Diaphyseal Tibial Fractures Treatment & Management

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]