Diaphyseal Tibial Fractures

Fractures of the tibia and the fibula are the subject of ongoing controversy and discussion. Despite newer innovations in implants and external fixation devices, tibial fractures essentially remain unresolved; they are among the most challenging fractures to be treated by an orthopedic surgeon. These injuries are different and variable in presentation, and their outcomes are unpredictable.

The literature has traditionally included two schools of thought regarding management of these injuries: operative and nonoperative therapy. Although gray zones have been resolved, no consensus has been reached on the optimal management of diaphyseal fractures of the tibia. This problem is predominantly attributed to the high prevalence of concomitant closed and open soft-tissue injuries. Therefore, diaphyseal tibial injuries are prone not only to infection and nonunion in the long term but also to significantly increased morbidity caused by polytrauma and associated injuries in the acute setting.

The delayed unions and nonunions that occur in these fractures are themselves a separate problem covered extensively in the literature and in academic forums. As Marvin Tile wrote[1] :

We should reject the theories of the dogmatists who say that all tibial fractures should be treated operatively or that all tibial fractures should be treated nonoperatively. It is time to remove this kind of dogma from one's thinking and to individualize the treatment of these fractures. The optimal treatment of a tibia fracture stems from an analysis of the natural history of the fracture. A thorough assessment of the fracture type and pattern and then correlating it with the natural history of a similar fracture type permits achievement of the best functional outcomes for each individual patient.

The ability to treat tibial shaft fracture by conservative or operative means depends on what is often termed the natural history of the fracture. John Charnley hypothesized that the periosteal hinge was the important factor in the management of fractures. Conservative management was more likely to fail in fractures that had a residual fracture gap or an intact fibula than in others. Some factors that influence the natural history of tibial fractures include the location and extent of displacement, comminution, soft-tissue injury, and contamination. Another factor is antecedent sepsis.

The Edwin Smith papyrus (an ancient Egyptian treatise on trauma surgery from the 17th century BCE) contained references to the management of long-bone fractures with splints and bandages. Hippocrates recommended the use of bandages and splints in his treatise on fractures; he stressed the need to change these bandages frequently to accommodate changes in limb swelling.

The advent of plaster and the design of functional casts revolutionized the management of tibial fractures.[1, 2, 3, 4] Anthonius Mathijsen, Fedor Victor Krause, Pierre Delbet, and, more recently, Augusto Sarmiento considerably refined the indications and methods of conservative management of tibial fractures. Understanding wound debridement and knowing Sir Joseph Lister's work on antisepsis[5] enabled surgeons to treat open diaphyseal tibial fractures with some prospect of avoiding amputation.

Albin Lambotte first pioneered external fixation in the tibia, and Ernest William Hey Groves introduced internal fixation with nails, which Gerhard Küntscher and J Otto Lottes later popularized. The AO (Arbeitsgemeinschaft für Osteosynthesefragen) school further refined the practice of intramedullary nailing and interlocked nailing.

Knowledge of the relevant anatomy is essential for recognizing and planning management of both the diaphyseal tibial fracture and the soft-tissue injuries that could be associated with it.

The tibia is triangular in cross-section, with proximal and distal flares. It has three surfaces: medial, lateral, and posterior. This bone is thinnest in cross-section at the junction of the middle and lower thirds. The anteromedial border is subcutaneous throughout its length and is called the shin. The broad and smooth medial surface is also subcutaneous throughout its length.

The nutrient artery to the tibia (see the image below) arises from the posterior tibial artery, which enters the tibia at the posterolateral cortex distal to the origin of the soleus at the oblique line of the tibia. Inside the medullary canal, it gives off three ascending branches and one descending branch, which form the endosteal vascular tree. This, in turn, anastomoses with the periosteal vessels originating from the anterior tibial artery.

As it passes through a hiatus in the interosseous membrane, the anterior tibial artery is particularly prone to injury in diaphyseal fractures of the tibia. The peroneal artery has an anterior communicating branch to the anterior tibial artery. Hence, an occlusion of the peroneal artery may exist, even in the presence of a dorsalis pedis pulse. The distal third of the tibial shaft is supplied by the periosteal anastomoses around the ankle, with branches entering the tibia through ligamentous attachments. A watershed zone may exist at the junction of the middle and lower thirds of the tibial shaft.

When the nutrient artery is obstructed, reverse flow is established through the cortex. In such a situation, the periosteal blood supply becomes more important. This situation emphasizes the importance of preserving the periosteal attachments during fixation procedures.

Tight osteofascial compartments surround the tibia. The crural fascia divides the leg into four compartments (see the image below); one of these is for the weaker muscle group of extensors, and the other three serve the stronger flexor musculature.

The compartments of the leg are as follows:

• Anterior (extensors and dorsiflexors of the foot)
• Lateral (strong everters and plantarflexors of the foot)
• Superficial posterior (plantarflexors of the foot)
• Deep posterior or medial (plantarflexors of the foot)

The septa are as follows:

• Anterior septum, between the anterior and lateral compartments
• Posterior septum, between the lateral and posterior compartments
• Transverse septum, between the medial and posterior compartments
• Interosseous membrane, between the anterior and middle compartments

The pathoanatomy of the fracture includes the location, morphology, and soft-tissue status of the limb. Because of its subcutaneous location, the tibia is extremely prone to soft-tissue injury and compounding (see the image below). This damage can occur at the time of injury or at the time of surgery. Closed soft-tissue trauma can be significant and may go unrecognized.

Diaphyseal fractures are slow to heal and are often unpredictable in terms of their course to union. Trauma is greater with long, spiral fractures than with transverse and short oblique fractures. The degree of trauma is further manifested in the extent of the comminution and displacement, both of which are also indicative of extensive soft-tissue disruption. Soft-tissue damage may be overt or may be a frank open injury.

Ipsilateral limb fractures, polytrauma, visceral injuries, and comorbid factors, such as the patient's general condition and age, as well as coexistent arterial or nerve injuries, also markedly influence outcomes.

Good nonoperative management is preferred to bad operative management.

The mechanism of a diaphyseal tibial injury can be direct or indirect. Direct mechanisms of injury are high-energy fractures (road traffic accidents), penetrating injuries, and three-point bending injuries. High-energy mechanisms produce transverse or comminuted displaced diaphyseal injuries, with a higher incidence of compounding and soft-tissue injury.[6, 7]

Penetrating injuries (eg, gunshot wounds) may produce a variable pattern, depending on the missile involved in the injury. Bending forces (eg, ski-boot injuries) produce short, oblique, spiral fractures and sometimes a small butterfly fragment. On occasion, a highly comminuted segmental pattern of injury may be observed. The prevalence of open and closed soft-tissue injuries is high.

Indirect mechanisms are primarily torsional, low-energy injuries, which produce spiral, nondisplaced, minimally comminuted fractures with minimal soft-tissue damage.

United States and international statistics

Tibial plateau fractures account for 1-2% of all fractures presenting to the orthopedic surgeon.[8, 9] The incidence is 10.3 per 100,000 people annually.[10] The distribution of tibial plateau fractures is bimodal, with fractures occurring in young men from high-energy injury and in older women from low-energy injury. Overall incidence is higher in men than women.

There is evidence to indicate that the incidence of tibial shaft fractures has decreased over time. In a Swedish registry-based study, Weiss et al identified a decrease in the incidence of such fractures, from 18.7 per 100,000 person years in 1998 to 16.1 per 100,000 in 2004.[11] Court-Brown et al found that the overall incidence of tibial shaft fractures in adults fell from 27 per 100,000 in 1990[12] to 14 per 100,000 in 2008[13] ; a large part of this trend could be attributed to improved road safety. A 2017 large-scale study, using data from the National Trauma Data Bank, reported an annual incidence of 16.9 per 100,000 population.[14]

An epidemiologic analysis of open long-bone fractures performed over 6 years at the Edinburgh Orthopaedic Trauma unit revealed tibial shaft fractures to be the most common diaphyseal fractures.[4] The authors also analyzed 2450 consecutive fractures of the tibia and the fibula over 3 years.[15] Of these fractures, 21.3% were diaphyseal.

The average age of affected patients rose almost linearly as the injuries progressed from AO type A to AO type C (see Staging). The most common causes were road traffic accidents and sporting injuries. Open fractures accounted for 23.5% of these fractures, with Gustilo grade 3 being the most frequent of the three types. Only 8% were grade 3C, requiring vascular reconstruction.[4, 15]

Results of a later study of open fractures showed that the severity of injury represented by the fracture index was correlated with the injury severity score for each fracture type and location.[16]

Approximately 21% of patients who present with open fractures have considerable musculoskeletal injuries. Those with open femoral fractures tend to be most severely injured. Patients with distal tibial fractures tend to have an injury severity score and a fracture index that are lower than those of patients with diaphyseal tibial fractures. In addition, most vascular injuries occur in persons with diaphyseal fractures, and many of these persons eventually undergo amputation.

Furthermore, tibial shaft fractures in working-age adults have been shown to have a significant financial impact in terms of both direct medical costs and lost productivity.[17]

A review of the burden of nonunion in tibial fractures reported that the incidence of nonunion was 12% percent of all tibial fractures.[18] The risk of a closed fracture going into nonunion was about 10%, whereas the risk of an open fracture going into nonunion was more than double (23%). Notably, the patients who went into nonunion also consumed a greater number of prescription medications in the follow-up period, and the costs associated with their treatment were twice as high.

Age- and sex-related demographics

The average age of those with a tibial fracture is approximately 37 years (men, 31 y; women, 54 y). Data indicate a bimodal distribution, with a preponderance in young men. In fact, the highest incidence of adult diaphyseal tibial fractures is seen in male adolescents aged 15-19 years, in whom the incidence is approximately 109 cases per 100,000. The second peak, which appears after age 80 years, especially affects the female population and is attributed to osteoporosis. However, the demographic patterns could change if stringent gun control laws and better road safety measures were to be instituted.

Tibial fractures in elderly and frail patients are known to be associated with particular problems of their own. It has been reported that there is a change in the pattern of tibial diaphyseal injuries, with increased numbers occurring in women older than 65 years.[19] The rate of open fracture in these patients can be as high as 30%. Nonunion rates approach 10%, with malunion rates of 17%.

The outcome and prognosis of a diaphyseal tibial fracture depend on what Schatzker and Tile called the "personality" of the fracture.[1] Other factors include the location of the fracture, the extent of comminution (which signifies the extent or energy of the trauma), the degree of soft-tissue trauma, the presence of comorbid factors (eg, diabetes), and the presence of polytrauma. Limb-threatening vascular and nerve injuries also substantially alter the patient's prognosis.

The outcomes vary and are universally worse with higher grades of compounding and closed soft-tissue injuries. The method of treatment is also a contributory factor.

In the acute setting, distal vascular injuries are associated with an increased rate of amputation and poorer results after limb salvage. Higher rates of nonunion, delayed union, infection, and amputation are seen in patients with higher grades of soft-tissue and bony injury.

Predictors of secondary procedures in a tibial fracture are an open fracture, a transverse fracture, and a postoperative fracture gap. Smoking and comorbid factors also increase the rate of nonunions. Tibial and fibular shaft fractures are associated with one of the highest nonunion rates (~55 per 1000 fractures annually), which can impose a heavy toll on the healthcare system and lead to prolonged opioid usage.[18]

When the use of external fixators is the primary management, the rate of infection increases with conversion to intramedullary nails, irrespective of the care taken before nailing, with respect to pin-track healing. The prevalence of delayed union and nonunion is also high in fractures with extensive comminution or instability that are treated with nonoperative methods.

The rates of infection and soft-tissue breakdown are sufficiently high with conventional plate techniques that they might be better avoided altogether. However, early results with minimally invasive plate osteosynthesis and locked compression plates are encouraging; the procedures are indicated in selected patients with articular or periarticular extension and metaphyseal comminution.

Long periods in a functional brace or cast uniformly gives rise to severe hindfoot disabilities. Notably, however, these methods have yielded the best results in patients with low-energy fractures.

Intramedullary nailing is the benchmark in the treatment of diaphyseal long-bone fractures. Results are consistent and predictable, and complications are easily manageable. Infection rates have been low in most series, albeit higher in Gustilo grade 3 injuries than in others. In these cases, using an unreamed nail may be judicious. All other fractures, including grade 1, grade 2, and low-grade closed fractures with soft-tissue injury, can be treated with reamed nails. Unreamed nails are best in grade 3B injuries; though it should be noted that the use of unreamed nails is associated with a significant risk of bone healing complications and fatigue failure of locking screws.[20]

A Cochrane review on intramedullary nailing of the tibia failed to find significant conclusive evidence in favor of either reamed or undreamed nailing. However, reamed nailing appeared to have a lower risk of nonunion and implant failure compared with unreamed nails.[21]

The degree of reaming does not have any statistically significant influence on the outcomes of nailing; however, more aggressively reamed tibias tend to have faster healing times and faster return to function.[22]

A French study of 28 cases of isolated tibial fractures found intramedullary nailing to be a useful mode of treatment to prevent nonunion and varus angulation in tibial fractures without fibular fractures. Intramedullary nailing is the preferred first-intention mode of treatment in these injuries.[23]

A review of a about 323 cases of open tibial fractures treated in Singapore showed that there was no difference in infection rates even if the fractures were operated on within 6 hours of admission. The authors found complication rates to be much higher amongst multiply injured patients.[24]

In a randomized controlled trial of 114 patients from Turkey with isolated tibial diaphyseal fractures without fibular fracture who were treated with either plating or intramedullary nailing, Saied et al found that plates yielded a better chance of union in these fractures where the fibula was intact.[25] Patients who underwent intramedullary nailing were more like to require a second procedure for delayed union or nonunion.

Management of high-grade open injuries of tibia and fibula

With the increase in incidence of high-velocity road traffic accidents, there has been an increase in the incidence of open fractures of the tibia. Debridement is the mainstay of treatment to manage the soft-tissue injuries. However, stabilization of the bone is as important as management of the soft tissue to ensure healing of the osteocutaneous injuries. These injuries are also associated with greater incidence of vascular and nerve injuries, which may affect the postoperative course and functional prognosis following injury.

Traditionally, these fractures were treated with wound debridement and external fixation followed by soft-tissue coverage and bone reconstruction. The period of treatment would last from months to years. There has been a trend toward offering single-stage management of these injuries with internal fixation and early flap coverage to improve functional results.

Gopal et al described the acute management of these fractures with the dictum of "fix and flap" using immediate intramedullary nailing and early or immediate soft-tissue coverage, with encouraging results.[26] They suggested immediate or early referral to a suitable center equipped with plastic- and super-specialty services as early as possible.

In another paper analyzing the outcomes of open tibial fractures over 9 years in Singapore, it was observed that the more severe injuries of the tibia were often associated with polytrauma, increased hospital stays, and multiple reoperations. The severity of polytrauma may determine the feasibility of early surgery within 6 hours; the authors mentioned no significant benefits of surgery within 6 hours in this subset of patients.[24]

The special issues incurred in addressing open tibial fractures sustained in combat were assessed and described in a paper by Penn-Barwell et al.[27] The authors noted the need for aggressive prevention of infection and the need for orthopedic plastic surgical management. They also noted the tendency for poorer bony healing in this group of patients. They had an amputation rate of 13%. They did not find a relation between the mode of fixation and the final functional outcomes.

In a review of staged conventional treatment of Gustilo grade 3B/C tibial fractures (external fixation, soft-tissue coverage, and then internal fixation) in a short series of 25 patients, Hu et al reported good and comparable results using their methods and preemptive early bone grafting.[28]

Some papers have highlighted the use of the limb reconstruction system (LRS) as a definitive mode of treatment for Gustilo grade 3A/3B injuries. The results have been comparable with this sturdy single-plane external fixator system.[29, 30]

A retrospective review of the infection and nonunion rates in a group of 120 patients showed that infection rates can be as high as 30% and that smoking can have an adverse effect on both union and infection.[31]

Patient education regarding fractures and their management is important for optimizing treatment results. Useful information is available from a wide range of sources.[32, 33, 34]

Upon admission, a detailed patient history must be obtained to determine the nature of the injury and to determine whether any other injuries are present.

Clinical examination starts with excluding life-threatening injuries and stabilizing all vital parameters. A comprehensive screening to rule out pelvic, abdominal, chest, and head injuries is necessary. Thereafter, attention should be given to the limb to immediately assess for limb-threatening vascular and neurologic injuries.

The patient should be assessed for compartment syndromes, closed soft-tissue injury, and open wounds (see the image below). The extent of injury is roughly classified, with the assessment being completed only intraoperatively. A bulky dressing and an above-knee splint are applied, and radiographs are ordered.

The diagnosis of a traumatic tibial shaft fracture is usually straightforward and is made on the basis of classic symptoms and signs. However, stress fractures can be missed by reason of the subacute or chronic nature of the presentation.[35] The possibility of serious infections (eg, necrotizing fasciitis[36] and gas gangrene[37] ) must be considered in open fractures with delayed presentation, as well as perioperatively in the presence of extensive injury.

Laboratory studies should include a workup for diabetes, neurologic conditions, and cardiac conditions.

Radiographs of the affected limb should be obtained in at least two planes, including anteroposterior (AP) and lateral. Additional oblique views are also occasionally needed to determine the extent of the comminution and the fracture anatomy. Imaging the knee and the ankle as part of the radiographic survey is mandatory. Additional radiographs may be needed to assess for other injuries. (See the images below.)

Computed tomography (CT) or additional radiologic investigations have no role unless articular extension is present.[38]

When a fat embolism syndrome is suspected, it may be necessary to perform arterial blood gas (ABG) analysis, a platelet count, CT of the chest and/or brain, and Doppler ultrasonography (US) of the carotid.[1, 39, 40] The use of these investigations must be restricted to specific indications only.

A swab is collected from the muscle in all open high-grade injuries. The authors culture the swab to specifically rule out spore bearers. In the authors' emergency departments, all patients with open wounds receive prophylactic immunization against tetanus and gas gangrene.

Numerous fracture classifications have been proposed over the past decades. Most of these tend to be descriptive in nature and are based on the following criteria:

• Open versus closed injury
• Involvement of the proximal, middle, or distal thirds
• Number and position of fragments, such as comminution or butterfly fragments
• Transverse, spiral, or oblique fractures
• Varus, valgus, anterior, or posterior angulation
• Displacement or the percentage of cortical contact
• Rotation
• Associated injuries

The Orthopedic Trauma Association (OTA) has divided fractures into three types, each of which has three subtypes, as follows:

• Type A (simple) - A1, spiral; A2, oblique greater than 30°; A3, transverse less than 30°
• Type B (wedge,butterfly fragment) - B1, spiral; B2, bending; B3, fragmented
• Type C (complex or comminuted) - C1, spiral; C2, segmented; C3, irregular

Open fractures

Open fractures are commonly classified with the system that Gustilo and Anderson proposed in 1976 and modified in 1984.[41]  In this system, the grades are defined as follows:

• Grade 1 - The skin opening is 1 cm or less; this injury is most likely due to an inside-out mechanism; muscle contusion is minimal; the fracture pattern is transverse or short oblique
• Grade 2 - The skin laceration is greater than 1 cm, with extensive soft-tissue damage, flaps, or avulsion; a minimal-to-moderate crushing component may be noted; the fracture pattern is simple transverse or short oblique, with minimal comminution
• Grade 3 - Extensive soft-tissue damage includes the muscle, skin, and neurovascular structures; this is a high-velocity injury with a severe crushing component
• Grade 3A - This involves extensive soft-tissue laceration (10 cm) but adequate bone coverage and includes segmental fractures and gunshot wounds
• Grade 3B - This consists of extensive soft-tissue injury with periosteal stripping and bone exposure; it is typically associated with massive contamination and inadequate bone coverage; treatment requires flap advancement or a free flap
• Grade 3C - This is a vascular injury requiring repair

Owing to its importance in determining the prognosis, the Gustilo-Anderson system has gained popular support. However, its main drawback has been the wide interobserver variation in its implementation in clinical settings. The higher grades have complication rates that are uniformly higher than those of the lower grades. (See the images below.)

Subclassification of grade B injury with special reference to limb salvage

Rajasekharan reported that the Gustilo-Anderson classification of the grade 3 fracture was too generalized and was associated with high interobserver and intraobserver variability.[16] Type 3B fractures make up a wide spectrum of injuries, with major complications being common. Accordingly, the author proposed a trauma score for grade 3B open fractures, which was devised to assess injury to the following three components:

• Covering tissues
• Musculotendinous units
• Bone

Severity in each category was assessed on a scale of 1-5. Seven comorbid factors known to influence the prognosis were each given a score of 2; these scores were then summed. Rajasekharan's preliminary results suggested that this system of classification of type 3B fractures is easy to apply and reliable in determining the prognosis after limb salvage and the outcome measures in severe, open injuries of the tibia.

Closed soft-tissue injuries associated with fractures

Tscherne and Oestern classified closed soft-tissue injuries associated with fractures as follows[42] :

• Grade 0 - Soft-tissue damage is absent or negligible; the fracture is a result of indirect forces with a simple fracture pattern
• Grade 1 - Superficial abrasion or contusion is caused by fragment pressure from within; the fracture configuration is more severe than that of grade 0
• Grade 2 - Deep, contaminated abrasion is associated with localized skin or muscle contusion from direct trauma; impending compartment syndrome is part of this grade of injury, which is usually the result of direct violence
• Grade 3 - This injury is characterized by extensively crushed, contused skin and severe muscle damage; other criteria are subcutaneous avulsions, decompensated compartment syndrome, and rupture of a major blood vessel; usually, patients have a severe, complex fracture pattern

Acceptability of reduction

Criteria for acceptability of reduction of tibial shaft fractures in adults are as follows:

• Less than 5° varus/valgus angulation
• Less than 10° anterior/posterior angulation
• Less than 10° rotational deformity
• Less than 1 cm of shortening
• Greater than 50% cortical contact

More angulation along the AP axis and external rotation are both acceptable. Also, external rotation deformities are more easily tolerated than internal rotation deformities.

These traditional guidelines were not based on hard data. Merchant and Dietz assessed the amount of angulation that was compatible with good long-term function and the avoidance of osteoarthrosis by evaluating a group of patients an average of 29 years after a fracture of the tibia.[43] Clinical and radiographic outcomes were unaffected by the amount of anterior, posterior, varus, or valgus angulation. Their data suggested that angular deformities of less than 10-15° are well tolerated over the long term when the development of late osteoarthrosis is considered.

However, some data have indicated that as the level of deformity approaches the distal third of the tibia, even a minor degree of malalignment can affect the ankle joint. The malalignment alters the biomechanics of the ankle joint by decreasing the total area of contact pressure, which results in regions of increased load where the residual contact occurs, leading to increased shear stresses on the articular cartilage and premature osteoarthrosis of the joint.

Malrotation is a less well understood phenomenon in tibial injuries treated with intramedullary nailing. Research published in the Indian Journal of Orthopedics addressed this problem by analyzing the malrotation in 60 patients treated with reamed intramedullary nailing for diaphyseal fractures. A surprising 30% of patients had malrotation greater than 10°.[44]

The two general modes of management for an acute tibial fracture are as follows:

• Nonoperative - External casting with a long leg cast, followed by a patellar tendon-bearing cast or a cast brace; functional bracing
• Operative - External fixation; intramedullary nailing; plating 

Definitive indications for surgery include the following:

• Associated intra-articular and shaft fractures
• Open fractures
• Major bone loss
• Neurovascular injury
• Limb reimplantation
• Compartment syndrome
• Floating knee

Relative indications for surgery include the following:

• Associated intra-articular and shaft fractures
• Unstable fractures
• Inability to maintain reduction
• Relative shortening of segmental fractures
• Tibial fracture with an intact fibula
• Transition-zone fracture
• Polytrauma

Delayed indications for surgery include the following:

• Failure to maintain the reduction
• Unacceptable reduction
• Complications

Reports in the literature have described the effects of growth factor–impregnated sponges and the use of recombinant bone morphogenic protein (BMP) in both closed and open fractures of the tibia. Results with both methods are encouraging, and these products are expected to be available for wider clinical use in the future. The primary factor limiting their use in complex fractures is their cost.

Newer designs and innovations in external fixation and internal fixation techniques, as well as the advent of better imaging and computer-assisted surgical approaches, have improved the efficacy of fixation in compound and closed tibial fractures.[45]

External casting

The use of plaster of Paris casts has long been the most popular method of treatment for fractures of the shaft of the tibia. This method was used irrespective of the degree of soft-tissue damage or comminution or stability of the fracture.

The early days of conservative management of tibial shaft fractures involved a preliminary period of traction followed by the use of a weightbearing cast.

Ernst Dehne first studied the effects of weightbearing casts versus traction followed by casting. He advocated immediate weightbearing in a cast and achieved good results despite shortening of the affected limb. Incidentally, about the time of Dehne's studies, distraction caused by traction was recognized as a probable deleterious influence on union. Sarmiento and Latta noted that the initial shortening rarely increased with weightbearing.[46]

Indications and considerations

Cast immobilization has been the mainstay of treatment for low-energy and minimally displaced fractures of the tibial shaft with a soft-tissue injury of Tscherne grade 0 or 1, provided that postreduction deformity is within acceptable limits. Charnley emphasized the role of an intact soft-tissue hinge and the interosseous membrane for the cast treatment to succeed. High-energy injuries with extensive soft-tissue disruption and comminution are optimally treated with intramedullary rods.

When one opts for cast management, one must be reasonably sure that the above-knee cast is removed in 12-16 weeks and converted to a patellar tendon-bearing cast or brace. Longer periods in a cast cause severe ankle and subtalar stiffness.

A long leg cast is usually applied as soon as possible after the injury. The fracture reduction is best achieved with the gravity-assisted method, with the patient's leg hanging by the side of a table. Bony prominences are padded, and a below-knee cast is first applied and then extended above the knee. In the event of swelling at this time, the cast is slit to the skin and elevated for 48 hours, and the patient is monitored for compartment syndrome. The cast must to be changed after the swelling subsides.

A very common mistake is to apply the cast with the leg extended and an assistant holding the toes. This would create a hyperextension deformity at the fracture site. The degree of flexion allowed at the knee would depend on the desirability of allowing weightbearing in the cast. The lead author of this topic gives 10-20º of knee flexion in the cast if weightbearing is not to be encouraged.

With stable fractures, the patient is allowed to stand and bear weight, as tolerated and comfortable, reaching full weightbearing by 2-3 weeks. Serial radiography at 15 days, 1 month, and 2 months permits close follow-up of the position of the fracture. By 4-8 weeks or when the earliest sign of union is seen, a patellar tendon-bearing cast or functional brace is applied.

This protocol essentially depends on the nature of injury. An excessively comminuted fracture or an isolated tibial fracture with an intact fibula needs a longer period in a long leg cast. The usual consensus is 4-6 weeks of nonweightbearing followed by progression to full weightbearing over 2-4 weeks.

Factors influencing outcomes

Factors influencing outcome and healing times include the initial displacement, the degree of comminution, and the status of the fibula.

In 1998, Littenberg et al performed a matched pair analysis to study the three most common methods of treatment of these fractures.[47] The authors analyzed the literature between 1966 and 1993 and found that the data from the literature were insufficient to establish decision-making protocols with respect to the treatment of closed fracture in tibias. However, it was determined that closed treatment was associated with shorter union times and better functional results than open reduction and internal fixation (ORIF).

It is important to note that in the presence of a documented infection and an external wound, delayed internal fixation should be avoided. The tenets of the Ilizarov method should be followed, and an internal bone transport should be performed. Thus, changing the fixator frame to a hybrid or ring fixator and then internal bone transport would be the best management option in these cases.

Complications

Joint stiffness, mainly of the ankle and subtalar joints, is clearly the major problem associated with casting of tibial fractures. This long-term disability is often associated with fractures that are rigidly immobilized for the full period of treatment in an extended cast.

Joint stiffness is often attributed to plaster disease. However, Tile maintained that the argument for plaster disease needs careful scrutiny.[1] According to Tile, plaster disease is a syndrome characterized by swelling under the cast, followed by permanent stiffness of the immobilized joints, and this condition is a residual of one of the following unrecognized events:

• Compartment syndrome
• Reflex sympathetic dystrophy
• Thromboembolic disease
• Severe soft-tissue injury

McMaster looked at hindfoot disability after the use of a long leg cast.[48] All the fractured tibia were unilateral fractures. The author noted that patients who had good hindfoot function were younger and had been immobilized for a relatively short time in a cast.

Merchant and Dietz retrospectively analyzed long-term outcomes of tibial and fibular fractures at an average of 29 years after surgery.[49] Clinical and radiographic outcomes were unaffected by the amount of anterior, posterior, varus, or valgus angulation. These data suggested that angular deformities of less than 10º-15° are well tolerated over the long term with respect to the development of osteoarthrosis.

Court-Brown analyzed a large body of literature and noted the extreme paucity of detailed analyses of patient function after tibial shaft fractures.[4]

Functional bracing

Sarmiento analyzed, popularized, and refined functional bracing. He published a report of 135 cases of tibial fractures that were treated using a patellar tendon-bearing type of functional brace.[50] The average time to union was 15.5 months, with an average shortening of just 6.4 mm. In a later paper, Sarmiento and Latta discussed the indications for the use of bracing, which included most closed fractures and many open fractures with a low degree of soft-tissue damage.[46] Unstable tibial fractures were excluded.

Rigid attention to detail ensures success with functional bracing in well-selected cases. The patellar tendon-bearing cast was designed on the basis of the patellar tendon-bearing prosthesis used by below-the-knee amputees. (See the image below.) Sarmiento stated that the maintenance of limb length is the result of the hydraulic environment created by the compressed water-rich soft tissue surrounding the fractured limb.

The degree of shortening is determined by the local soft-tissue damage. The motion that takes place between fragments during function and weight bearing is elastic and conducive to union. The use of functional bracing is likely to be successful if the fracture is intrinsically stable (eg, reduced transverse fractures) or axially unstable (eg, oblique, spiral, comminuted), with acceptable initial shortening of less than 12 mm and angular deformities within acceptable limits.[46]

A circular, well-fitting cast or cast brace should be made of a material that can be adjusted to the girth of the limb, which is likely to change with changes in soft-tissue edema and resolution of soft-tissue injury. If this is not done, unacceptable angulation may occur. Angulatory deformity of less than 8° in the mediolateral plane is not of importance and is easily tolerated.

The ideal time for application of the brace is week 2-4 after the injury, when the patient's comfort levels are good enough to permit brace application. The interim period has the limb spent in a cast. Any fracture that is likely to require the patient be anesthetized in order to undergo a reduction is probably unstable and is best managed operatively.

The lead author of this article does not use cast bracing as a primary mode of management of tibial shaft fractures. Rather, a cast brace is applied after the tibia has had an initial period in a long leg cast and some documentation of a primary union has been obtained. Sarmiento’s treatment methods, however, are well documented and can be used when the indications are suitable.

Indications

Indications for functional bracing include the following:

• Low-energy transverse fractures that are intrinsically stable because of lack of displacement or that have been rendered stable after closed reduction
• Axially unstable closed fractures that are oblique, spiral, or comminuted
• Low-energy closed segmental fractures with initial shortening of less than 12 mm
• Grade 1 open fractures that fit these criteria for length and angulation

External fixation, though popularized as the primary treatment of fractures, is currently most popular in the management of complex limb fractures such as diaphyseal fractures that extend into the metaphysis or joint, nonunions, delayed unions, and fractures with infections. External fixators are used as the primary management of high-grade open fractures and as the primary management in damage-control surgery in polytrauma.[51] (See the images below.)

The recommended initial frame constructs include the uniplanar unilateral, uniplanar bilateral, unilateral biplanar, and bilateral biplanar types. (See the image below.) One of the recommended frame constructs is a unilateral and uniplanar frame applied anteriorly or anteromedially on the tibia. Variations of this frame can be devised for fractures that extend into the knee, ankle, or the metaphysis. Application of an external fixator in open injuries should also take into account the requirements of providing a soft-tissue cover. An anteromedial frame might interfere with a cross-legged flap and may need to be revised to an anterior frame. It is best to anticipate this at the primary application itself.

Advantages of external fixators include the following:

• Ease of application
• Good stability
• Excellent access to the limb for wound care and secondary soft-tissue procedures
• Early ambulation

The major problem with external fixators is the high rate of hardware-related complications. Most of these are related to the pins, including pin-track infection, pin loosening, and pin breakage. The prevalence of pin-track infections can be decreased with meticulous attention to detail when the fixator pins are inserted and with good pin-track care. The risk increases with the time the affected limb is spent in the fixator; therefore, a plan to minimize this time is required.

Some of the alternative options are conversion to a cast, dynamization, early posterolateral bone grafting, and conversion to intramedullary nailing.

Dynamization is a procedure wherein the external fixator is modified to allow axial loading and micromotion without permitting torque and loss of reduction. Approximately 0.5 mm of micromotion is ideal; more motion may actually be detrimental. Early removal of the frame and cast application has had mixed responses, with a high prevalence of delayed union and nonunion.

If one opts to keep the frame on the limb once the soft tissue has healed and until fracture union occurs, it may be advisable to carry out posterolateral bone grafting at an early stage. The advantage of this approach is that it permits placement of a large volume of graft material in a well-vascularized virgin area away from compromised anterolateral and anteromedial tissues. Before bone grafting, an interim period during which antibiotic beads are implanted in the wound may be necessary in grade 3 open injuries.

Delayed nailing (see the image below) is associated with a higher risk of infection than primary nailing is, especially if the patient has a history of pin-track sepsis or if the index fracture is a high-grade open injury with contamination and sepsis.

Secondary intramedullary nailing following external fixation is somewhat controversial, especially with respect to the duration of external fixation that is allowable before the risk of infection after later nailing becomes too great.[52]

Siebenrock et al reported that early intramedullary nailing was preferable to plating.[52] Sequential nailing can be performed as early as 2-3 weeks after trauma without the necessity of a safety interval between removal of an external fixator and the insertion of a nail.

According to Court-Brown et al, several principles and indications for nailing after external fixation are applicable.[53, 54] The procedure should be performed as early as possible, before pin sepsis develops, preferably within 4 weeks. Soft-tissue healing should be complete. No pin-track sepsis should be present. No open tracks should be present; one should wait for all pin tracks to heal completely, in a cast or cast brace, if necessary. No ring sequestrum should be visible. Antibiotic coverage should be administered. The preferred procedure is static locked nailing. Finally, reaming should be slow, gentle, and not excessive so as to decrease trauma to the bone and soft tissues.

Indications and contraindications

Indications for external fixation include the following:

• Gustilo grade 3 open fractures
• Tscherne type 2 or 3 closed fractures (to permit fixation without waiting for soft-tissue healing)
• Temporary use of external fixation intraoperatively for reduction
• Limb-lengthening, internal bone transport, and secondary limb reconstruction procedures following primary soft-tissue healing

According to Court-Brown, relative contraindications include the following[53, 54] :

• Osteoporosis
• Poorly controlled diabetes
• Predictable poor patient compliance
• Hemiplegia, tetraplegia, or paraplegia
• HIV or hepatitis B virus (HBV) positivity
• Severe vascular disease

Intramedullary nailing is the gold standard in the treatment of diaphyseal long-bone fractures. The options include the following:

• A single unlocked nail (eg, Lottes nail, V nail or Küntscher-Herzog nail, Küntscher nail, Rush rod) ^[55]
• A single, large-diameter, interlocking tubular nail, with or without reaming
• Multiple flexible intramedullary pins (although this is less popular)
• An expandable nail

The most important indication for the use of an intramedullary nail in tibial fractures is an unstable diaphyseal tibial fracture. Factors involved in classifying a tibial fracture as unstable include the severity of the soft-tissue injury, the scope of articular extension, the presence of a complete initial displacement, and comminution that exceeds 50% of the circumference of the bone. The presence of transverse fractures, fractures of the fibula, and fractures of both the fibula and tibia are indicative of a high-energy mechanism and should be a contraindication for nonoperative management. (See the images below.)

Goals of management

The goal of management is solid union within a reasonable time period. Results should be comparable to those of closed management.

Treatment failures should be minimized, and secondary procedures such as bone grafting and nail exchanging should be avoided in order to decrease the prevalence of implant-related complications such as nail and cross-bolt breakage and pin-track infections. Intramedullary nails are the ideal implants for closed diaphyseal, short oblique, simple transverse, or short oblique fractures with or without comminution. Extended indications include proximal and distal metaphyseal extension of a diaphyseal fracture and more proximal and distal fractures.

With grade 1 or 2 open injuries and closed Tscherne type 0-2 injuries, Court-Brown et al found that the results of closed nailing were essentially good, but a detailed analysis of the treatment times indicates that union times increase as the degree of soft-tissue injury increases.[54]

Most orthopedic surgeons agree that Gustilo grade 1 and 2 open fractures can be safely treated with emergency closed intramedullary locked nails without much increase in nonunion or infection rates. The preferred method is use of a static locked nail. Infections or nonunions can be successfully managed by exchange nailing. Puno et al also found that the results of intramedullary nailing are superior to those of casts.[56]

Court-Brown et al have written extensively on high-grade open tibial fractures treated with reamed and unreamed intramedullary nails, aggressive soft-tissue management and early coverage, and exchange nailing and bone grafting early when indicated.[53, 54]  They reported high union rates and manageable complications.

Petrisor et al evaluated the possible causes of intramedullary infection in closed and open fractures treated with reamed intramedullary reaming.[40]  The authors noted the causes of infection, possible effects on union time, and the requirement for additional reconstructive procedures. Of the closed fracture group, 43.8% developed infection; the causes were related to inappropriate fasciotomy closure and poor attention to exchange nailings. In open fractures, the rate of infection was 62.5%, attributed to complications of plastic surgery.

Petrisor et al noted that most infections are preventable if one pays adequate attention to details.[40]  Particular attention must be paid to correct reaming, exchange nailing, and fasciotomy closure in closed fractures. In open fractures, marginal flap necrosis should be actively treated and not left to granulate.

Antibiotic-coated interlocking intramedullary nails have been developed that may be used in the treatment of tibial shaft fractures. A propsective randomized study by Rohilla et al compared the functional and radiologic outcomes of primary ring fixator with those of antibiotic-coated nails in open tibial diaphyseal fractures.[57]  The two approaches achieved comparable rates of union and similar complication rates. Functional and radiologic outcomes were comparable in the two groups. The authors concluded that the use of antibiotic-coated intramedullary nails can be a reliable option for open grade 2 and grade 3A injuries.

In a systematic review and meta-analysis (N = 712) addressing dynamic (n = 234) versus static fixation (n = 478) in intramedullary nailing of open tibial diaphyseal fractures, Loh et al found that primary dynamic fixation yielded a significantly shorter average time to bony union and a lower reoperation rate.[58] It remains to be determined which patient factors and fracture patterns would best benefit from dynamic fixation.

Reaming

Brumback and Virkus pointed out that the terms "small-diameter nailing" and "large-diameter nailing," which are often used for unreamed (small diameter) and reamed nails (large diameter), do not specify whether reaming is part of the nailing process. Therefore, such terms are best avoided.[59]

The term reamed nail is used for the technique wherein the proximal and distal fragments are reamed with the specific intention of enlarging the endosteal diameter to permit insertion of the largest possible nail diameter. The instrumentation inside the medullary canal has the potential to disrupt the blood supply to the endosteum, especially where the nail fit is the tightest.

This type of vascular disruption is less with unreamed nailing because the fit is relatively looser, with more space between the endosteal cortex and the nail. Additional damage to the endosteum can be caused by the rise in temperature that is associated with reaming, causing thermal damage in addition to the mechanical effects.

Nailing is also associated with an elevation in intramedullary pressure, which disseminates fat and marrow emboli into the systemic circulation, with the potential to cause acute respiratory distress. This risk is higher with reamed nails. Careful intraoperative assessment and meticulous technique, including the use of slow and gentle reaming in a to-and-fro motion with sharp reamers, can significantly limit the risk of this complication, as does good hydration during and after surgery.

Reaming has the following advantages:

• It ensures passage of the intramedullary nail into the center of the medullary canal without obstruction or incarceration
• It permits insertion of the largest possible nail, providing better resistance to fatigue failure
• It increases endosteal contact with better stability
• The reaming material deposited at the fracture site is thought to have an osteogenic effect, much like a bone graft

The use of reaming in Gustilo 3 fractures is still controversial. Devascularization of the cortex, inherent to reaming, leads to a higher complication rate with respect to infection, nonunion, and delayed unions. The combination of endosteal damage and bone necrosis resulting from injury can cause extensive damage. This, in association with the insertion of a tight intramedullary nail and a potentially contaminated soft-tissue environment, gives rise to the higher risk of infection.

Advantages of unreamed solid nails include the following:

• Less damage to the intramedullary circulation
• Lower infection rates in open and high-grade, closed soft-tissue injuries
• Feasibility of use in high-grade open fractures
• Decreased risk of compartment syndrome in at-risk limbs

Tile described the use of unreamed solid nails as "conventional wisdom in the management of open injuries and in fractures associated with extensive soft-tissue injury."[1]

Several disadvantages of using unreamed solid nails are noted. This approach involves small-diameter nails; hence, by necessity, they are solid and stiff. The locking screws must also be smaller than standard nails. When a small-diameter nail is used in a wide canal, a blocking screw may be used in the canal to ensure central placement of the nail. Such screws are known as Poller screws.

The most common complication is failure or breakage of the nails and cross-bolts. The construct is less stable with unreamed nails than with reamed nails. In addition, the risk of failure is higher with fractures that are more proximal or distal or that extend into the metaphysis. Finally, delayed unions and nonunions are more prevalent with the use of unreamed nails than with other methods.

Prospective studies comparing reamed nails with unreamed nails have confirmed the efficacy of reamed and locked nailing in low-energy and low-grade tibial fractures. The benefits and disadvantages of reaming are in question only with Gustilo grade 3 fractures. In these cases, the use of a statically locked unreamed nail is recommended.

Reuss and Cole analyzed the effect of delayed treatment on open tibial fractures.[60]  In a series of 77 patients with 81 tibial fractures, the authors found that time to fixation was not a predictor of nonunion or infection. Conversion nailing from external fixation to intramedullary nailing had a significantly higher rate of infection. Severity of injury had a definite influence on outcomes, and multiple debridements and infection were related. Longer time to treatment up to 48 hours did not adversely affect outcomes—provided that adequate trauma department open fracture care and early initiation of antibiotics were coupled with standardized and thorough debridement in the operative theater.

Although closed reduction is the usual procedure, it may at times be necessary to perform an open reduction of the fracture through a minimal incision rather than accept an inappropriate reduction.

Tang et al studied the relative risks of infection if open reduction had to be carried out during intramedullary nailing.[61]  The authors showed that “limited open techniques can greatly facilitate the reduction of closed tibial shaft fractures but raise concern for infection through exposure of the fracture site" and that although the rate of infection for open reduction was higher relative to closed reductions, the difference was not statistically significant.

One-stage reconstruction in grade 3B injuries of the tibial shaft was reported by Tropet et al.[62]  The study involved five patients and described a combination of two procedures in the emergency department: internal stabilization of the bone by intramedullary locked nailing whenever possible and coverage of the fracture site with a pedicle (upper third of the leg) or free muscle flap (lower third of the leg).

When there was extensive bone loss, Tropet et al also performed autogenous cancellous grafting. They reported no nonunions and excellent functional results, concluding that “Aggressive emergency management of severe open tibial fractures provides good results... improves end results markedly, not only by reducing tissue loss from infection, but also reducing healing and rehabilitation times.”[62]

Expandable nails

Used in the unreamed fashion, expandable nails are formed of a hollow rod that can be inflated once inside the canal, with normal saline and the use of a special pump. Expandable nails were created to retain the advantages of large-diameter nails and to improve the torsional stability, while avoiding the biologic disadvantages of reaming and inserting tight-fitting, large-diameter intramedullary nails.

The nail is folded longitudinally in a specially designed press. This tubular structure is sealed distally with a cone-shaped cap and proximally with a one-way valve. The cross-section of the nail is circular with four reinforcement bars; after expansion, abutment of the longitudinal bars to the inner surface of the canal along its entire length provides fixation of the nail to the bone, ensuring no risk of migration, rotatory stability, fragment alignment, and the length of the fragments, excluding the need for interlocking screws.[63]

The clinical and economic factors of using both expandable and interlocking nails was explored by Ben Galim et al.[64]  They noted that using expandable nails decreased surgical and hospital costs by 39%. In addition, expandable nails showed important clinical advantages for the fixation of tibial fractures, and complications related to lengthy operations, reoperations, and rehospitalizations were substantially reduced.[64]

The use of plates has been associated with a high rate of complications in the tibia (see the image below), leading to a paradigm shift toward the use of intramedullary nails.

In the past few years, there has been a significant effort to reduce the incidence of plate-related complications such as stress shielding and refracture by using biologic principles and indirect reduction techniques. The principles used have led to the development of the point-contact fixator plate (PC-FIX), the limited-contact dynamic compression plate (LC-DCP), the less-invasive stabilization system (LISS), and the locking compression plate (LCP; see the images below), which combines the best features of the dynamic compression plate (DCP) with that of the locking plate.

Indirect reduction techniques and minimal but optimal use of implant material is a current concept for achieving undisturbed fracture repair in diaphyseal and metaphyseal fractures.[65]  The aim of fracture fixation is no longer rigid anatomic fixation. Rapid integration of unreduced but vital fragments into the fracture callus, which increases the mechanical strength of the fracture and reduces the risk of overload and fatigue failure of the implant, seems to be most important. Thus, biologic techniques maintain alignment by bridging the fracture without compression, rather than relying on absolute rigid fixation through compression. These are frequently referred to as “internal splintage” fracture fixation methods.

Some of the plates used include the LISS and the PC-FIX, the noncontact plate (NCP), the Zespol plate, and the LCP. These plates are not just simple plates but complex systems with holes designed to fit the region in question. The LCP in particular has been designed to incorporate the features of the locking plate as well as the DCP in the same hole (see the image below), thus providing versatility for the operating surgeon.

It is also important that the plate itself stays off the bone, making no contact with the periosteum, thus functioning essentially as an internal fixator.[66]  This means that the plate is fixed in the bone at a stable angle without direct contact between the plate and cortical bone.

Technically, the angular stability is achieved by means of an entirely new screw and plate design. The screws have a smaller pitch and, consequently, a higher core diameter and are firmly fixed in the plate. This fixation in the plate is achieved with a conical thread on the screw head and a corresponding conical threaded hole in the plate. When locked in this way, the screw is axially and laterally secured without pressing the plate onto the bone in the process. In contrast to previous conventional systems, the stability of the bone fixation is not achieved by pulling the fragments toward the plate.[66]

The use of minimally invasive percutaneous plate osteosynthesis (MIPPO; see the images below) has been found to be effective in metaphyseal and diaphyseal tibial fractures.[67]

Preparation for surgery

Preoperative planning is essential to achieve the goals of treatment as defined earlier. This planning starts with assessing the characteristics of the fracture, determining the degree of soft-tissue injury, and evaluating the extent of the fracture and the presence of any comorbid factors and life- or limb-threatening injuries.

Once preoperative planning is completed, the implant is selected. If the patient does not have a soft-tissue injury or has only a low-grade soft-tissue injury, locked intramedullary nailing is the operation of choice. Internal fixators such as the LCP may be a better choice than conventional plates. Conventional plating poses a risk of soft-tissue breakdown (see the image below) and should be avoided. The authors prefer biologic plating and MIPPO.

Once the implant and system are selected, the appropriate size is determined. The length of the nails needed can be determined by means of many different methods, including scanograms, spotograms, intraoperative radiography, the two-guide-wire technique with reamed nails, and preoperative templates, or assessing the nail against the limb on fluoroscopy images in cases of unreamed nails. An analysis of these methods showed that the preoperative technique of joint line–to–joint line measurement is the most error-free and reproducible method for planning nail length.

Technical details

The limb position for nailing may vary with the surgeon. The most common position is the leg hanging with the knee flexed to 90º, with a bolster placed under the knee. However, the best method is placement on a fracture table, with the knee flexed 90° with a calcaneal pin for traction. This method permits good control of length and rotations and unobstructed motion of the image intensifier.

The incision for nailing is identified on the basis of the entry point. The authors of this topic prefer a paramedian incision approximately 2-3 cm in length; the entry portal may be taken through the patellar tendon or next to the patellar tendon after retracting it to one side. Reamed nails are preferred, except in type 3 Gustilo injuries, wherein an unreamed nail is preferred.

The progress of the reamer in the canal must be carefully observed. The reamer should be slowly advanced in a to-and-fro motion without any exertion of pressure. This method not only prevents incarceration of the reamer in a tight canal but also decreases other potential for deleterious effects.

Maintenance of hydration and good intraoperative monitoring are mandatory for preventing fat embolism and acute respiratory distress.

Distal locking is performed freehand by using the standard techniques of visualizing the locking hole as a perfect hole on the lateral image and then using an aiming device to introduce the bolt.

The number of cross-bolts depends on the fracture configuration. In an uncomplicated comminuted fracture, the authors of this topic routinely lock both cross-bolts proximally and distally. Before locking, ensure that no fracture gap has been left and that the alignment has been restored well; these steps help prevent early failure. (See the images below.)

The authors routinely use a tourniquet for nailing and plating procedures, as well as drains in posterolateral bone grafts and plating procedures. However, in nailing operations, suction drains are avoided.

Antibiotics are given immediately before and after surgery for 24-48 hours. The use of antibiotics is therapeutic, not prophylactic; therefore, antibiotics should not be misused, even in the treatment of open injuries.

A bulky postoperative dressing is applied, and the limb is elevated on a pillow or pillows for 48 hours. Compartment pressures must be monitored if the limb is deemed to be at risk for compartment syndrome.

Once the patient is comfortable, he or she is allowed to be mobile on a walker or crutches. Weightbearing is permitted in nailing procedures, depending on the fracture configuration. In a simple low-energy fracture, immediate weightbearing is permissible. Otherwise, instituting nonweightbearing or partial weightbearing schedules is preferred. Patients undergoing plating and external fixation should not be allowed to bear weight until signs of healing are evident radiologically.

In extensively comminuted fractures, the authors of this topic use a well-molded functional brace to provide added protection and to stimulate early healing.

The use of reaming in Gustilo type 3 fractures is still controversial. The devascularization of the cortex inherent to reaming leads to a higher complication rate with respect to infection, nonunion, and delayed union. Furthermore, the combination of endosteal damage and bone necrosis due to the injury can cause extensive damage. This, in combination with the insertion of a tight intramedullary nail and a potentially contaminated soft-tissue environment, gives rise to the increased risk of infection.

Compartment syndrome is a transient increase in intracompartmental pressures. The extravasation of reaming material and blood into the tight tibial compartments can increase the risk of compartment syndrome.

Anterior knee pain can be a complication. Possible causes are multiple injuries, ipsilateral fractures in other bones, the presence of a proximal locking screw, quadriceps weakness, an unrecognized knee injury, and the incision itself, among others.

Neurologic damage can occur as a result of traction, local pressure from the limb being in casts or splints, soft-tissue injury, and injury to the fibula or proximal tibiofibular joint.

Other complications include thermal injury to the cortical bone, posterior cortical perforation, screw discomfort, delayed union or nonunion, amputation, and implant failure.

Another risk is pulmonary embolism (PE) and acute respiratory distress syndrome (ARDS) with the dissemination of fat emboli into the system. Fat embolism syndrome has been defined as a complex alteration of homeostasis that occurs as a complication of fractures of the pelvis and long bones, manifesting clinically as acute respiratory insufficiency, cerebral dysfunction, and petechial rash occurring 24-48 hours after injury.[39] This syndrome has been estimated to occur in 0.5-11% of all long-bone fractures and approaches an incidence of 5-10% in multiple fractures associated with pelvic injuries.

Gurd’s criteria for diagnosis of fat embolism syndrome are divided into major and minor features; the diagnosis requires at least one major feature and at least four minor features.[39] Major features are respiratory insufficiency or hypoxemia, central nervous system depression, and petechial rash. Minor features are pyrexia, tachycardia, retinal changes, jaundice, presence of fat in the urine or oliguria, sudden anemia or thrombocytopenia, high erythrocyte sedimentation rate (ESR), and fat macroglobulinemia. Fat embolism syndrome can be further subcategorized into primarily neurologic, pulmonary, or systemic.

Orthobiologics and pharmacologic interventions for bone healing enhancement

In a systematic review of the role of orthobiologics and pharmacologic interventions for bone healing enhancement in acute diaphyseal long-bone fractures, Morongiu et al identified strong evidence supporting the use of bone grafts, both vascularized and nonvascularized.[68] The use of demineralized bone matrix and phosphate ceramics for acute tibial fractures with or without segmental bone defect has been supported by a few high-level studies. Among growth factors, recombinant human BMP-2 (rhBMP-2) has shown strong evidence of efficacy in acute open tibia fractures; recombinant human fibroblast growth factor (rhFGF) showed good healing rates when combined with intramedullary nailing. 

Current evidence limits use of bone marrow aspirate concentrate (BMAC) and platelet-rich plasma (PRP) techniques to the treatment of long-bone nonunions.

Although data on the use of teriparatide in acute long-bone fracture healing remain limited, promising results have been shown in atypical femoral fractures, periprosthetic femoral fractures, and atypical periprosthetic femoral fractures.

A healthy diet with adequate amounts of both macro- and micronutrients is essential, both for decreasing fracture risk and for enhancing the healing process after a fracture. A balanced diet that covers the daily caloric needs and the required daily intake of calcium and vitamin D is advised.[69]

The success of any kind of treatment of any long-bone injury is best measured by the time to return to preinjury activity levels. Hence, early recovery demands good commitment to a physical therapy program so as to maintain or regain good joint motion and muscle power. The specific rehabilitation plan will depend on the clinical status of the patient, the choice of treatment (conservative vs surgical), and the type and strength of the implant (load-bearing vs load-sharing). 

Chest physical therapy has been shown to be effective in maintaining pulmonary function and preventing or reducing respiratory complications in multiply injured patients. 

Better fixation techniques and clear protocols for rehabilitation have allowed early motion of the knee and ankle. Controlled but appropriately aggressive early mobilization and range of motion (ROM) with progressive weightbearing, combined with multimodal pain control and psychosocial support, help achieve early recovery.[70]

It is necessary for individuals to wear necessary protective equipment (eg, pads or guards) to prevent injury when engaging in contact sports (eg, soccer, hockey, or rugby). Evidence suggests that stress fractures can be prevented by reducing the amount of weightbearing exercises performed, without sacrificing fitness.[71] Also, it is essential to start exercising gradually and reduce the initial training volume before progressing to a vigorous exercise program; this is especially true for recreational athletes, who are the ones most vulnerable to stress fractures. 

Once mobile, the patient is discharged from inpatient care. Radiographs should be obtained at periodic intervals. The authors of this topic prefer intervals of 3 weeks, 6 weeks, 3 months, and every 6 weeks thereafter until radiologic evidence of union is apparent.

Regaining full knee and ankle function should be stressed while the union is being achieved. As signs of union are noted, crutches may be discarded in favor of a cane. If union is delayed or is not progressing, early bone grafting or exchange nailing to stimulate union is better than other approaches.

Various scales have been devised over the years to quantify progress of union in the tibia, including the following:

• Hammer scale
• Tower scale
• RUST (Radiographic Union Scale for Tibial fractures) ^[72]

The RUST score assesses the presence of bridging callus and a fracture line on four tibial cortices (anterior, posterior, medial and lateral) seen on orthogonal radiographic views, with each cortex receiving a score of 1 to 3. A cortex with a visible fracture line and no callus is scored as 1; a cortex with callus and a visible fracture line was present is scored as 2; and a cortex with bridging callus and no fracture line within the callus bridge is scored as 3. RUST has good interobserver and intraobserver correlation and has proved to be reliable for predicting tibial fracture healing.[73]