Tibial Shaft Fractures

Transcription

1 Tibial Shaft Fractures Mr Krishna Vemulapalli Consultant Orthopaedics Surgeon Queens & King George Hospitals

2 Queens Hospital 14/03/2018 Google Maps Map data 2018 Google 10 km

3 Orthopaedics Department Covers > M population 12 Trauma & Orthopaedics Consultants 2 Trauma Consultants One of the Busy Trauma department 24 Trauma lists per week Hip fractures per year

4 FOOT AND ANKLE Paediatric Orthopaedics 29/03/2018 Vemulapalli

5 Services Ponseti Treatment- Club foot/ Talipes DDH Diabetic Foot Service

6 Courses Queens Ponseti Course Queens FRCS(orth) Clinical course- Queens Orthopaedics for Emergency staff (A&E) Queens Foot & Ankle Course

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9 Tibial shaft fractures Surgical anatomy Epidemiology Investigations Classification Treatment Plaster cast- non operative Operative treatment Open Fractures Compartment syndrome

10 Anatomy- structure & function Tibia- Latin word- means Flute 2 nd largest bone in body Articulates with Femur above and talus below Carries 5 times the body weight Tibia is subcutaneous for much of its course- prone for direct trauma

11 Surgical Anatomy Strong, Noncompliant fascia completely surrounds the muscle accompanying the tibia

12 Epidemiology Most common long bone fracture Incidence-26/ Most fractures are found in young males Male-41/ Average Age 31 Female-12.3/ Average Age 54yrs Second peak in elderly patients.

13 Why is it important? Most common Long bone fracture-492,000 fractures/year Most common Open Fracture Significant cost 569,000 hospital days Major cause of disability Significant complications 50,000 non unions /year

14 Mechanism of injury & Presentation Direct trauma- sports RTA Unable to weight bear Pain; swelling and deformity of the leg? Bleeding from open wound

15 Diagnosis Fracture-Very Obvious Soft tissue assesment Open or closed Compartment syndrome

16 Investigations X-ray- AP/Lat Knee and Ankle to be included

17 Investigations CT scan Planning the operation For assessing the # extension into the joints

18 Radiographs 1. The location and morphology of the fracture 2. Presence of secondary fracture lines 3. Presence of Comminution, signifying a high energy injury 4. Bone defects/missing bone 5. Fracture lines extending into the knee or ankle

19 AO Classification

20 Treatment Goals 1. Establishing Bone union 2. Establishing and Maintaining normal length, alignment and rotation 3. Establishing and maintaining the normal anatomical relationship between the knees and ankles for weightbearing, motion and Propulsion

21 Treatment Options Non operative Cast or Braces Operative IM Nailing Plating External fixator Mono or Circular

22 Non-operative Treatment

23 Nonoperative treatment Non operative treatment does NOT mean no treatment Closed reduction and plaster of Paris application achieve good results Non operative treatment is difficult and demanding

24 Cast Treatment- Indications Low- energy Stable Un displaced or Minimally Displaced Isolated Tibial shaft Fractures

25 Cast Treatment- Contraindications High Energy Unstable Segmental Off-ended Excessive shortened ( >1 cm) Neuro vascular damage Compartment syndrome Macerated/damaged Skin Polytrauma

26 Advantages of Cast No infection No need of sophisticated equipment Can be readily performed under most Spartan conditions Cast failure is easier to correct than implant failure It does not make subsequent operative treatment impossible

27 Disadvantages of Cast Requires a compliant patient Patient must accept some deformity- Malunion; Delayed union Accept the possibility of prolong treatment Ankle & Subtalar Stiffness

28 Non operative treatment Plaster can prevent lateral shift Plaster can prevent angulation Plaster can control rotation Plaster can NOT prevent shortening

29 Cast Treatment Weight bearing Long Cast application with 5-10 degrees flexion of knee for 4 weeks Patellar tendon-bearing cast / brace for 4-6 weeks Weekly X-rays for the first 3-4 weeks Continue brace until osseous union demonstrated on X-rays

30 Cast Application- Treatment Under Analgesia or Spinal or General Leg Hanging of table with knee flexed ( Relax Gastrocs and allows traction by Gravity) Fracture reduced Padding starting from toes with extra padding over the heel, malleoli, fibula neck Plaster applied from toes to just above the Tibial tubercle

31 Cast application. Molding with palms done over medial tibia, behind both malleoli, over the arch of the foot No molding over the fibular head or Tibial tubercle Plaster extended proximally 2 finger breadths below the greater trochanter Knee flexed 5-10 degrees

32 Following cast Xray to confirm the position For Angular deformity corrections <10 degrees- Wedging

33 Cast wedging Can be Open or Close Wedging Open wedging- Minor risk of distraction of fracture Close wedging- Pinch or compress the skin- Necrosis Can be at site of fracture-watson or junction of long axis of 2 fragments

34 Stop Casting Operative Rx Malposition of >10 0 Shortening of > 1 cm Repeated wedging Wedging more than 10 0

35 Operative Treatment Internal fixation IM Nails Reamed or Un reamed Plates Classic or MIPO External fixation Unilateral Circular Hybrid

36 Indications of internal fixation Failed Closed treatment Unstable tibial fractures Ipsilateral tibial & femoral fractures Fractures with intra articular extension Segmental fractures Bilateral tibial fractures Open fractures Pathological fractures Fractures with vascular complications & compartment syndrome

37 Internal Fixation- IM nailing Work Horse Indicated in most of the shaft fractures Fracture Zone should be 5 cm below Knee and 5 cm Above Ankle Reamed Vs Unreamed Locking Vs Unlocking

38 Operative treatment- Nailing- Advantages Indirect reduction which preserves softtissue attachments Allows movement at fracture site which results in early union with callus formation Anatomical reduction rare but restoration of length, axis and rotation is usual

39 Nailing- Advantages Nails function as internal splints Nails can withstand heavy loads Nails can be mobilized with early weight bearing

40 Complications of IM nail Anterior knee pain Thermal necrosis Destroys endosteal circulation Iatrogenic fracture Compartmental syndrome

41 Plate & Screws

42 Internal fixation- Plates & Screws- Indications Metaphyseal fractures Fractures extending into Knee or Ankle joint Malunions Nonunions

43 Internal fixation- compression plate- facts Destroys periosteal circulation Direct reduction will destroy soft tissue attachments Rigid fixation will result in slow union without callus formation Anatomical reduction Plates cannot withstand weight-bearing forces Plates will not permit early weight bearing

44 Internal fixation- Plates & Screws Disadvantage Skin Necrosis* Wound Dehiscence Infection Restricted weight bearing Non union Re fracture (After plate removal) *avoid tourniquets ( <20%)

45 Ex-fix

46 Ex-Fix Mainly used in Sick patient Sick limb

47 External fixation- Indications Open fractures Fractures with bone loss Nonunion Malunion Infected nonunion Closed fractures complicated by Compartment syndrome Vascular injury Head injury Burns Impaired sensation

48 Types of Ex fix Mono Circular Hybrid

49 Disadvantages Pin track infections High rate malunion High Reoperation rate Requires frequent adjustments Visual reminder of the disability (social & psychological effect) Fractures through pin sites

50 Summary of Fixation devices

51 Tibial Fixation Options Plate Ex Fix IM nail

52 Complications of Tibial Shaft Fractures Delayed / Non Union Infections Malunion & Shortening Vascular injuries Compartmental syndrome Joint Stiffness & Ankylosis Traumatic arthritis RSD Fat embolism

53 Open fractures

54 Open fractures An open fracture is one in which a break in the skin and underlying soft tissue directly communicates with the fracture and its hematoma

55 Gustilo And Anderson Classification Type Wound Level of Contamination Soft Tissue Injury Bone Injury I <1 cm long Clean Minimal Simple, Minimal comminution II >1 cm long Moderate Moderate, Some muscle damage III Moderate Comminution A >10 cm High Severe with Crushing Usually Comminuted; Soft-tissue Coverage of bone possible B >10 cm High Very Severe loss of coverage C >10 cm High Very severe loss of coverage plus vascular injury requiring repair Bone Coverage poor; usually requires softtissue reconstructive surgery Bone coverage poor Usually requires softtissue reconstructive surgery

56 Tschern classification of soft tissues Grade-0 Minimum soft tissue injury Simple # pattern Grade-1 Superficial Abrasion Mild to moderate # pattern Grade-2 Deep Abrasion Impending compartment syndrome Severe # pattern Grade-3 Extensive crush Severe # pattern +/- Vascular injury Compartmental syndrome

57 Complications and Prognosis are directly related to degree of soft tissue injury

58 Compartment syndrome

59 Compartment syndrome Pain Excessive to fracture Pain Passive stretching of toes Pain Uncontrollable with normal analgesia

60 Compartmental syndrome Anterior compartment very common Deep Posterior second commonest Lateral compartment always associated with ant of post compartment syndrome

61 Diagnosis High Index of suspicion Clinical Hx & Examination 29/03/2018 Vemulapalli

62 Compartment syndrome- Diagnosis High Index of Suspicion Pain; Pain; Pain Tight/ Tense Compartments Nerve paresthesia Compartmental pressure monitors

63 Treatment Fasciotomy

64 Summary Tibial fractures are very common Young people fracture Can be treated non-op or operatively Open fractures are common High index of suspicion for diagnosing compartmental syndrome

65 THANKYOU 29/03/2018 Vemulapalli

66 A fracture in plaster of Paris will not displace more than its previous maximal displacement Sarmiento,York 1998