Tibial Shaft Fractures Treatment & Management

Casting

Initially, all tibial shaft fractures should be stabilized with a long posterior splint with the knee in 10-15° of flexion and the ankle flexed at 90°. Admission to the hospital may also be necessary to control pain and to monitor closely for compartment syndrome.

Closed fractures with minimal displacement or stable reduction may be treated nonoperatively with a long leg cast, but cast application should be delayed for 3-5 days to allow early swelling to diminish. The cast should extend from the mid thigh to the metatarsal heads, with the ankle at 90° of flexion and the knee extended. The cast increases tibial stability and can decrease pain and swelling. Early ambulation with weightbearing as tolerated should be encouraged. Tibial shaft fractures treated with casting must be monitored closely with frequent radiographs to ensure that the fracture has maintained adequate alignment. Adequate callus formation generally takes 6-8 weeks before cast therapy can be discontinued.

Despite proper casting techniques and adequate follow-up, not all nonoperatively treated tibial shaft fractures heal successfully. In addition, 6 weeks without knee motion often results in a stiff joint. In fact, Kyro et al found that 53% of patients reported a fair or poor result using long leg casts to treat tibial shaft fractures.^[15] This and many other studies have shown that simply putting a tibial fracture in a long leg cast may lead to increased joint stiffness, some difficulty ambulating, and increased union times.^{[16, 17]}

Another type of cast, the patellar tendon–bearing cast, was proposed by Sarmiento to be used early in treatment of tibial shaft fractures in place of the long leg cast. Sarmiento reported good results for treatment of tibial shaft fractures with the patella tendon–bearing cast.^[18] In general, however, better results are reported with internal fixation of displaced tibial shaft fractures than with nonoperative treatment. Hooper et al found that the results of treatment of displaced tibial shaft fractures were not as satisfactory as those with intramedullary nailing.^[19]

Bracing

Three years after describing the patellar tendon–bearing cast, Sarmiento proposed another treatment, the functional brace.^[18] The functional brace has since replaced the long leg cast in many circumstances because it can be put on within 2-4 weeks of injury. It allows more movement of the knee and ankle while still protecting the tibial fracture. Movement of the knee and ankle may decrease the stiffness that patients encounter after the fracture is healed. However, the long leg cast is still used for the first few weeks until the fracture begins to stabilize. As with the patellar cast, Sarmiento found very good results; however, others subsequently discovered problems, including a 40% nonunion rate in 1 trial.^[14]

While no definitive nonoperative treatment has been determined for tibial fractures, many authors have noted increased nonunion and healing time with casts and braces compared with surgical fixation.^{[14, 15, 16]} Therefore, casts and braces have limited use, especially with displaced fractures. The ideal candidate for nonoperative treatment is a young patient with a nondisplaced fracture.

Operative fixation is required when fractures are unstable.

The initial step in the operating room is to examine the injury with the patient under anesthesia. This gives the surgeon a better understanding of fracture stability without causing pain to the patient. In managing an open tibia fracture, the surgeon should then begin with extensive irrigation and debridement of devitalized tissue and bone. This step is very important to prepare the fracture for reduction and to combat infection.^[20]

If a tibial shaft fracture is associated with a break in the skin, the wound should be treated as an open fracture. The important factors to the successful treatment of contaminated open tibial fractures include radical debridement of necrotic tissue, pulsed lavage of the area to remove bacteria, and prophylactic intravenous antibiotics. Open fractures are surgical emergencies. Most patients should be scheduled for debridement and irrigation within 6 hours of the injury (see Indications, above). For antibiotics, frequently an aminoglycoside combined with a cephalosporin is adequate. For low-grade open fractures, antibiotics such as first-generation cephalosporins are used. For higher-grade injuries in which dirty wounds and infection are more likely, penicillin and aminoglycosides are appropriate.

Repeat debridements (every 24 h, as needed) often are used in injuries with extensive soft-tissue injury, in severely contaminated wounds, or in wounds with vascular compromise in which additional necrotic tissue may present itself. Soft tissue usually is covered (using sterile technique) within 1 week of injury.

A splint should be used for stabilization. The splint usually remains intact until the patient is prepared in the operating room.

Plating tibial shaft fractures is a viable surgical option and was once the treatment of choice. The procedure involves using a large surgical incision, reducing the fracture, placing a metal plate over the fracture, and fixing the plate onto the bone with multiple screws. Because of the extensive soft-tissue manipulation required, plating can be difficult for the surgeon and damaging to the local vascular supply. In fact, some authors believe that it is not indicated for open fractures because of an infection rate as high as 44%.^[21] Intramedullary nailing and external fixation have replaced fracture plating because they entail decreased technical difficulty, infection rates, and damage to local soft tissues.

One study designed a 2-stage protocol for tibial segmental fractures and assessed the outcome of this treatment. After anatomic reduction followed by soft-tissue reconstruction, a low-profile locking plate was temporarily applied as an external fixator. In the second stage, internal fixation with a locking plate was applied using a percutaneous plate osteosynthesis technique. After a median follow-up of 32 months, the data noted that all fractures achieved union; median time for the proximal fracture union was 23 weeks and 27 weeks for the distal fracture union. These results suggest that this 2-stage procedure achieves excellent knee and ankle joint motion and good functional outcomes.^[22]

External fixation is a widely used and very successful method for treating some types of tibial shaft fractures. The procedure involves multiple pins attached to the external rods to maintain length and alignment. This therapy is particularly useful for proximal tibial fractures that may be difficult to align properly with an intramedullary nail. Another common indication for external fixation is a severely comminuted fracture pattern that is difficult to align for reaming and nailing. External fixation is also useful for tibias in which the intramedullary canal is too narrow to ream. See the images below.

In one study, statically locked intramedullary nailing with traveling-traction external fixation was found to be successful in providing acceptable alignment for proximal and distal one-third extra-articular tibial shaft fractures.^[23]

Throughout the years, many different designs of external fixators have been used and studied without consensus opinion for any specific type.^{[6, 21, 24, 25, 26]} Despite the various options available, external fixation is associated with higher rates of nonunion and malunion than intramedullary nailing.^{[24, 27, 28]} These complications may be avoided, however, with proper reduction in the operating room and with fracture fixation for at least 6 weeks.^{[25, 29]}

Intramedullary nailing with locking screws has become the treatment of choice for most tibial shaft fractures.^{[30, 31, 32, 33, 34]} The prevalence of nonunion and malunion is greatly decreased compared with the other methods of fixation. Patients are also able to return to low-impact activities much sooner than with the other treatments.

While intramedullary nailing is generally accepted as the standard of care for treating many types of tibial shaft fractures, specific techniques are not without controversy. The point of contention most frequently involves whether the tibia should be reamed before the intramedullary nail is placed.

Animal studies have demonstrated an increase in blood flow to the periosteum and surrounding muscles with reaming, which would presumably lead to a better result.^[35] Keating et al performed a prospective, randomized trial that compared reaming with nonreaming in open tibial fractures, and no differences were noted in union time; rates of nonunion, malunion, or infection; or outcome.^[36] In a similar study performed on closed fractures, however, reamed tibial fractures had substantially better results than unreamed tibial fractures.^[37] A prospective, randomized trial also appears to show a benefit for reamed nailing over unreamed nailing in closed fractures.^[38] Regardless of preference for the reamed or unreamed technique, tibial nails remain the treatment of choice for open tibial fractures.

In a multicenter, blinded, randomized study of 1226 patients with tibial shaft fractures, reamed nailing (622 patients) and unreamed nailing (604 patients) were studied regarding rates of reoperations and complications. The investigators found a possible benefit for reamed intramedullary nailing in patients with closed fractures but no difference between approaches in patients with open fractures.^[38]

Amputation is uncommon but is sometimes indicated for severe tibial fractures, especially those with extensive soft-tissue injury or those in patients with vascular compromise, such as in diabetic patients. Amputation for grades I and II fractures is rare, but the rate of amputation is increased for grade III fractures. In fact, fractures requiring revascularization (type IIIc fractures) have a corresponding amputation rate of greater than 20%.^{[39, 40]} The Mangled Extremity Severity Score is a tool that has been developed to help the surgeon decide whether or not amputation is indicated, but it is only part of the equation. Surgical expertise and patient communication are of vital importance when making amputation decisions.

After surgery, the patient should be monitored in the postanesthesia care unit until stable. Depending on the extent of the other injuries, the patient may be transferred to the surgical intensive care unit or to a regular ward bed. Initially, the patient's vital signs should be monitored repeatedly, with careful attention paid to any abnormalities. If a complication occurs, early discovery almost always improves the prognosis. On the first postoperative day, the patient should be examined by the surgical team and a complete blood count should be obtained. Once the patient has recovered from surgery and is considered safe to leave the hospital, he or she should be discharged to home or to a suitable rehabilitation facility.

Depending on surgeon preference, the patient usually is seen in a clinic 2-3 days after discharge, and radiographs are taken to view the reduction. If the reduced fracture is still properly positioned, the patient returns on a regular, less-frequent basis for radiographic and clinical examination of the leg. Once the patient has healed, braces and external fixators may be removed. Many tibial nails are not removed and may remain in the patient indefinitely.

The complication that should concern every physician treating a tibial shaft fracture is compartment syndrome. Compartment syndrome occurs when the pressure inside a particular fascial compartment of the leg is elevated to a point that it can cause restriction of blood flow and nerve damage. The usual causes of compartment syndrome include hematoma and soft-tissue swelling. The signs of compartment syndrome traditionally are defined as increased pressure, pulselessness, paresthesia, pain, and pallor to the distal affected extremity; pulselessness and pallor are also associated with vascular injury. The most reliable signs are increasing pain with passive stretching of the muscles within the compartment and hypesthesia.

The physician does not need to observe all of the signs to diagnose compartment syndrome. The physician should have a high index of suspicion for this complication, and aggressive surgical treatment is mandatory. Always remember that decreased pulses may not manifest until late in the process. Many surgeons now advocate the use of pressure monitors to aid in treatment decisions. Compartment pressures greater than 25-30 mm Hg are concerning and indicate the need for consultation with a surgeon. Treatment for compartment syndrome involves fasciotomy.

A fasciotomy is performed by making 2 longitudinal incisions in the affected leg, one laterally and one medially. The lateral incision allows the surgeon to access and decompress the anterior and lateral compartments, while the medial incision offers access to the posterior compartments. During this procedure, all 4 compartments must be opened to survey damaged vessels and to ensure decompression.

Infection is a concern with any surgical procedure, especially with open fractures. The risk of infection also increases when surgical hardware (nails and fixator pins) is placed into the area. For this reason, irrigation, debridement, and intravenous antibiotics are vitally important. Also, the value of conscientious nurses and house staff cannot be overemphasized for the recognition and treatment of early infection.

A common and frustrating complication of tibial fractures is nonunion. Nonunion is defined as a fracture that has been present for 9 months with no visible signs of healing for the past 3 months.^[41] Some of the many causes of nonunion include infection, malnutrition, unstable fracture fixation, and incomplete fracture reduction. Treatment of nonunion is guided by the underlying cause. If the wound is infected, irrigation, debridement, and antibiotics are indicated. After the infection is cleared and any malnutrition is treated, a different method of fixation may be used. It should be noted, however, that adding hardware such as intramedullary nails or external fixator pins is almost never indicated in an infected leg.

If nonunion is due to malalignment without infection or malnutrition, exchange nailing and bone grafting are the preferred treatments. Exchange nailing involves removing the previously used tibial nail, reaming the canal, and placing a new, larger nail in its place. This treatment has a very high success rate, and has been advocated by many surgeons.^[42]

The treatment of tibial shaft fractures of all forms has been fraught with complications. An analysis of prospective, randomized, controlled trials has demonstrated that the combined prevalence of nonunion was lowest with operative treatment, but the prevalence of infection was greatest with operative treatment. The prevalence of infection with plate fixation was greater than that with intramedullary nailing.^[43] To deal with the problem of nonunion, initial external fixation of open tibial shaft fractures has undergone subsequent conversion to intramedullary nailing. Studies have shown poor progression to union with this technique, as well as increased surgical complications.^[44] Alternative treatment options should be considered before conversion of external fixation to intramedullary rodding.

The outcome of tibial shaft fractures can be less than ideal under many circumstances. These fractures almost always heal with some angulation, rotation, or shortening, which alters load transmission across the extremity. Patients with tibial shaft fractures have been evaluated with respect to joint pain, disability, osteoarthritis, and joint stiffness. Studies have shown that long-term outcomes for tibial shaft fractures generally are good, but a small increase in osteoarthritis of unclear etiology in the knee and ankle has been observed.^{[45] [46]} The cause of increased osteoarthritis appears to be multifactorial. Reamed intramedullary nails with interlocking screws provide an excellent means to control rotation and limb shortening (see Treatment, Intraoperative details, above).

Many different designs of external fixators have been used and studied without consensus opinion for any specific type. Intramedullary nailing is generally accepted as the standard of care for treating many types of tibial shaft fractures; however, specific techniques are not without controversy, especially whether the tibia should be reamed before the intramedullary nail is placed (see Treatment, Intraoperative details, above).