Closed Tibial Shaft Fractures

Introduction

Closed tibial fractures are the most common long bone fractures, resulting in 77,000 hospitalizations and 825,000 office visits per year.¹  Data indicate a bimodal distribution, with sports-related injuries causing most fractures in adolescent males.  A second, smaller peak occurs in patients over 80 years old, whose injuries likely resulted from a simple fall.  While intramedullary (IM) fixation has become the mainstay of treatment, management of diaphyseal fractures of the tibia still presents a challenge to the orthopaedic surgeon.

Structure and Function

The tibia is recognized as the strongest weight-bearing bone, receiving up to 4.7 times body weight of axial force during walking.²  Soft tissue injury and compartment syndrome often complicate closed tibial shaft fractures due to the bone's subcutaneous location and surrounding tight osteofascial compartments.  Blood supply to the tibial shaft is primarily derived from the nutrient artery, a branch of the posterior tibial artery.  The anterior tibial artery, which gives rise to several periosteal vessels, is often damaged as it passes through a hiatus in the interosseus membrane.

Diagnosis and Classification

There is no role for CT in the diagnosis of tibial shaft fractures, unless articular extension is suspected.  The most commonly used classification system is the AO/OTA classification, which designates the region of the bone, a letter (A, B, C) for the severity of the fracture, and a number (1, 2, 3) for increasing complexity and comminution.³  Tscherne and Gotzen developed a classification system to evaluate soft tissue injury in closed tibial shaft fractures.  Injuries range from type 0, with minimal soft tissue injury and a simple fracture, to type 3, which consists of severe muscle injury, compartment syndrome, and a complex fracture.⁴

Treatment

There is no conclusive evidence in the literature as to the optimal management of non-displaced tibial shaft fractures. While most traumatologists prefer operative intramedullary fixation, cast immobilization is a viable alternative for fractures with minimal soft tissue injury (Tscherne and Gotzen types 0 and 1), angulation, rotation, and shortening (< 1cm).^5,6  A long leg weight-bearing cast should be molded with the knee in 10-15 degrees of flexion.  After radiographical evidence of union, the patient should be transitioned to a patellar tendon-bearing cast or brace to prevent ankle stiffness.

Interlocking IM nails are the preferred implant for operative management of displaced tibial shaft fractures.⁷  For displaced tibial fractures, or those with significant soft tissue injuries, multiple studies ^8,9 have demonstrated that intramedullary fixation results in quicker union, less malunion, and faster return to work than closed management.  While the debate over reaming has generated much controversy among orthopaedic surgeons, Bhandari et al recently reported that reamed IM nails resulted in a lower re-operation rate than unreamed nails in closed tibial shaft fractures.¹⁰  Reaming provides better endosteal contact and permits insertion of a larger nail, thus reducing the risk of fatigue failure.

Because of the lack of soft tissue covering the tibia, internal fixation with plates is generally not recommended.  Plating is a reasonable treatment option for management of tibial shaft nonunions.  External fixation is an acceptable alternative to IM nails in patients with severe soft tissue injury, articular extension of the fracture, or damage control surgery in polytrauma.¹¹  If converting to an  IM nail, the procedure should be done as soon as possible, preferably within 4 weeks to minimize the likelihood of pin sepsis.¹²

Outcome

Complications of closed tibial shaft fractures include:

• Soft tissue damage
• Vascular injury
• Compartment syndrome
• Fat embolism
• Infection (rare)

While IM fixation is the standard of care and predictably provides successful outcomes, it can be complicated by nonunion, malunion, anterior knee pain, infection, and implant failure, especially in unreamed nails.  Interestingly, the presence of an intact fibula has been associated with more rapid union, yet is associated with an increased incidence of malunion.⁶

Fractures of the proximal third of the tibia present a unique challenge to the orthopaedic surgeon.  Malunion is an unfortunate consequence of nailing these fractures, occurring in 84% of patients in one case series,¹³ versus up to 37% of all closed tibial shaft fractures.¹⁴  Careful selection of a lateral starting point can help prevent a valgus deformity while the use of blocking screws can prevent posterior displacement of the fracture.^5,15

The prognosis depends on the fracture type and location, extent of soft tissue damage, presence or absence of infection, and medical comorbities.  For low-energy closed tibial fractures, most achieve union by 10-13 weeks.  High-energy fractures can often require as much as 20 weeks time to union.¹⁶

Pearls

• Intramedullary nailing is the mainstay of treatment for closed tibial shaft fractures, consistently providing high rates of union with few complications.
• Cast immobilization of non-displaced fractures often requires as much technical skill as placing an IM nail. Care should be taking to avoid a hyperextension deformity when casting, and frequent radiographic follow-up is essential.
• Reamed IM nailing appears to offer a benefit over unreamed nails for closed fractures, but not for open fractures.
• Give the fracture time to heal.  Delaying re-operation for nonunion for at least 6 months can reduce the necessity for another procedure.
• Surgical techniques such as blocking screws and a lateral entry portal can help prevent malreduction during intramedullary fixation of proximal tibia fractures.

References

1. Praemer A, Furner S, Rice DP. Musculoskeletal conditions in the United States.  Park Ridge, IL.  American Academy of Orthopaedic Surgeons; 1992.
2. Wehner T, Claes L, Simon U.  Internal loads in the human tibia during gait. Clin Biomech 2009; 24(3):299-302.
3. Fracture and dislocation compendium. Orthopaedic Trauma Association Committee for Coding and Classification. J Orthop Trauma,1996;10 Suppl 1: 1-154.
4. Tscherne H, Gotzen L, editors Fractures with soft tissue injuries. New York: Springer; 1984.
5. Schmidt AH, Finkemeier CG, Tornetta P.  Treatment of closed tibial fractures.  J Bone Joint Surg Am. 2003;85:352-68.
6. Sarmiento A, Sharpe FE, Ebramzadeh E, Normand P, Shankwiler J.  Factors influencing the outcome of closed tibial fractures treated with functional bracing.  Clin Orthop.  1995;315:8-24.
7. Alho, Ekeland A, Stromose K, Folleras G, Thoresen BO.  Locked intramedullary nailing for displaced tibial shaft fractures. J Bone Joint Surg Br.  1990;72:805-9.
8. Hooper GJ, Keddell RG, Penny ID.  Conservative management or closed nailing for tibial shaft fractures.  A randomised prospective trial.  J Bone Joint Surg Br. 1991;73:83-5.
9. Bone LB, Sucato D, Stegemann PM, Rohrbacher BJ.  Displaced isolated fractures of the tibial shaft treated with either a cast or intramedullary nailing. An outcome analysis of matched pairs of patients.  J Bone Joint Surg Am.  1997;79:1336-41.
10. Bhandari M, Guyatt G, Tornetta P, et al. Randomized trial of reamed and unreamed intramedullary nailing of tibial shaft fractures. J Bone Joint Surg Am. 2008;90:2567-2578.
11. Dall'oca C, Christodoulidis A, Bortolazzi R, Bartolozzi P, Lavini F. Treatment of 103 displaced tibial diaphyseal fractures with a radiolucent unilateral external fixator. Arch Orthop Trauma Surg. Apr 2 2010.
12. Court-Brown CM, Keating JF, Christie J, McQueen MM. Exchange intramedullary nailing. Its use in aseptic tibial nonunion. J Bone Joint Surg Br. May 1995;77(3):407-11.
13. Lang GJ, Cohen BE, Bosse MJ, Kellam JF. ;Proximal third tibial shaft fractures, Should they be nailed?  Clin Orthop.  1995;315:64-74.
14. Williams J, Gibbons M, Trundle H, Murray D, Worlock P.  Complications of nailing in closed tibial fractures.  J Orthop Trauma.  1995;9:476-81.
15. Cannada LK, Anglen JO, Archdeacon MT, Herscovici D Jr, Ostrum RF. Avoiding complications in the care of fractures of the tibia. J Bone Joint Surg Am. 2008;90:1760-8.
16. Skoog A, Sodergvist A, Tornkvist H, Ponzer S.  One year outcome after tibial fractures.  Results of a prospective fracture registry. J Orthop Trauma. 2001;15:210-15.