TIBIAL FRACTURES

BENJAMIN MUKULU NDELEVA

Egerton university
 OUTLINE
• TIBIAL PLATEAU (PROXIMAL TIBIA)

• TIBIAL SHAFT

• TIBIAL PLAFOND (DISTAL TIBIAL)

 OUTLINE
• INTRODUCTION
• ANATOMY
• PRESENTATION
• INVESTIGATIONS
• CLASSIFICATION
• TREATMENT
• COMPLICATIONS
TIBIAL SHAFT FRACTURES
 INTRODUCTION

• The tibial is the most commonly fractured

long bone

• More commonly sustains an open fracture

than any other long bone

• Injuries range from non dispalced closed #s

to traumatic amputations
The Tibia as a Bone

• Differs from femur,

humerus
• Blood supply 75%
endosteal
• Subcutaneous
• Weight bearing
OCCURRENCE

• UK data:incidence 2 per 10 000 per year.

• Males > Females.

• Aetiology: > 50% MVA (boda boda)

Sports
PATHOMECHANICS

Twisting force - spiral fracture at different

levels of both bones

Angulatory force - transverse/short oblique

fracture at the same level.

Direct injury usually high energy i.e. MVA

Indirect injury is usually low energy-

spiral/long oblique #
CLINICAL PRESENTATION

• History of trauma
• Evaluate patient: ATLS principles.
• Examine limbs for:
• Bruises
• Swelling
• Deformity
• Open wound
• Absent or weak pulses
• Sensation
• Motor deficits/loss of function
RADIOLOGICAL INX

X-RAY
• AP and LAT views (rule of twos)
• Oblique views at 45°(nondisplaced spiral #s)

• Note:# type
Level
Rotation
Angulation
Translation
Shortening
AO CLASSIFICATION
CLASSIFICATION
• AO
TREATMENT

Goals of treatment:
1.Complete union 6 months without
complications.
2.AP Angulation <10º
3.Varus / Valgus angulation <5º
4.Rotational alignment<10º
5.<1.5 cm of shortening
Options for Treatment
I. Non-operative Rx:
1. Plaster of Paris
2. Functional Bracing

II. Operative Rx.

1. Intramedullary Nailing
2. External Fixation
3. Plating
POP

• Undisplaced/minimally displaced #s.

• Reduce under sedation
• LLC 6-8wks with partial weight bearing
• Then PTB cast 6-8wk WBAT.
• PT
Long leg Cast
PTB CAST
• A sarmiento cast
Indications for operative RX

• Bilateral #s
• Pathological #s
• Severe knee ligamentous injury
• Ipsilateral injury - Floating knee,
ankle/calcaneus #.
• Segmental #s.
• Polytrauma
INTRAMEDULLARY NAILING

• Method of choice for internal fixation.

• Union in 95% cases.
• Less suitable for #s near bone ends.

• Non-reamed im-nail for Gustilo I II and

IIIA
IM NAILING
EXTERNAL FIXATION

Main indication:
Open #s.
Poor surgical risk pt.

Advantage:
Good access to soft tissue care.
Avoids # site exposure
Allows adjustments to be made
PWB allowed. Compression.
TIBIAL PLATEAU
FRACTURES
 INTRODUCTION
• Originally termed a bumper or fender fracture

• Force is directed from the femoral condyles onto

the medial and lateral portions of the tibial plateau,

• Young pt - # pattern = Splitting

• Older pt - # pattern = Depression/Comminution

Osseous Anatomy

 Proximal Tibia
 Widens into lateral and medial tibial flares
 Flares lead to medial and lateral plateau
(condyles)
 Intercondylar eminence
 Tibial tubercle (patellar tendon)
 Proximal tib/fib joint
 Epidemiology
• Mean age in most series of tibial plateau fractures is
about 55 years
– Large percentage over age 60

• Comprise 1% of all # & 8% of all #in the elderly pop

• Older women >older men

Clinical Details

• Patients may present with:

– Knee pain
– Knee effusion (Swelling)
– Inability to bear weight on the limb
Physical Exam

 Vascular exam
 Popliteal artery and medial plateau injuries
 Beware of posteriorly displaced fracture fragments

 Neurologic exam
 Peroneal nerve!

 Ligamentous/ Meniscal injuries

Radiological investigations

• Include
– AP

– Lateral

– Oblique views (40 degrees) if fracture not well

visualized.
Radiographs
CT image through tibia plateau
Classification: Schatzker

I
Type I: consists of a wedge
fracture of the lateral tibial
plateau, produced by low-
force injuries.
Classification: Schatzker

Type II: combines the

wedge fracture of the
lateral plateau with
depression of the lateral
plateau.

II
Classification: Schatzker

III
Type III: fractures are
classified as those with
depression of the lateral
plateau but no
associated wedge
fracture.
Classification: Schatzker

Type IV is similar to type

I fracture, except that it
involves the medial tibial
plateau as opposed to
the lateral plateau.

IV
Classification: Schatzker

Type V fractures are

termed bicondylar and
demonstrate wedge
fractures of both the
medial and lateral tibial
plateaus.

V
Classification: Schatzker

Type VI fractures consist

of a type V fracture
along with a fracture of
the underlying diaphysis
and/or metaphysis.

VI
The goals in treatment of a tibial plateau
fracture are to obtain a stable, aligned,
mobile, and painless joint and to minimize
the risk of posttraumatic osteoarthritis.
Urgent Treatment
• Beware of Compartmental syndrome

• Provide temporary external stabilization

– Relieves pain
– Stabilizes bone and soft tissues

• Consider spanning external fixation if:

– Complex fracture pattern
– Large amount of shortening
– Soft tissue conditions or other injuries make
immediate ORIF unsafe
Treatment …cont’d
Most Shatzker #s treated operatively

Indication for surgery are:

– Fractures associated with instability,
– Articular incongruity
- 5mm young pt, 10mm elderly pt
– Ligamentous injury,
– Significant articular displacement;
– Open fractures; and
– Compartment syndrome
Treatment …cont’d
• Less than 5 mm in stable fractures, nonoperative,
early motion and delayed weight-bearing.
Prognosis

• According to classification and type and

adequacy of treatment.

• Type I to IV can have good prognosis if well

managed

• Type V and VI may be followed by arthritis

Complications
• Associated soft tissue injuries e.g. collateral lig,
menisci, cruciate lig, etc
• Neurovascular e.g. femoral/popliteal aa
• Compartment syndrome
• Arthritis
• Malunion
• Joint instability
• Stiffness
• Associated injuries
PILON FRACTURES
Introduction

• AKA Distal tibia intraarticular #s = tibia

plafond #s
• 85% fibula involvement
• Risk of complications is high
• Causes:
– low-energy rotational forces
– high-energy axial compression forces arising
from MVA or falls from a height
Epidemiology

• Less than 10 % of all lower extremity #

• Males > females

• Less common to children and elderly

• Average age 35 to 40 years

Classification cont…
AO/OTA
Radiological evaluation
• X-ray; - Standard AP and LAT views plus

- Mortise view.

- Contra-lateral ankle X-ray (“template”)

• CT Scan
Treatment

• Closed reduction & splinting – Role limited

– Applied in few injuries, minimal displaced
Type A or Type C1 #s.

• However, true pilon # need ORIF

Complications

• Malunion
• Non union and delayed union
• Sepsis
• Stiffness – ankle
• Ankle OA