In summary, clinicians managing tibia and fibula diaphyseal fractures should always be aware of the possibility of compartment syndrome as it is particularly common after these injuries. Once the diagnosis is made, emergent fasciotomy is indicated as discussed in Chapter 29

Anterior Knee Pain

Anterior knee pain is the most common complication following IM nailing of tibial fractures with reported rates of 19% to 73%.25,52,53,94,121,138,231,239,252 The etiology is probably multifactorial and the contributing factors remain largely unknown. Conflicting reports exist regarding the role of the surgical approach, whether this be transtendinous or paratendinous,120,232,240 nail prominence,25,61,121,219,252 and time from surgery.239 
In a large series of 443 tibial fractures treated with IM nails, knee pain was found to be inversely correlated to fracture union,200 although the mechanism and causal relationship remain unclear. Other proposed causes include postoperative thickening of the patellar tendon, fat pad scarring and adhesions,91 infrapatellar nerve damage,139 and proximal interlocking screw pain.132 Insufficient data exist to determine the effects of semiextended and suprapatellar nailing techniques at this time. Multiple studies have reported inconsistent resolution of knee pain following implant removal53,121,239,241 and poorer functional outcomes in patients with long-term knee pain.53,219,239 In our clinical practice we routinely discuss the risk of anterior knee pain with patients prior to IM nailing. 

Symptomatic Hardware

Reported rates of implant removal following treatment of tibial diaphyseal fractures vary widely (10-65%) and appear to be similar for plates and nails.72,162,242 The main indication for implant removal, which is not associated with infection, is hardware-related pain, though some surgeons recommend routine removal of all implants. Refracture after plate removal occurs in up to 11% of cases113 and there is no evidence to guide surgeons as to best time for implant removal. Given the wide range in time to union for tibial fractures, it is unlikely that any specific time would be ideal for all injuries. In our clinical practice we prefer to wait several months after complete radiographic and clinical union has been achieved. Usually we wait at least 1 year from injury but this recommendation is not justified in the literature. 
Removal of interlocking screws from tibial nails is common as these are often symptomatic, particularly if the screws are too long. Removal of these screws does not require removal of the entire nail, so the risk of refracture is very low. Similarly, removal of long screws in a plate has a lower risk of refracture and could be performed sooner after fracture union than removal of the entire implant. Implant removal surgery has a low complication rate and is associated with high patient satisfaction, improved pain scores, and improved functional outcomes, despite complete resolution of pain in only about 50% of patients.161 In the absence of infection, we rarely perform hardware removal following IM nailing and in the vast majority of cases that have hardware removal it is only the interlocking screws and not the nail that are removed. 

Malunion

Unfortunately, there is no clear definition of tibial malunion and different parameters are used throughout the literature making comparisons between studies challenging. This is probably because the parameters for acceptable alignment of tibial diaphyseal fractures have not been rigorously tested. Similarly, the short- and long-term effects of malalignment on function are not known. Published parameters for acceptable alignment typically fall within the following ranges: varus/valgus <5 to 10 degrees, recurvatum/procurvatum <5 to 10 degrees, rotation 0 to 10 degrees, and shortening <1 to 2 cm. However, the possible combinations of these values are numerous and Bridgman and Baird34 reported that a suboptimal outcome could be assigned to between 4% and 42% of patients in their study on cast treatment depending on which definitions for acceptable alignment and shortening were used. 
Limited animal data suggest that mild tibial malalignment does not result in significantly abnormal cartilage contact pressures or cartilage degeneration at the ankle or knee.144,208 However, in a cadaveric study mimicking tibial malaligments of 5 to 20 degrees, McKellop et al.152 showed that angulation could increase pressure on the knee cartilage by up to 106%. This effect was most pronounced for fractures of the proximal third of the tibia. Some data suggest that greater degrees of ankle malalignment correlate with poorer functional outcomes but the numbers were very small.189 Vallier et al.243 reported that pain was more common in patients with malalignment >5 degrees following distal tibia fixation. However, Lefaivre et al.138 reported that up to 35% of tibial diaphyseal fractures show evidence of ankle arthritis and 42% have ankle stiffness at long-term follow-up even in the absence of malalignment. Recent level II evidence has shown a frequency of 41% tibial malrotation after IM nailing but there was no significant functional impact even with malrotation of up to 20 degrees.229 Merchant and Dietz157 reported no correlation between tibial malunion and subsequent radiographic arthritis or functional change at the knee or ankle. However, traditional beliefs persist that even small angular deformities of the tibia can result in significant functional loss.51,115,167 
The treatment of symptomatic or cosmetically unacceptable tibial malunion usually requires osteotomy and correction can be complex when multiple planes of deformity are involved. Surgical fixation is required after osteotomy and can be performed using IM nails, plates, or external fixators. Multiplanar computer-guided circular external fixator systems are especially suited to the simultaneous correct of multiple planes of deformity and also facilitate lengthening via distraction osteogenesis if needed. The value of the prophylactic treatment of asymptomatic tibial malunion is not yet known. Further information about malunions and their treatment can be found in Chapter 28

Nonunion

Defining nonunion and delayed union is significantly more complicated for tibial diaphyseal fractures than for many other fractures. Whereas the majority of fractures elsewhere in the body will heal in approximately 3 months, this time-point cannot be used for tibial diaphyseal injuries which heal more slowly. Definitions of delayed or nonunion for the tibia vary throughout the literature. The diagnosis of delayed and nonunion is complicated by poor agreement between surgeons on the definitions and criteria for assessing fracture healing.20,125,164 
Approximately 80% of nonoperatively treated closed tibia fractures heal in 20 weeks.173 Operative treatment decreases average healing time irrespective of the fixation method.28,48 For example, Bone et al.28 showed that the mean time to union for closed fractures treated conservatively is approximately 26 weeks compared to 18 weeks in those treated surgically. However, mean time to union following operative treatment is 15.7 to 35.8 weeks for open and closed fractures combined.72,101 
Nonunion rates after conservative management of closed tibia fractures range from 1.1% to 10%,28,188,204 but can be as high as 27% when open fractures are included.101 Operative treatment of closed tibial fractures is associated with nonunion rates ranging from 1% to 8%113,188,199 compared to the operative treatment of open tibial fractures where the nonunion rate varies between 5.3% and 24%.113,117,199 Nonunion rate in open fractures is not increased by preliminary external fixation prior to definitive internal fixation.23 Nonunion or delayed union in uninfected nailed tibial fractures can be successfully treated with exchange nailing.57 The indications and results of this treatment have been detailed by Court-Brown et al.57 
Definitions of delayed healing most commonly involve incomplete healing between 3 and 6 months.67,101,162,167,188 The most commonly used threshold for nonunion of tibia fractures is 6 months.162,169,188,242 Published definitions typically involve lack of complete healing,169,242 pain with weight bearing, and absence of visible fracture callus160 or failure of fracture consolidation188 after 6 months. 
Severe open fractures and compartment syndrome are both associated with a significant delay in time to union.117,193 Chua et al.46 reported that the average time to union was 10.7 months in open tibial fractures and others have reported healing times of up to 42 weeks when both open fracture and compartment syndrome occur simultaneously.117 Similar delays in healing have been reported with ring external fixation for severe combat blast injuries (220 days).122 
An increased risk of delayed or nonunion has been reported with open fractures, deep infection, a postoperative fracture gap, distal fractures, and smoking.117,122,162,193,220 Surgical intervention for the treatment of delayed or nonunion performed earlier than 6 months may result in unnecessary surgery220 and longer delays may be prudent when dealing with more severe open injuries. The diagnosis, investigation, and management of nonunion are discussed in detail in Chapter 27

Deep Infection

Deep infection rates after internal fixation mainly vary with fracture severity. Infection is relatively rare (1.8%) in closed and type I open tibia fractures, but occurs in up to 8% to 16% of type III injuries.31,56,87 Infection is therefore a significant risk for poor outcome in mangled extremities sustained in both civilian and military tibial injuries.31,122 
The most commonly implicated organism is Staphylococcus aureus which has been reported to cause 64% of deep tibial infections,263 but high rates of nosocomial pathogens have also been reported leading some authors to recommend administration of antibiotics with activity against nosocomial agents at the time of definitive soft tissue closure.87 Deep infection after IM nailing has been related to thermal necrosis, inappropriate fasciotomy management, exchange nailing, primary external fixation, the severity of the open fracture, substance abuse, and complications of soft tissue coverage.185 
Treatment of deep infection following IM nailing can be performed with or without nail removal depending on the stage of fracture healing.16,263 However, the presence of a contaminated implant with a biofilm can make clearance of infection significantly more challenging. The use of temporary or permanent antibiotic nails has been described by multiple authors for IM infections of the tibia.78,156,177,191,195 Antibiotic nails are associated with improved fracture stability compared to other antibiotic delivery methods such as spacers and beads. 
Some authors have reported success rates of infection clearance to be as high as 90%, 263 but the rate appears to be lower when the nail is retained than for retention of plates.16 However, challenges associated with treating tibial osteomyelitis should not be underestimated. Patients can present with recurrent infection years after an apparent cure. Severe or recalcitrant infections may be an indication for late amputation.106 Tibial osteomyelitis often requires aggressive bony debridement and saucerization with long-term intravenous antibiotic therapy. Lifelong suppressive oral antibiotic therapy is also given in extreme cases. The investigation, diagnosis, and treatment of orthopedic infections and osteomyelitis are detailed in Chapter 26

Author’s Preferred Method of Treatment

Operative Treatment Algorithm

An algorithm for treating tibial diaphyseal fractures is presented in (Fig. 57-35). 

Fibular Diaphyseal Fracture

Epidemiology

The majority of fibular fractures occur in association with injuries to the tibia or ankle. In their review of 5,953 fractures in adults in 2000 Court-Brown and Caesar51 did not report any isolated fibular diaphyseal fractures, but a review of the data in Chapter 3 shows that in the year that was analyzed the incidence was 7.9/105/year (Table 3-3). Given the rarity of these injuries little is published regarding their frequency, treatment, and outcomes. Oblique or spiral fracture patterns typically seem to occur secondary to twisting injuries,178 whereas comminuted or transverse patterns are caused by a direct impact to the lateral leg or by ballistic injuries. Spontaneous fibular fractures related to forceful muscle contraction have also been reported in athletes.124,248 
The fibula has been estimated to only carry between 7% and 16% of body weight under normal circumstances,88,135 whereas the periarticular portions of the proximal and distal fibula are important for stability of the knee and ankle respectively. The central part of the fibular diaphysis can be removed for use as a vascularized bone graft without significant reduction in leg function.35,137 Therefore, it is not unexpected that isolated fibular diaphyseal fractures are of minimal functional significance. 

Assessment

The clinical and radiographic assessment of a patient with an isolated fibular diaphyseal fracture differs little from that described above for tibia diaphyseal fractures. Since fibular diaphyseal fractures can often occur in conjunction with subtle associated injuries, evaluation should focus on ruling out unstable combinations. Full-length AP and lateral radiographs of the tibia and fibula should be obtained with supplemental imaging of the knee or ankle as needed. Isolated fibula diaphyseal fractures rarely require further work-up with a CT or MRI scan. 
The clinical history should focus on the timing and mechanism of the injury as well as the location and quality of pain. Full physical examination of the leg should be performed including distal neurovascular examination. Tenderness, swelling, ecchymosis, and ligamentous stability of the ankle and knee should be assessed. Fibular fractures caused by a direct blow to the lateral leg can be associated with medial knee ligamentous injury and valgus knee instability, whereas proximal fibula fractures can have associated varus knee stability because of loss of lateral collateral ligament tension. Fibular fractures at all levels can be associated with ankle syndesmosis injuries. Evaluation for signs and symptoms of compartment syndrome should be performed as for all lower extremity injuries. 
Although case reports exist describing compartment syndrome in patients with low-energy fractures of the fibula or ankle these are extremely rare.10,110,262 However, civilian ballistic fractures of the fibula are associated with higher than expected rates of compartment syndrome (11.6%), especially in the proximal one–third.159 Isolated fibular fractures related to industrial or crush injuries are also at higher risk of having an associated compartment syndrome. A high index of suspicion should be maintained when evaluating a patient who has sustained a gunshot-related fibular fracture and care should be taken to specifically rule out compartment syndrome in these patients. 

Special Case: Maisonneuve Fracture

Apparent isolated proximal spiral fibular diaphyseal fractures can be associated with injury to the ankle syndesmosis and the interosseus membrane between the tibia and fibular diaphyses. This injury pattern is known by the eponym Maisonneuve fracture after the French surgeon Jules Maissoneuve who first described it. The lateral injury can be associated with injuries to the medial malleolus or to the medial ligamentous and capsular structures alone. Unlike other fibular diaphyseal fractures, these injuries are highly unstable. Although some authors advocate nonoperative treatment,158 these injuries typically require surgical stabilization of the syndesmosis and medial bony injury.224 For this reason, the radiographic evaluation of all apparent isolated fibula diaphyseal fractures should include AP, lateral, and mortise views of the ipsilateral ankle. External rotation stress views of the ankle may also be helpful in assessment of syndesmosis injury. Further discussion on the treatment of Maisonneuve fractures can be found in Chapter 59

Treatment

The treatment for an isolated fibular diaphyseal fracture is almost always nonoperative and the union rate is very high (Fig. 57-36). In our clinical practice, these injuries are treated with immediate weight bearing as tolerated in a walking boot. The patient is weaned from the boot as comfort allows and allowed to return to work and sports as tolerated. Even in open fractures treated with irrigation and debridement, fixation of the fibula fracture is rarely indicated or performed and nonunions as demonstrated in Figure 57-37 are rare. Nonoperative treatment of isolated fibular diaphyseal fractures is relatively straightforward because the limb’s length, rotation, and ability to bear weight are maintained by the intact tibia. 
Figure 57-36
AP (A) and lateral (B) radiographs of a fibular diaphyseal fracture from a civilian gunshot wound.
 
The fracture healed uneventfully with nonoperative treatment (C and D).
The fracture healed uneventfully with nonoperative treatment (C and D).
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Figure 57-36
AP (A) and lateral (B) radiographs of a fibular diaphyseal fracture from a civilian gunshot wound.
The fracture healed uneventfully with nonoperative treatment (C and D).
The fracture healed uneventfully with nonoperative treatment (C and D).
View Original | Slide (.ppt)
X
Figure 57-37
An open fibular fracture that was treated with debridement and no fixation.
 
This usually results in union or an asymptomatic nonunion, but in this case a symptomatic nonunion developed (A and B) which was successfully treated with plate fixation and bone grafting (C and D).
This usually results in union or an asymptomatic nonunion, but in this case a symptomatic nonunion developed (A and B) which was successfully treated with plate fixation and bone grafting (C and D).
View Original | Slide (.ppt)
Figure 57-37
An open fibular fracture that was treated with debridement and no fixation.
This usually results in union or an asymptomatic nonunion, but in this case a symptomatic nonunion developed (A and B) which was successfully treated with plate fixation and bone grafting (C and D).
This usually results in union or an asymptomatic nonunion, but in this case a symptomatic nonunion developed (A and B) which was successfully treated with plate fixation and bone grafting (C and D).
View Original | Slide (.ppt)
X
There are no published data reporting outcomes following isolated fibular diaphyseal fractures nor is there significant controversy regarding the recommended treatment for these injuries. Published reports and ongoing investigations focused on the treatment of fibular fractures are almost universally concerned with what to do with those that occur in with associated tibial, knee, or ankle injuries. 

Acknowledgment

The authors would like to thank Dori Kelly, MA for assistance with the manuscript. 

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