Treatment of Tibia and Fibula Fractures.pptx

Treatment of Tibia and Fibula Fractures.pptx

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  Treatment of Tibiaand Fibula Fractures Dr. Mohammad Taqi Ehsani PGY3 of Orthopedics, FMIC 8 August, 2025
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  contents • Proximal TibialMetaphyseal Fractures • Tibial and Fibular Diaphyseal Fractures • Nondisplaced Oblique or Spiral Tibial Fracture With an Intact Fibula (Toddler’s Fracture) • Displaced Tibial Fracture With an Intact Fibula in an Older Child. • Displaced Tibial Fracture With a Fibular Fracture in an Older Child. • Open Tibial Diaphyseal Fractures • Distal Tibial Metaphyseal Fractures • Stress Fractures of the Tibia • Ipsilateral Femoral and Tibial Fracture (“Floating Knee”)
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  Proximal Tibial MetaphysealFractures (Treatment) Nonoperative in the majority of cases • under conscious sedation, reduction when valgus deformity of the tibia is present after injury • angled greenstick fracture: broken through by bending the leg toward the angulation and slightly overcorrecting the deformity • long-leg cast with three-point fixation to maintain the reduction. • non–weight bearing, for approximately 5 to 7 weeks, depending on the age of the child, serial radiographs for the first 2 weeks to ensure maintenance of alignment • After the cast is removed, fully weight bearing , monitoring at regular intervals of approximately 3 to 6 months • developing valgus deformity, as high as 90% in some series Operative treatment is rarely indicated • closed reduction fails to reduce the valgus deformity (The only exception ) • most often because of soft tissue interposition (pes anserinus, periosteum, or the MCL) • If fracture stability is a concern, smooth Kirschner wires can be placed in crossed fashion and supplemented with a cast
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  • (A andB) AP and lateral of the knee in an 8y11m-old girl, injured on a trampoline indicate a proximal tibia fracture near the physis without obvious significant injury to the physis or need for reduction. The child went on to uneventful healing in a long-leg cast but returned 18 months later with an obvious growth arrest and symptomatic deformity. • (C and D) AP and Lateral of the knee now, at age 10y6m • (E and F) CT scan demonstrates the central physeal bar
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  Tibial and FibularDiaphyseal Fractures Nonoperative Treatment: • vast majority of children’s tibial fractures of all age groups can be treated by cast immobilization after fracture reduction, even adolescents, nonoperatively with a high rate of success and low complications • The role and ability of cast wedging should be understood by the treating surgeon
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  Nondisplaced Oblique orSpiral Tibial Fracture With an Intact Fibula (Toddler’s Fracture) • usually younger than 6 years, sustained a twisting injury of the foot while walking or running • long-leg cast, for approximately 3 to 4 weeks, serial weekly radiographs • full weight-bearing status without further immobilization after cast removal • difficulty in making the diagnosis, often beneficial to place a child who is thought to have a toddler’s fracture in a long-leg cast • Radiographs, 2 weeks to identify whether a fracture is present. If no signs of callus formation are present, the cast can be removed • Fracture callus confirms the diagnosis, and removable immobilization can continue for an additional 2 to 3 weeks.
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  Displaced Tibial FractureWith an Intact Fibula in an Older Child • manipulate the fracture with the child under conscious sedation in the emergency department and use fluoroscopy to check the reduction • Acceptable fracture reduction: within 5 to 10 degrees in all planes • non–weight bearing in the cast for 4 to 6 weeks, after that changed to a short-leg walking cast, depending on the age of the child and the amount of radiographic healing. • Radiographs should be obtained weekly during the first 2 to 3 weeks after reduction • We recommend manipulation of the fracture via corrective wedging of the cast when varus angulation of greater than 5 degrees is present on follow-up radiographs • Comparison studies: • no difference in outcomes between operatively (elastic stable intramedullary nailing) and nonoperatively managed cohorts, with the exception of a shorter time to immobilization discontinuation in operative patients, lending the authors to conclude that these should continue in most instances to be managed nonoperatively
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  Displaced Tibial FractureWith a Fibular Fracture in an Older Child • generally in children older than 10 years and result from direct, high- energy trauma. • Because of significant instability from the associated fibular fracture, these injuries may be difficult to reduce adequately, and conscious sedation or general anesthesia is frequently required for reduction. • Acceptable reduction must include at least 50% bony apposition of the fracture fragments and less than 5 to 8 degrees of angulation in both the sagittal and coronal planes. • These fractures are prone to residual varus in the coronal plane and posterior angulation (apex anterior or recurvatum) in the sagittal plane. • To correct this deformity: • three-point mold should be placed to compensate for varus • Ankle: 15 to 20 degrees of plantar flexion to prevent posterior angulation • Knee: 30 to 45 degrees of knee flexion to provide rotational control of the fracture and restrict the patient from bearing weight on the affected extremity Treated by: Dr. Salahuddin Siraj, FMIC
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  • univalve thesecasts to allow for swelling and decrease the risk of compartment syndrome • admitted: for soft tissue monitoring, with the leg elevated, ice packs placed at the level of the fracture, and neurovascular assessment performed every 2 hours by the nursing staff • Close radiographic monitoring is required at 1 to 2 weeks to ensure that the initial fracture reduction is maintained • non–weight bearing until callus is present • transition from a long-leg to a short-leg cast or fracture boot • Once callus is present a gradual return to weight bearing can be initiated
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  Operative Treatment • rarelyrequired in a closed tibial fracture in children, (<5% of cases) • The main indications are: • excessive fracture instability that cannot be maintained with external immobilization • loss of reduction that cannot be corrected by cast wedging during the follow-up period • significant comminution and shortening that cannot be corrected with closed treatment • a displaced fracture in a skeletally mature patient. • Modes of operative treatment: • flexible intramedullary rods • percutaneous pin fixation after adequate closed reduction • external fixation • open reduction with internal fixation • locking rigid intramedullary rods.
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  Flexible nails • Doesnot always control rotational stability, need for a long-leg cast temporarily • Complications associated with the use of flexible nails: • Nonunions • delayed unions • nail migration through the skin • leg length differences • residual angular deformity • deep infections • compartment syndrome following intramedullary nailing of tibia fractures varies from 0% to 19% Operated by: Dr. Salahuddin Siraj, FMIC
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  • External fixationremains an option for highly unstable closed tibial fracture (A) Injury film demonstrating a distal tibiofibular fracture (B and C) Following external fixation, adequate alignment and healing occurred after 2 months.
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  Percutaneously placed crossed Kirschnerwires • are also an option in younger patients with potential for rapid healing • The wires are left outside the skin to allow easy removal in the clinic 4 weeks from the time of injury • Cast immobilization is performed Percutaneous closed reduction and percutaneous pinning of a tibial fracture (A) Radiograph of a 15-year-old boy with a displaced midshaft tibiofibular fracture. Attempts at closed reduction and casting were unsuccessful because of unacceptable alignment (B) Closed reduction with percutaneous pinning was performed
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  Rigid intramedullary fixation hasrevolutionized the treatment of tibial fractures in adults and can be used in the older adolescent who is skeletally mature
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  • Routine platefixation is less commonly employed for diaphyseal fractures in children, because of: • the significant soft tissue stripping required • the increased risk for infection and nonunion • the need to remove the hardware at a later date • Advantages of plating included: (vs flexible nail) • shorter immobilization by 3 weeks • less angular deformities exceeding 5 degrees • substantially lower rates of subsequent surgery despite higher rates of complications • distal diaphyseal fractures (likely to be treated by plate osteosynthesis which may indicate a relative anatomically localized indication) Operated by: Dr. Salahuddin Siraj, FMIC
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  Open Tibial DiaphysealFractures Treatment • In general, open tibial fractures fare worse than closed fractures • Outcome: depends on the condition of the soft tissue envelope, the quality of débridement to minimize the risk of infection, revascularization of the limb when arterial injury is present, and prompt assessment and treatment of any compartment syndrome. • Infection: between 5% and 15%, depends most on the severity of the soft tissue and bony trauma • It is essential that aggressive débridement of all necrotic soft tissues be performed to provide the optimal chance for soft tissue healing as well as to limit the chance of infection. • Arterial injury occurs in 2% to 10% of cases. Approximately 50% of all type IIIC open injuries result in amputation, either during the initial surgical treatment because of the severity of the injury or later because of failed vein interposition grafting • Compartment syndromes: 5% of patients, most often in grade II open fractures
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  Steps for openfracture management: • Early Treatment: Antibiotics, Débridement, and Splinting • Wound Management • Soft Tissue Management • Management of Bony Defects • Fracture Stabilization • Treatment of Neurovascular Injury
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  Early Treatment: Antibiotics,Débridement, and Splinting • The first steps in management: • prompt evaluation and initial classification of the soft tissue injury in the emergency department • application of a povidone-iodine (Betadine)-soaked dressing • splinting of the fracture • Staphylococcus aureus is isolated in most open tibial shaft fractures that become infected • In addition to aggressive operative débridement, the prompt administration of intravenous antibiotics is essential in minimizing infectious complications • Intravenous administration of antibiotics that cover both skin flora and gram-negative soil organisms is indicated for all fractures, for all grade III injuries and severely contaminated wounds. Penicillin can be considered as an addition to the antibiotic regimen for all farm-related accidents. • Continue intravenous antibiotics for 48 hours following the patient’s final surgical débridement. • Recently, antibiotic stewardship trends have included adoption of practices focused on institution- or geographic-specific organism therapies, so that at our institution the use of piperacillin- tazobactam has now replaced the traditional cefazolin plus gentamycin as firstline therapy for contaminated open fractures
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  Wound Management • Ifthe wound is on the medial aspect of the leg, with little soft tissue coverage, an anterolateral incision should be used to gain access to the fracture site and injured soft tissue • All incisions made by the surgeon can be closed at the initial surgery, whereas traumatic wounds may be left open if a second debridement is deemed necessary • We prefer to place nonabsorbable horizontal mattress sutures in the traumatic portions of wounds without tying the sutures. This method allows drainage of the leg to help prevent the accumulation of infectious material, can be closed at the bedside in 24 to 48 hours. • Any bony fragment with little or no soft tissue attachment should be discarded • Any concern regarding the amount of contamination: serial repeat irrigation and débridement every 48 hours until adequate viable tissue is seen. • Necrotic muscle or muscle that is thought to be ischemic should be débrided • Signs of muscle viability are: • muscle contraction when stimulated by pinching with forceps, • arterial bleeding when incised • presence of a healthy pink color • Repeat irrigation of the soft tissue with 5 to 10 L of normal saline should be performed • It is our preference to irrigate these wounds under low pressure using cystoscopy tubing and gravity-driven lavage rather than high-pressure pulsatile lavage because the latter was shown in an ovine model to result in a higher bacterial retention rate by forcefully driving bacteria deeper into soft tissues The 4-C: Muscle Color Consistency Contractility Capacity of bleed
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  Soft Tissue Management •often requires coverage with the use of split- or full-thickness skin grafts, myocutaneous flaps, or free muscle flaps • We prefer to have the plastic surgeon present to assess the wound as soon as possible • Coverage procedures should be done as soon as possible, preferably within 5 to 7 days, to prevent seeding of the leg with a secondary infection • Studies demonstrated that decreased time from injury to flap coverage is associated with lower infection and overall complication rates • Vacuum-assisted closure (VAC) devices are valuable for managing large soft tissue defects awaiting definitive closure • Most injuries in children can be treated with a split-thickness skin graft or with a local flap • gastrocnemius flap in the proximal part of the leg • soleus flap in the middle aspect of the leg • lower part of the leg often require a vascularized free flap • Free muscle flaps are used for massive soft tissue injuries in any part of the leg • Free flaps are an excellent barrier to secondary infection and have a rich blood supply, which enhances soft tissue and bone healing
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  Management of BonyDefects • first ensure that the native bony and soft tissue bed is clear of all necrotic tissue and bacterial contamination • “Masquelet” technique: • use of antibiotic-impregnated polymethyl methacrylate beads. Although these beads are commercially available, we prefer to prepare them at the time of surgery by mixing 1 g of powdered cefazolin and 2.4 g of powdered tobramycin with powdered cement • Options for treating large segmental bony defects include: bone transport, a vascularized fibular transfer, or autologous bone grafting • Stabilization
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  Fracture Stabilization • Theprimary modes of fracture stabilization for open tibial fractures in children are long-leg cast immobilization with a window over the traumatic wound, flexible intramedullary nails, and external fixation • Approximately 50% of all open tibial fractures are treated by cast immobilization, and the rest are treated with an external fixator or internal fixation and a cast • grade I and smaller grade II wounds: that will not require repeat débridement in the operating room, cast immobilization • grade II and all grade III: intramedullary nails or a monolateral external fixator will provide stabilization and subsequent soft tissue access
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  Treatment of NeurovascularInjury • rare in children and accounts for approximately 5% of all tibial fractures • Revascularization of the leg should be performed within 4 to 6 hours of injury and should not be delayed by arteriography in the radiology suite • If the ischemia time is approaching the 4-hour limit, an arteriogram obtained with the patient on the operating room table is the best way to determine the exact location of the arterial injury • The timing of bony stabilization and revascularization also depends on the ischemia time. We prefer to stabilize the fracture by applying an external fixator so that definitive revascularization can be performed. • ischemia time is approaching 4 hours, insertion of temporary intraluminal shunts to provide a vascular supply to the distal part of the leg takes precedence over fracture stabilization • Compartment pressures should be measured in any child with an open fracture that requires revascularization, and the surgeon should have a low threshold for performing four-compartment fasciotomies. Prophylactic fasciotomies should be performed in any patient with an ischemia time of 4 hours or longer • Indications for amputation in a child with a severe tibial fracture are: • (1) vascular injury that is not reconstructible because of extensive soft tissue destruction • (2) associated neurologic injury that does not allow protective sensation on the sole of the foot • (3) severe muscle injury associated with extensive bone loss • (4) The Mangled Extremity Severity Score (MESS) greater than 7 indicates the need to perform an amputation in adults
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  Distal Tibial MetaphysealFractures • A greenstick fracture is the most common fracture pattern • Nondisplaced or minimally displaced fracture: in a young child, Cast immobilization • Displaced fractures: fracture reduction under conscious sedation or general anesthesia followed by cast immobilization • In a young child (<6 years) with a minimally displaced fracture: short-leg cast for 4 to 6 weeks. • In an older child or in any child with a displaced fracture: a long-leg cast, knee flexed to 40 degrees, 3 to 4 weeks, followed by 2 to 3 weeks in a short-leg cast • It is often necessary to place the cast with the foot in 20 degrees of plantar flexion to maintain reduction of the apex-posterior fracture
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  Stress Fractures ofthe Tibia • activity modification to decrease the continuous forces placed on the tibia. • The fracture should heal completely before these activities are resumed • Cast immobilization is not required unless the patient is uncooperative with treatment • Restriction of activity should continue for 6 weeks or until symptoms completely resolve, followed by gradual resumption of activities
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  Ipsilateral Femoral andTibial Fracture (“Floating Knee”) • depends on the patient’s age and injury pattern, including the state of the soft tissue envelope • In general, we prefer to obtain stable fixation whenever possible • In children 20 kg and larger, surgical stabilization of the femoral fracture with flexible intramedullary rodding provides stable fixation of the fracture and allows easier manipulation and cast immobilization or fixation of the tibia; it also prevents angular deformity and shortening • In an adolescent, stable intramedullary fixation of both the femur and the tibia allows treatment without external immobilization and permits early weight bearing and range-of- motion exercises of the knee and ankle. Operated by: Dr. Salahuddin Siraj, FMIC
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  Thank you