Major trauma
Closed fractures of the tibial shaft in adults

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Abstract

Diaphyseal tibial fractures are the most common long bone fracture. There are a variety of treatment options, both operative and non-operative, and satisfactory outcomes are reliant on a thorough understanding of the strengths and weaknesses of the different treatment modalities and their appropriate application. Certain fracture patterns present particular difficulties and these must be recognized preoperatively so that a suitable surgical strategy can be executed.

Introduction

This review focuses primarily on the management of closed diaphyseal tibial fractures in adults. The essential anatomy of the tibia is considered along with the principles of initial management and surgical options for definitive treatment.

Section snippets

Epidemiology

Fractures of the tibial shaft are the most common long bone fracture.1 The majority of these fractures are closed, with one large study putting the proportion of open fractures at 23.5%.2 A recent Danish epidemiological study found that the most common fracture pattern was the spiral fracture (AO-type 42-A1), representing 34% of all tibial shaft fractures.3 Estimates for the average annual incidence range from 16.9 to 22 per 100 000 patient years,3, 4, 5 although this may be falling.4

Men have

Osteology and compartments

The tibia is the second largest long bone in the body. The proximal tibia is characterized by a tibial plateau that forms the lower half of the knee joint. The diaphyseal segment is triangular in cross-section, with the medial border of the tibia being subcutaneous, making it susceptible to open fractures. Distally, the tibial shaft narrows and finally expands slightly to form the superior articular surface of the ankle joint. The medial end of the tibia has a malleolar process, which also

Classification of tibial fractures

Surgeons usually classify tibial fractures using simple descriptive terms. Anatomical location (proximal, middle, distal) and fracture pattern (transverse, oblique, spiral, segmental, comminuted, or butterfly etc.) are commonly used to describe the variety of possible injuries. These terms are well understood and facilitate communication between colleagues, but are too ambiguous and subjective for research and publication purposes. The most commonly used classification system is the AO/OTA

Soft tissue injury classification

Of equal importance when classifying tibial fractures is the extent of the soft tissue injury, which for closed injuries is best described using the Tscherne classification.7 This grading scale has been shown to have a strong correlation with outcome (see Table 1).8

Initial management

Tibial shaft fractures can present as either an isolated low energy injury or a high-energy injury, typically seen in the poly-traumatized patient. Patients with high-energy injuries often have other serious injuries with multiple systems involved. These patients should therefore be managed in accordance with Advanced Trauma Life Support (ATLS) protocols in order to identify and treat life-threatening injuries first, before moving on to manage less serious injuries.

The history should be focused

Imaging

Orthogonal antero-posterior (AP) and lateral radiographs are usually sufficient for diagnosis and pre-operative planning. They should include the ipsilateral knee and ankle in order to check for intra-articular extension and associated injuries. Computed tomography (CT) is rarely required, but may be useful to clarify possible intra-articular extension and may also include angiography in cases of suspected vascular injury.

Magnetic resonance imaging (MRI) may be required to diagnose associated

Non-operative treatment

There is no strong consensus on the optimal management of minimally displaced closed midshaft tibial fractures, with both cast treatment and intramedullary nailing (IMN) having strong support.11

Papers that have looked at the outcomes of cast treatment suggest that the indications for non-operative treatment are closed, minimally displaced, two part fractures, without significant soft tissue injury.12, 13, 14

An important consideration, however, is the patient's expectation of the speed of return

Intramedullary nailing

Locked intramedullary nailing (IMN) is generally thought of as the gold standard treatment for closed unstable tibial shaft fractures.19 However, there are several relative contraindications, such as ipsilateral knee replacement/arthrodesis, pre-fracture deformity of the tibia and an intramedullary canal diameter of <7 mm, as this would require excessive reaming to accommodate an IMN.20, 21

Most modern tibial nails are cannulated, designed to be inserted in a reamed fashion and are made of

External fixation

External fixation of tibial fractures can be used as temporary or definitive treatment.

Temporary fixators are usually monolateral half pin constructs but may also be bi-planar to increase stability; they are used in damage control orthopaedic surgery (DCO) or when the soft tissue envelope is not suitable for definitive fixation, or skeletal stability is required for fasciotomies in compartment syndrome.

Definitive external fixation can take the form of fine wire constructs, half pin constructs

Plating

Because of the poor soft tissue cover of the tibia, plate fixation has often been associated with a high infection rate, therefore plate fixation is usually reserved for metaphyseal injuries that are harder to control using IMNs. However, some authors have reported good long-term results from plating tibial shaft fractures.64

Formal open reduction and interfragmentary compression techniques can yield excellent postoperative radiographs but perhaps are not appropriate if they threaten the

Proximal third fractures

Proximal third tibial fractures present significant difficulties and malunion is relatively common. The usual deformities are valgus, flexion, shortening and posterior translation of the distal fragment.51, 54 These problems are particularly evident following IMN, with malunion rates of up to 84% being reported.54

The valgus deformity occurs due to a mismatch between the axis of the nail within the proximal fragment and the anatomic axis of the medullary canal in the distal fragment.66 Causes

Conclusions

Closed fractures of the tibial shaft are common; there are many options for fixation of these fractures. The choice of fixation method for operative cases should be reviewed on a case-by-case basis. In immobile, frail patients with un-displaced tibial shaft fractures non-operative management has a role. In most other cases a reamed tibial nail is the treatment of choice. Proximal and distal fractures are particularly challenging and the surgeon should be aware of the surgical options available

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