12.57 Tibial shaft fractures

The tibia is the most commonly fractured long bone in the body. The majority of tibial shaft fractures result from high-energy road traffic and sports-related injuries. They tend to occur in the young, active, and economically productive population. The average age of the patients in a large published series was 37.2 years. Tibial fractures result in a significant number of hospital admissions and surgical operations. The goal of the treatment is to achieve union of the fracture with minimal complications and to help return the patients to the best possible functional state. The current trend is to treat most displaced tibial fractures by internal fixation.

One-third of the tibia is subcutaneous in its entire length on the anteromedial surface. For this reason, it is more susceptible to open fractures than any other long bone. The posterior tibial artery through its nutrient branch is the main source of endosteal blood supply to the tibial shaft. The source of periosteal blood supply is from the anterior tibial artery. The blood flow through an uninjured tibia is centrifugal. After a fracture, the pressure head reverses to a centripetal flow. The periosteal vessels are therefore an important source of blood supply after displaced fracture of the tibia. The importance of preserving the soft tissue envelope at surgical fixation of the tibia cannot be overemphasized.

The tibial diaphysis is triangular in its cross-section with an anteriorly directed apex. The majority of the diaphyseal medullary canal is round and symmetric, a configuration amenable to intramedullary nailing. The medullary canal has a narrow isthmus in the middle third with a proximal and distal metaphyseal flares. An intramedullary nail used for either proximal or distal fractures has minimal cortical purchase in these locations, which contributes to high rates of malunion when nailing proximal or distal fractures.

The soft tissue envelope covering the tibia is divided by the interosseous membrane and the intermuscular septa into four closed osteofascial compartments (Figure 12.57.1). The anterior compartment contains tibialis anterior, extensor hallucis longus, extensor digitorum communis, and anterior tibial vessels. The deep peroneal nerve also courses through this compartment and supplies an autonomous sensory zone on the dorsum of the foot between the first and second toes. In the proximal third of the anterior compartment, the neurovascular bundle lies on the interosseous membrane and courses more anteriorly as it proceeds distally.

The lateral compartment envelops the fibula and contains the peroneus brevis and longus muscles. The common peroneal nerve runs under the peroneus longus, winds round the neck of the fibula and divides into superficial and deep branches. The superficial peroneal nerve lies within the lateral compartment.

The superficial posterior compartment contains gastrocnemius and soleus muscles and the sural nerve. The deep posterior compartment contains the tibialis posterior, flexor hallucis longus and flexor digitorum, and posterior tibial vessels and nerve. Each compartment contains a nerve with its own autonomous area of supply. Careful assessment of sensations in these autonomous zones may aid in diagnosing involvement of that particular compartment.

The thick interosseous membrane connects the posterolaterally oriented fibula to the tibia. The fibula also articulates with the tibia at the proximal and distal tibiofibular joints. The fibres of the interosseous membrane run downwards and laterally and are torn in major torsional fractures of the tibia and fibula.

The anterior tibial artery enters the anterior compartment at the superior margins of the interosseous membrane and is at risk of injury with proximal tibial fractures and proximal tibiofibular joint dislocations. The common peroneal nerve is also at risk with these fracture patterns, especially with fibular neck fractures. It is also vulnerable to direct blows or undue pressure from cast, splints, or constricting wraps.

The distal third of the tibial shaft has particularly poor soft tissue cover. The majority of the soft tissue in this area is tendinous and thus the extraosseous blood supply is minimal. The nutrient artery narrows as it reaches the distal third of the shaft and anastomoses with the distal metaphyseal endosteal vessels. If a displaced fracture occurs in this region, this small nutrient artery is often damaged resulting in loss of endosteal blood supply downstream from the site of injury. This lack of intramedullary blood supply combined with tenuous soft tissue envelope may account for delayed unions and non-unions, which occur frequently following high-energy distal-third tibial shaft fractures.

The tibial shaft fractures are most commonly associated with open wounds and varying degrees of soft tissue injury. The degree and the extent of the soft tissue injury dictate the functional outcome. Fractures that present with high-grade soft tissue injuries, either open or closed, usually result from high-energy trauma. Up to 30% of tibial fractures occur in multiply injured patients. When evaluating these fractures the surgeon should carefully examine and record the neurovascular status of the limb and look for the presence of an associated compartment syndrome. Diligent clinical examination and compartment pressure monitoring in unresponsive or unconscious patients is essential to diagnose this devastating complication.

High-energy tibial fractures may also be associated with ipsilateral knee dislocations or femoral shaft fractures. The so-called ‘floating-knee’ injury (ipsilateral tibial and femoral fractures) can also occur in concert with ligamentous disruption about the knee. In addition, fractures and dislocations about the ankle may also occur in association with tibial shaft fractures, and therefore routine radiographs of the tibia should always include the knee and ankle.

Fractures at the diaphyseal–metaphyseal junction should be carefully evaluated for any extension into the articular surfaces. These fracture lines may be subtle and not readily apparent on standard anteroposterior (AP) and lateral radiographs. Preoperative computed tomography (CT) scanning may be helpful to identify an undisplaced fracture line, and assists in preventing displacement of such occult fracture during surgical intervention.

High-energy tibial shaft fractures are also associated with vascular injury. High index of suspicion is essential, particularly when evaluating tibial fractures in polytrauma patients. Early diagnosis and urgent involvement of vascular surgeon is essential for limb saving.

Tibial shaft fractures associated with low-energy injury usually have little associated soft tissue injury and the interosseous membrane is intact and provides some degree of inherent stability, which may allow for conservative management.

Falls from a great height, direct blows, and motor vehicle-related injuries are high-energy mechanisms, which impart more kinetic energy in producing a fracture. The fracture patterns reflect this energy expenditure and have primarily a transverse orientation that may be accompanied by butterfly fragments or comminution, depending on the magnitude of the bending force. Fractures produced by crushing injuries or high-velocity gunshot projectiles are often the most severe. The fracture patterns are highly comminuted and may be segmental. The soft tissue component of the injury may be vastly underestimated, especially with crushing injuries, which often present as a closed de-gloving type of injury.

The level of the fibular fracture may indicate the type of injury mechanism, i.e. direct injury results in a fracture of both tibia and fibula at the same level, whereas fractures at a different level result from indirect forces or rotation.

‘Stress’ fractures are caused by repetitive stress, particularly in endurance athletes. Stress fracture management should take into consideration the injury site (low risk vs high risk), grade (extent of microdamage accumulation), and the individual’s competitive situation. This separation into two groups is based on the biomechanical environment and natural history of the fracture. The anterior tibial shaft stress fractures are considered high-risk fractures. The undertreatment of high-risk stress fractures can lead to catastrophic bone failure and/or prolonged loss of playing time. Overtreatment of low-risk stress fractures can result in unnecessary loss of physical conditioning and activity.

Tibial fractures have been traditionally described in terms of their anatomical location—proximal, mid, or distal third fractures. The amount of initial displacement is recorded as a percentage of the diameter of the bone. The fracture pattern is described as spiral, oblique, or transverse with further description of the presence and extent of comminution, which correlates with absorbed energy and is an indicator of fracture severity.

The AO/Orthopaedic Trauma Association (OTA) comprehensive classification system (Figure 12.57.2) is commonly used to classify tibial fractures. This classification scheme does not account for the degree of soft tissue injury.

Unstable fractures are less conducive to non-operative management. Severe soft tissue injury, extension into or involvement of either the proximal or distal tibial articular surfaces, 100% initial displacement of the fracture, comminution of more than 50% of the bone circumference, and transverse fracture orientation are all hallmarks of an unstable fracture pattern. The presence of a fibular fracture in association with a tibial fracture at the same level often indicates an unstable injury from a high-energy mechanism (Figure 12.57.3).

Critical review of comparative studies reveals that non-operative treatment of high-energy tibial fractures is associated with high prevalence of malunion, stiffness of the knee and ankle joints, and poor functional outcome. Therefore classification of tibial shaft fractures into stable and unstable types may be more practical and useful when considering treatment options.

Determining the mechanism of injury is critical during the initial stages of patient evaluation. A cooperative conscious patient who has had a minor slip-and-fall accident is managed differently from an unconscious victim of a motor vehicle versus pedestrian accident. In the face of a high-energy injury, the examiner will not only focus on the tibial fracture, but will evaluate the patient for other associated injuries

The time between injury and evaluation is important, especially for fractures associated with open wounds, arterial disruption, and compartment syndromes. The patient’s previous medical history should be noted, in particular conditions causing immunocompromise. Social history including occupation, smoking, drug and alcohol use all affects treatment decisions and the outcome.

High-energy tibial shaft fractures in multiply injured patients should be managed as per Advanced Trauma life support (ATLS®) guidelines. Deformed limbs should be gently splinted in relatively straight alignment. A visual inspection should reveal any obvious open wounds or exposed bone.

Lacerations, puncture wounds, and abrasions should not be probed or rigorously explored. The presence of such wounds in the vicinity of a fracture is considered to be open fracture. The vascular status should be documented by assessing the presence or absence of palpable pedal pulses, capillary refill, skin colour, and skin temperature.

Loss of motor function and sensation to the foot is a sign of nerve injury or significant limb ischemia. Neurological examination should evaluate the tibial and peroneal nerves and limb ischemia should be ruled out as the cause of any neurologic dysfunction.

Compartment syndrome is common in all tibial fractures and should be assessed on a regular basis.

Mangled extremity severity score (MESS) or Ganga Hospital Injury severity score can be used to assess the open tibial shaft fractures. Ganga Hospital Injury severity score has been shown to be more sensitive and specific and help in determining treatment strategies (see Further reading).

Once the leg is splinted, an AP and lateral radiographs should be obtained for all tibias in which a fracture is suspected. The knee and ankle should be included to detect fracture–dislocations or articular extension.

Cone-down or magnification spot radiographs or CT scans are useful to evaluate subtle fracture lines, callus formation, or stress fractures.

CT scanning has been shown to be useful to determine the adequacy of fracture reduction, including rotational alignment as well as limb length. Additionally, CT imaging has been shown to be useful for those transitional injuries (junction of diaphysis and metaphysis) that present with extension into the articular regions. CT scanning has now replaced plain linear tomography for the routine evaluation of non-unions.

If diminished pulses are present, the ankle pressure index has been shown to correlate highly with the presence or absence of arterial disruption. Doppler-assisted blood pressure is obtained at the ankle and brachial arteries. A ratio of ankle to brachial systolic pressure below 0.9 indicates a probable arterial injury.

Arteriography is indicated when arterial disruption is suspected. Direct compartment pressure monitoring is routinely performed, especially when patients are unable to cooperate with the physical examination or where the surgeon has a high index of suspicion.

Diagnostic ultrasound is used to assess the early presence of callus and is predictive of fracture healing in situations where hardware, such as intramedullary nails and complex external fixators, occlude adequate routine radiographic evaluation.

All closed fractures are immobilized initially with an above the knee splint. Appropriate imaging is obtained in order to plan definitive treatment.

Non operative treatment in the form of casting should be considered in all isolated tibial fractures which are either stable or undisplaced.

Fractures with stable configurations as seen on the initial radiographs merit treatment by closed reduction and application of a long leg cast. Careful and regular follow-up with serial weekly radiographs is essential to detect secondary displacement and angulation within the cast. Any residual angulation can be corrected to an acceptable degree by wedging of the plaster cast. A functional cast brace (patellar tendon bearing cast) and early weight bearing is encouraged when the fracture becomes ‘sticky’.

If wide displacement or significant shortening is seen on initial screening radiographs, it is unlikely that even an anatomical initial reduction will be maintained throughout the course of treatment found that there was no difference between the amount of shortening seen on the initial versus final radiograph in over 80% of cases. There is experimental data to indicate that as the level of deformity approaches the distal one-third of the tibia, even a small degree of malalignment can affect the loading of the ankle joint. Most surgeons strive to achieve alignment with less than 5 degrees of angulation in any plane and 10 degrees of rotation. However, these values for acceptable reduction are not based on any hard data and good long term function has been reported with angulation of up to 10–15 degrees.

Excellent results have been reported with the use of closed reduction, casting, and subsequent functional bracing in over 1000 closed tibial fractures. Initial treatment was with closed reduction and long leg casting. Weight-bearing was permitted in the cast as tolerated. If length and alignment were acceptable and pain and swelling had subsided, patients were then converted to a fracture brace at an average of 3.7 weeks. In 95% of the fractures, the final amount of shortening was up to 12mm (average 4.28mm). Final angular deformity was less than 6 degrees in 90% of patients. In this series, the rate of non-union was less than 1.1%. This form of treatment was recommended for those closed injuries with no more than 15mm of initial shortening or stably reduced transverse fractures (Figure 12.57.4). Tibial fractures with an intact fibula were a relative contraindication to functional bracing because significant varus deformity (more than 5 degrees) was more likely to develop.

Other authors have noted the hazards of treating tibial shaft fractures with intact fibulae. Delayed or non-union was reported in 26% of adult patients with fractured tibia with intact fibula treated with cast immobilization. Sixty-one per cent experienced one or more complications during conservative treatment. The intact fibula prohibits axial loading of the tibia and therefore decreases the weight-bearing axial stimulus to healing (Figure 12.57.5).

A prospective randomized study has compared the results of application of the patellar ligament-bearing cast with those of operative treatment with closed interlocking intramedullary nailing. This study revealed longer healing times and increased residual angular deformity, limb shortening, and disability in the group treated conservatively. Hindfoot stiffness occurred in 15% of the patients treated in casts. Twenty-two per cent of patients in the closed-treatment group eventually underwent operative intervention for failure to maintain adequate reduction.

There are numerous limitations to the treatment with casts and functional braces. Loss of reduction as well as a residual limb length discrepancy is common. Prolonged treatment with a cast may result in excessive stiffness of the knee, ankle, hindfoot, or all three, which may require extended rehabilitation to regain the patient’s pre-injury level of function. Even with earlier weight-bearing, residual joint stiffness has been reported in approximately 20–30% of patients treated conservatively.

Fractures that are associated with serious soft tissue compromise are not easily treated conservatively. Effective casting or bracing is highly dependent on the ability of the soft tissues to tolerate a well-contoured device. Limb oedema, contusions, abrasions, etc., may inhibit the early application of sufficient external support. Failure and complications of non-operative treatment indicate that there are many tibial fractures that benefit from operative treatment.

Some studies have suggested the benefit of pulsed, low-intensity ultrasound in shortening the time to healing in non operative treatment.

Unstable tibial shaft fractures, fractures with associated ipsilateral lower limb fractures, tibial shaft fractures in multiply injured patients, and fractures extending to either knee or ankle joints generally require surgical stabilization. Open tibial shaft fractures and fractures associated with neurovascular injury or impending compartment syndrome are dealt with emergency surgical management. Surgery should also be considered in fractures where attempts at non-operative management have failed and when secondary displacement and angulation occurs in follow-up radiographs. Occasionally, operative intervention is recommended for non-compliant patients. The goals of operative treatment should be to restore the length and alignment of the limb, stable fixation to allow early mobilization, and rapid return to pre-injury function with no or minimal complications.

Locked intramedullary nailing has become the ‘gold standard’ treatment for most of the unstable tibial diaphyseal fractures. Interlocking intramedullary nails maintain axial alignment and provide rotational stability. The nails are either statically or dynamically locked depending on fracture configuration. The new-generation intramedullary nails that allow placement of distal locking screws near the end of the nail have helped extend the indications for nailing to metaphyseal fractures even with intra-articular extension (Figure 12.57.6). The current literature indicates high rates of fracture union in closed tibial diaphyseal fracture treated with intramedullary nailing.

Intramedullary nail insertion has traditionally involved the use of a fracture table to effect reduction. The time necessary for a fracture table set-up and correct positioning of the patient may be prohibitive when treating a multiply injured patient. In addition, complications such as nerve palsy and compartment syndrome have been related to the use of excessive traction.

Techniques have been developed to achieve and maintain reduction during intramedullary nailing when operating on a standard radiolucent orthopaedic table. Devices such as the femoral distractor or a temporary external fixator can serve this purpose. Accurate alignment without traction-related complications has been reported with the use of these reduction techniques (Figure 12.57.7).

The correct placement of the entry portal is an important technical consideration. It must be placed centrally in line with the medullary canal. Because of the wide discrepancy in tibial morphology, the centre of the tibial canal may be variable in its relationship to the patella and patellar tendon. The actual insertion site may be located lateral, medial, or directly posterior to the patellar tendon and should be verified with an image intensifier. Failure to place the entry portal centrally will result in varus or valgus malalignment. Entry portal can be placed either on the medial aspect of the patellar tendon or through a transpatellar tendon approach. Anterior knee pain is a common problem following intramedullary nailing with some reports showing an incidence of greater than 50%. In those patients whose work involves kneeling, consideration should be given to alternative methods of treatment. The relationship of the approach to postoperative anterior knee pain has been an area of controversy. However, recent randomized control studies have not demonstrated any correlation between the approach and anterior knee pain.

The major concern with operative management of tibial shaft fractures is the additional disruption of the blood supply caused by the operative procedure itself. Reaming the medullary canal devasularizes the inner two-thirds of the cortex, rendering the endosteal surface of the cortex ischaemic. Devascularization is reduced to one-third when the nail is inserted without reaming. Additional devascularization occurs through the entire cortex at the region of the fracture site. However, the relative avascularity is temporary and the medullary blood vessels regenerate after a relatively short time. Although reaming disrupts the blood flow to the cortex, reaming induces a sixfold increase in the periosteal blood flow. The periosteal blood supply compensates initially for the disruption of the intramedullary blood supply. Disruption of the intramedullary blood supply is usually not a concern for closed injuries that have a competent soft tissue envelope. However, in the treatment of open or high-energy fractures where the soft tissues including the periosteum may be completely disrupted, medullary reaming could further devascularize the fracture site.

Reaming during intramedullary nailing has biomechanical and biological advantages. Reaming allows insertion of a larger-diameter nail hence increasing its load sharing capacity. The biological effect of the increased periosteal vascularity is well known. Moreover, reaming has been shown to have faster rates of union and reduce the incidence of non-union.

Unreamed nailing has the advantage of being less time consuming offers advantages in the emergency setting for stabilizing polytrauma patients. Unreamed nails when used as a definitive method of fixation have a reduced incidence of reoperations, superficial infections, and malunions, when compared with external fixators.

Reaming allows the insertion of a bigger nail and locking bolts. Fatigue failure of small-diameter unreamed nails and/or interlocking screws has been reported in many series if union of the fracture is not achieved early. However failure of interlocking screws in some cases may facilitate fracture healing by autodynamization (Figure 12.57.8).

A recent large multicentre randomized study involving 1226 patients has compared reamed versus unreamed intramedullary nails. The study suggested that reamed nails offer a benefit in closed fractures with regard to further events (surgical intervention or autodynamization) within 1 year. Most of the difference was attributed to an excess of dynamizations (both surgical and autodynamization) in the unreamed group. A non-significant increase in number of postoperative events was noted in open fractures treated with a reamed nail. The authors note that overall the number of events for this study was less than previous randomized controlled trials. Previous grade II evidence, randomized controlled trials have shown that reamed nails have an advantage over unreamed nails with regard to rate of union and non-union.

Compartment syndrome has been reported following intramedullary nailing of the tibia. It is thought to be multifactorial and could be associated with excessive traction on the limb, limb tourniquet, and extravasation of the reamings. The type of anaesthesia and the postoperative analgesic regimen has been attributed to a delay in diagnosis of compartment syndrome.

The indications for intramedullary nailing have been extended to include very proximal and distal metaphyseal fractures. Nailing of proximal one-third tibial metaphyseal fractures are fraught with potential complications, primarily valgus malunion, anterior translation, and apex anterior deformities of the proximal segment. Review of proximal shaft fractures treated with intramedullary nailing found that 84% of these patients had residual angulation of more than 5 degrees and that 25% lost proximal fixation primarily related to the placement of a single proximal locking screw. Non-union rates have been reported as high as 26 %.

Surgical errors consisting of a medialized nail entry portal and a posterior and laterally directed nail insertion angle, all contribute to the malalignment. Suggested techniques for the successful nailing of proximal shaft fractures include a lateral entry portal, use of Poller’s ‘blocking screws’ and adjunctive antiglide plates located at the level of the fracture apex. This small plate serves to prevent translation and apex anterior angulation of the proximal fragment (Figure 12.57.9).

Contiguous ipsilateral distal intra-articular fracture extension and non-contiguous ipsilateral ankle fractures in concert with diaphyseal injuries can be successfully treated with intramedullary nailing techniques. Distal articular extension displaced less than 5mm, may be treated with mini open reduction and internal fixation of the articular component followed by intramedullary nailing. Non-contiguous ipsilateral ankle fractures may be treated with fixation of the ankle prior to or after insertion of the intramedullary nail. Technically, it is important to keep the articular lag screws in subchondral bone to allow room for nail insertion. It is also important to secure alignment of the entire fracture construct prior to nail insertion using a two-pin fixator, a femoral distractor, or calcaneal pin traction (Fig. 10).

The traditional open reduction and internal fixation with plates and screws is not a preferred option for high-energy tibial shaft fractures. This method of fixation requires extensile exposure and additional soft tissue stripping resulting in secondary devascularization of the soft tissues and fracture fragments. Reports in the literature quote high rates of complications such as wound break down, infection, aseptic and septic non-union of the fracture.

With the advent of minimally invasive plate osteosynthesis (MIPO) using locking plates, plating has regained its popularity. This technique utilizes the principles of biological fixation. The fracture is realigned in all planes utilizing indirect reduction techniques. The adequacy of reduction and the plate position are confirmed by image intensifier. Depending upon the personality of the fracture the definitive fixation is planned. In simpler fracture configuration (AO/OTA 32A and B) primary fracture fixation is carried out by using lag screws through small incisions. A precontoured plate is then tunnelled extraperiostally along the medial aspect of the tibia through a small skin incision, distant from the zone of injury. This plate is then fixed with locking screws percutaneously through stab incisions and acts as a neutralization device. In complex fractures (AO/OTA 32C) only MIPO plating is performed without any attempt at direct reduction of the fracture fragments. Here the plate acts as a bridge bypassing the area of comminution whilst stabilizing the fracture (Figure 12.57.11). The MIPO technique can also be carried out with usage of low-profile standard plates in non-osteoporotic bones. The main advantage of MIPO is that the fracture haematoma and the soft tissue envelope around the fracture are not disturbed. This method of fixation results in secondary bone healing by callus response. Review of recent literature confirms the efficacy of this fixation method and encourages its usage. A recent comparative study has shown the that plate fixation in distal tibial shaft fractures (4–11cm above the plafond) produced better rate of union as compared to intramedullary nails. Complications such as delayed union, malunion, and secondary procedures were more frequent after nailing.

Indications for plate osteosynthesis has also extended to proximal tibial shaft fractures with or without intra-articular extension with the advent of angular stable device such as less invasive stabilization system (LISS).

External fixation is carried out for both emergent and definitive management of tibial shaft fractures. In the initial management of open tibial fractures and in tibial fractures associated with polytrauma, skeletal stabilization is achieved in a rapid manner by using an external fixator assembly. This temporizing device is assembled with use of multiple Schanz pins inserted into the major fragments preferably outside the zone of injury. Such fixation allows wound care and subsequent reconstruction of the soft tissue envelope in open fractures. External fixation in multiply injured patients allows early mobilization and better nursing care and shown to have reduced mortality and morbidity. These devices can be exchanged to intramedullary nails within 2 weeks of index operation (Figure 12.57.12).

The use of an intramedullary nail following failed external fixation has demonstrated variable results. In general, if the external fixator is in place for less than 1–2 weeks, conversion to an intramedullary nail appears to have a low rate of associated infection. However, as the time period of external fixation increases, the risk of infection with immediate exchange to an intramedullary nail increases dramatically. Infection rates as high as 50% have been reported for patients who have had this immediate exchange. If this type of treatment is contemplated, patients who have a latency period of more than 1 month following removal of the external fixator and prior to intramedullary nailing have a marked decrease in their rates of infection as well as increased rates of union. Although a delay of several weeks or months between fixator removal and nailing may decrease the risk of infection, there remains some elevated risk. Deep infection rates of 17% have been demonstrated in open tibial fractures treated with secondary intramedullary nailing (IMN) after external fixation (EF). All deep infections occurred in Gustilo type III fractures (22.6%, 7/31).They concluded that early skin closure within 1 week is the most important factor in preventing deep infections when treating open tibial fractures with secondary IMN after EF.

The external fixation techniques have been successfully used for definitive management of closed tibial fractures. External fixation does not cause additional disruption of the soft tissue envelope or the vascularity of the fracture fragments or other osseous structures. Axial and rotational stability can be achieved by using ring fixators, monoplanar or multiplanar external fixator constructs. In high-energy fractures, particularly with fractures associated with bone loss, an external fixator is used not only to acutely stabilize the fracture but also to aid in fracture union and bone transportation in restoring bone loss (Figure 12.57.13).

With other fracture fixation methods, additional bracing or casting is often necessary to maintain a stable construct. With rigid internal fixation, primary bone healing demands that weight-bearing be delayed until full reconstitution of the cortex has been completed. Weight-bearing stimulates fracture healing. A major advantage of using adjustable external fixators is the ability to load the limb actively. Even in the most comminuted fractures, patients can begin at least partial weight bearing immediately after surgery without any supplementary casts or braces. Most frames allow for dynamization restoring cortical contact, achieving a more stable fracture construct, and decreasing the pin/bone stresses. By subsequently disassembling external fixation frames, progressive dynamization leads to a less stiff frame, which facilitates secondary callus formation and bone healing.

In general, closed fractures heal with external fixation on average within 4 months. The rates of non-union have been reported as high as 5% for closed fractures. In most series, it was felt that early dynamization or gradual frame disassembly should be performed in an effort to load the fracture and promote secondary callus formation. The most common complication was minor pin tract infection, which is seen in the majority of patients. Major pin-site infections requiring secondary surgical procedures were noted to be less than 5% in most series and none appeared to have led to any serious sequelae. Most authors agree that although external fixation requires closer patient monitoring and pin care, external fixation is a safe and reliable device for treating tibial shaft fractures.

The tibial shaft is the most common site for open fractures of the long bones. Most of the open tibial shaft fractures occur in young and active population as a result of high-energy injury and are particularly associated with road traffic collisions. The standard treatment consists of: early debridement of the open wound; thorough surgical toilet; antibiotics; stabilization of the fracture; adequate and early soft tissue coverage; successful reconstruction of the limb and subsequent fracture healing (see Chapter 12.7).

It has been shown that definitive stabilization by reamed intramedullary nail for low-grade open fractures produces satisfactory outcomes. The infection rate has been shown to be less than 3% for grade I open fractures. However, when reamed intramedullary nailing was performed on severe open fractures (grade IIIB), the rate of infection has previously been reported as high as 23%. Open tibial fractures stabilized with unreamed interlocking nails have reported rates of union greater than 96%, a low rate of malunion, and rates of infection in the range of 4–8% for grade IIIB fractures. More recent studies have shown that results of reamed nailing for grade IIIB fractures are comparable to unreamed nails in terms of union rates and complications.

Randomized prospective studies have been performed comparing the results of unreamed interlocking nails with external fixation for the treatment of open fractures. All of these studies demonstrated similar rates of infection and non-union for both treatment modalities, but a significantly higher prevalence of malunion with external fixation. The major advantage to intramedullary nailing is that it facilitates soft-tissue procedures, and delayed bone and skin grafting without the hindrance of an external fixation device. Recent evidence supports the usage of unreamed solid nails in stabilizing open grade IIIb and IIIc fractures.

External fixation is still considered a good choice for highly contaminated open fractures or fractures associated with prolonged delay prior to operative intervention (Figure 12.57.14). Rates of infection with external fixation for grade III injures has ranged from 4–7%. This relatively low rate of infection has been offset by the increased rate of malunion that has been reported when treating open tibial shaft fractures to completion with an external fixator.

When the tibial shaft fractures are treated conservatively, early weight bearing is encouraged. As soon as the patient is comfortable in the long leg cast and the swelling has subsided, conversion to a patellar tendon bearing cast is usually indicated. This will occur at 3–6 weeks. Following a short period of patellar tendon-bearing cast immobilization, the patient should be converted to a total-contact orthoses and full weight bearing encouraged.

The management of fractures treated with intramedullary nails can be varied depending on the fracture pattern, and configuration and morphology of the nail used. In general, reamed medullary nails are larger diameter and have bigger locking screws. When large locking screws are used the patient may be considered for early weight bearing. Regardless of the size of the nail and screws, if the fracture pattern is axially stable, the patient is allowed to progress to, at least, 50% weight bearing immediately after surgery. For fracture patterns with comminution or segmental injuries, which are axially unstable, then non-weight bearing should be maintained for at least 6 weeks. For the axially stable fracture patterns, full weight bearing can be initiated once progressive callus is seen on radiograph. For the axially unstable injuries, delaying full weight bearing for at least 3 months may need to be considered. Throughout the course of treatment, fracture healing should be monitored in order to avoid fatigue failure of the nail or locking bolts, especially for small nails. Early intervention is necessary to avoid these complications.

For tibial fractures treated with plate fixation, patients are usually immobilized either in a removable splint or cast until the incision heals. Soft tissue concerns are paramount in the early postoperative period to ensure that the wound heals without complications. Because the plate is a load-bearing device, weight bearing must be delayed. For the first 6–8 weeks, patients should be maintained as strict non-weight bearing, and if patient compliance is an issue, then long leg casting should be maintained with the knee flexed in order to prevent unrestricted weight-bearing. If the patient is reliable, then toe-touch non-weight bearing can be initiated immediately. In approximately 6–8 weeks when early cortical bridging and diminution of the fracture line is seen on radiograph, the patient can be advanced to 50% partial weight bearing. This may sometimes need to be augmented with a patellar tendon bearing orthosis or short-leg walking cast. When recorticalization is complete, the patient may progress to full unrestricted weight-bearing at approximately 4–6 months.

Postoperative management of external fixation is often problematic with respect to the management of the pin sites. In the case of circular small-wire external fixators for extra-articular injuries, full weight bearing may be initiated immediately after surgery. For most monolateral frames with dynamization capabilities, once early callus formation is noted the frames can be dynamized or sequentially disassembled to transfer more of the load to the fracture site itself and promote axial micromotion to facilitate healing. Following the removal of the external fixation device, a short period of orthotic management is required.

Regardless of the methodology of fracture fixation utilized, physical therapy should be initiated immediately to maintain knee and ankle range of motion. In cases of severe soft tissue injury and open fractures treated with external fixation, the foot should often be included in the fixation frame to avoid progressive equinus contracture due to the long period of non-weight bearing status necessary. Physical therapy should concentrate on maintaining a plantigrade foot. This is best established by allowing the patient to place the foot on the ground. This allows the foot to be placed in a plantigrade position while still avoiding full loading activities.

Complications of tibial shaft fractures include compartment syndrome, non-union, malunion, and infection. Arrest of the bony repair process with the formation of intervening fibrous or cartilaginous tissue is defined as a non-union. The usual time frame for this diagnosis is 6–8 months. Non-union most commonly occurs following open tibial shaft fractures, which have been treated with external fixation.

Secondary procedures have been advocated to promote union and avoid hardware failure in cases where delayed healing is likely. Nail dynamization, exchanged reamed nailing, open bone grafting, and fibular osteotomy all have been used alone or in combination to promote union (Figure 12.57.15).

Exchange nailing is a standard method of treatment for aseptic non-union. Progressive reaming until bone is seen on the flute of the reamer and exchange to a larger-diameter nail is recommended. Such nailing offers the unique biomechanical advantages of an intramedullary device, together with the osteoinductive stimulus of the by-products of reaming. A larger diameter nail also allows early weight-bearing and active rehabilitation. Following intervention it can be expected that 90% of non-unions will be united at an average of 3.5 months.

There is no consensus about the definition of malunion. The accepted arbitrary values for tibial shaft malunion are more than 10 degrees of angulation in sagittal plane, more than 5 degrees in coronal plane, and greater than 10 degrees of rotational malalignment. However, long-term follow-up studies have failed to establish any correlation between malunion and development of subsequent arthritis of ankle or subtalar joints. Established malunion is treated by corrective osteotomy along with refixation either by intramedullary or extramedullary devices.

Post-traumatic osteomyelitis occurs either after open fractures or surgically treated closed fractures. Treatment of an infected fracture utilizes a staged reconstruction protocol. If there is wound breakdown along with superficial infection, implants should be left in place in order to provide a stable fracture configuration. If the implant provides no stability at the time of debridement, all hardware should be removed. Furthermore, at debridement, all necrotic bone should be excised. Stabilization is necessary and is usually provided by external fixation. Serial debridements may be necessary to obtain a biologically sound wound. Dead-space is managed by using antibiotic beads or open-wound packing. Eventual soft tissue closure may be achieved with rotational flap or free-flap or coverage. Antibiotics directed at deep culture specimens should be administered for 4–6 weeks. Following resolution of the infection and healing of the soft tissues, delayed skeletal reconstruction is performed.

There are several well-accepted methods of treatment of tibial fractures. Orthopaedic surgeons tend to be preoccupied with the mechanics of fracture management and specifically with the implants to be utilized. However, there is no substitute for a thorough understanding of the so-called ‘personality’ of the fracture to help determine the best choice in treatment. Conservative management utilizing casts and functional orthoses is indicated for minimally displaced and axially stable fractures. Prospective studies indicate that intramedullary nailing with and without reaming both produce excellent results with high rates of union and low rates of occult infection. Reamed nailing has been shown to have shorter times to union and lower non union rates. Unstable closed fractures and open grades I, II, and IIIA fractures can be safely treated with reamed nails. External fixation, reamed and unreamed nails can be considered in grade IIIB fractures.

High-energy tibial shaft fractures pose a therapeutic challenge to the treating health-care professionals. These injuries are often seen in the context of polytrauma. Astute decision-making, collaboration with plastic surgeons, timely surgical intervention, and respect for soft tissue envelope of the leg will result in successful functional outcome. The recent development of minimally invasive fracture surgery will no doubt have a positive impact on the management of the tibial shaft fractures.