FRACTURES OF THE TIBIA AND FIBULA-1.pptx

A brief description of the different fractures that can occur in the two large bones in the lower limb

1. FRACTURES OF THE TIBIA AND FIBULA BY Madam Ruth : Department of Clinical Medicine

2. Classification Classified into: Fractures of the condyles of the tibia Fractures of the shafts of tibia and fibula (separately or together) Fractures and fracture-dislocations about the ankle Madam Ruth 2

3. Fractures of the condyles of tibia Tibial plateau fractures Madam Ruth 3

4. Fractures of the condyles of tibia Also termed as tibial plateau fractures Lateral condyle is most commonly affected Usual way of sustaining a tibial plateau fracture is by a road traffic accident. A bumper of the vehicle hitting the pedestrian on the leg. Other ways in which this fracture can be sustained include: a fall from a height, domestic and industrial accidents and during sports.

5. Classification Schatzker classification of tibial plateau fracture is the most commonly used classification for this fracture. Type 1 is a split fracture involving the lateral condyle Type 2 is a split fracture of the lateral condyle along with depression of the bone Type 3 is a depression fracture of the lateral condyle Type 4 is a fracture of the medial condyle Type 5 is a fracture involving both the condyles Type 6 is a fracture of both the condyles that extends downwards to the shaft of the tibia bone Madam Ruth 5

6. Classification of tibial plateau fractures Type 1 is a split fracture involving the lateral condyle Madam Ruth 6

7. Classification… Type 2 is a split fracture of the lateral condyle along with depression of the bone Madam Ruth 7

8. Classification… Type 3 is a depression fracture of the lateral condyle Madam Ruth 8

9. Classification… Type 4 is a fracture of the medial condyle Madam Ruth 9

10. Classification… Type 5 is a fracture involving both the condyles Madam Ruth 10

11. Classification… Type 6 is a fracture of both the condyles that extends downwards to the shaft of the tibia bone Madam Ruth 11

12. Classification… Type 1 to 4 are usually low energy injuries whereas type 5 and 6 are usually high energy injuries. Therefore type 5 and 6 may be associated with lacerations, contusions and bruises to the skin. Compartment syndrome, ligament injuries and injuries to the nerves and blood vessels may also be present. Madam Ruth 12

13. Fracture of the lateral tibial condyle Commonest of the condylar fractures. Madam Ruth 13

14. Fracture of lateral tibial condyle Cause: A force that abducts the tibia upon the femur while the foot is fixed on the ground. Commonly seen when the bumper of a car strikes the outer side of the knee of a pedestrian. Commonly the injury is called a bumper fracture Madam Ruth 14

15. Types of fracture pattern Three types: Comminuted compression fracture This is the commonest pattern The lateral tibial condyle with its articular surface is crushed and fragmented by the impact of the lateral condyle of the femur which is driven down into it. Madam Ruth 15

16. Fracture pattern Comminuted compression fracture Madam Ruth 16

17. Types of fracture pattern… Depressed plateau type A large part of the articular surface of the lateral condyle is depressed into the shell of the bone but remains largely intact as a single piece, without marked fragmentation. Oblique shearing fracture The whole or a large part of the condyle is sheared off in one piece through an oblique fracture. Madam Ruth 17

18. Fracture pattern… Oblique shearing fracture Madam Ruth 18

19. AP view of lateral tibial plateau fracture Madam Ruth 19

20. Lateral tibial plateau fracture Madam Ruth 20

21. Tibial plateau fracture Madam Ruth 21

22. Lateral tibial plateau fracture Madam Ruth 22

23. Tibial plateau fractures involving both lateral and medial sides Madam Ruth 23

24. Clinical features Pain in the knee region esp. laterally Swelling of the proximal part of the leg around knee The patient may complain of stiffness of the knee and be unable to weight bear on the injured leg. Inability to stand or walk Severe tenderness on lateral side of the knee Bruising may be seen over the skin Madam Ruth 24

25. Treatment Aim of treatment is to provide a stable, congruent and smooth joint surface of the upper end of tibia so that there is complete recovery of the knee joint function. Treatment depends on type of fracture Comminuted compression fracture: It is hardly practicable to restore the articular surface to its original smooth state. Further displacement is also unlikely to occur. The fracture which is through spongy bone unites readily. Madam Ruth 25

26. Treatment … Comminuted fracture … Treatment is to accept the displacement, avoid rigid immobilization, and to encourage active movements of the knee from the beginning. It is hoped that movement of the joint during granulation tissue formation may help restore a smooth articular surface. Madam Ruth 26

27. Treatment … Comminuted fracture… Confine to Bed rest initially for 2-4 weeks Aspirate any tense haemarthrosis Put a plaster slab during the night to protect the knee from unguarded and painful lateral movements at night. Remove POP slab during the day to allow for active exercises. Exercises to restore the tone of the quadriceps and hamstring muscles and flexion and extension movements of the knee. Madam Ruth 27

28. Treatment… Comminuted fracture… After staying in bed for 2-4 weeks, allow walking with support (walking stick) without external splintage. Cast-bracing can be used to prevent prolonged bed rest. Allows weight bearing within 1 or 2 weeks, and knee movements are permitted by the hinge. Madam Ruth 28

29. Treatment … Depressed plateau fracture without fragmentation: Aim at restoration of the articular surface of the tibial condyle to as near normal as possible. A window is cut in the antero-lateral cortex of the tibia a little below the level of the joint. Through this aperture the depressed fragment is pushed up from below until the articular fragment is flush with the surrounding cartilage. The cavity left is packed with cancellous bone chips to hold the fragment in position. The tibial condyle may be further buttressed by a broad plate fixed with transverse screws. Madam Ruth 29

30. Lateral tibial plateau fracture buttressed with a plate and screws Madam Ruth 30

31. Treatment … Oblique shearing fracture: Operative reduction and internal fixation with a long cancellous screw. The displaced fragment should be replaced perfectly in its bed to avoid any step in the articular surface. Madam Ruth 31

32. Treatment… Type 5 and 6 displaced fractures are surgically stabilized with screws and one or two plates if the skin condition is normal and with a external fixator frame if the skin is lacerated, contused or bruised. Madam Ruth 32

33. Treatment… Type 5 and 6 tibial plateau fractures Madam Ruth 33

34. Complications Injury to the common peroneal nerve if proximal fibula is involved Genu valgum Stiffness of the knee Osteoarthritis Madam Ruth 34

35. Fractures of the shafts of tibia and fibula P. J. Okoth Madam Ruth 35

36. Mechanism of injury and displacement Because of its subcutaneous position, the tibia is more commonly fractured , and more commonly sustains an open fracture than any other long bone. The fracture may occur from: Angulatory force Rotational [twisting] force Madam Ruth 36

37. Mechanism of injury … Fractures from an angulatory force tend to be: Transverse or short oblique About the same level in the tibia and fibula Fractures from a rotational (twisting) force: Are spiral Occur at a different level in the two bones Often the tibial fracture is at the junction of the middle and lowest thirds whereas the fibular fracture is near the junction of the middle and upper thirds. Madam Ruth 37

38. Mechanism of injury … As a rule there is considerable displacement of the fragments. Since the tibia is so close to the surface and so poorly protected by muscle, many fractures of its shaft are compound (open) A direct injury crushes or splits the skin over the fracture. Many of the fractures are caused by blunt trauma, and the risk of complications is directly related to the amount and type of soft tissue damage. Madam Ruth 38

39. Gustilo -Anderson classificaton of open fractures Type I Simple fracture with a tiny clean wound less than 1cm, due to perforation by a spike of bone from inside. Type II Is a moderately severe fracture with a wound more than 1cm long but no extensive soft tissue damage. Madam Ruth 39

40. Gustilo -Anderson classification… Type III Severe injury with extensive soft tissue damage and wound contamination. This type is further subdivided into: Type IIIA: those with adequate soft tissue coverage Type IIIB: those with skin loss Type IIIC: those associated with arterial injury that requires repair. Madam Ruth 40

41. Gustilo -Anderson classification… Type IIIC usually require multidisciplinary care. The incidence of infection ranges from 1% for type I to 30% for type IIIC. Due to infection, tibia-fibula fractures may take a long time to heal, normally 10-20 weeks. Madam Ruth 41

42. Clinical features Could be closed or open fracture Severe pain in the leg Inability to use the leg Swelling of the leg Open fractures have wounds of varying sizes depending on Gustilo type Bleeding wound Extensive soft tissue damage if crush injury Exposed bone Madam Ruth 42

43. Clinical features… The foot may be mangled with obvious deformity The leg may be bruised and markedly swollen The pulses should be palpated to assess circulation Sensation in the toes should be tested Madam Ruth 43

44. X-Rays May be a spiral fracture Tibial fracture lower third and fibular fracture at a higher level. Often there is: Lateral shift Overlap Outward twist below the fracture With a transverse fracture, both bones are broken at the same level. There may be shift, tilt or twist in any direction. Madam Ruth 44

45. Fractures of tibia and fibula Madam Ruth 45

46. Lateral and antero -posterior views of tibial fracture Madam Ruth 46

47. Spiral fracture of tibia/fibula from twisting force Madam Ruth 47

48. Treatment of closed fractures The principles of treatment are: To limit soft tissue damage and preserve skin cover To prevent or at least recognize compartment syndrome To obtain fracture alignment To start early weight bearing (loading promotes healing) To start joint movement as soon as possible Madam Ruth 48

49. Treatment of closed fractures… Conservative treatment should be the method of choice Operative treatment may be carried out in some cases The first priority is to assess the degree of soft tissue damage. A closed severe fracture with extensive soft tissue contusion may require early external fixation and elevation of the limb. Madam Ruth 49

50. Standard method of conservative treatment Reduce the fracture when necessary by closed manipulation Immobilize the limb in a full length POP with the knee slightly flexed and the ankle at right angle. The plaster may be changed from time to time if it should become loose or uncomfortable The knee is held slightly flexed to help to prevent rotation of the limb within the POP and to facilitate walking and sitting. Madam Ruth 50

51. Standard method of conservative treatment… If the fracture seems stable against redisplacement, (e.g. transverse fracture) walking should be encouraged after two or three weeks , when the acute local reaction to the injury has settled down. But if the pattern of fracture suggests that it is liable to redisplacement, weight bearing on the affected leg should be deferred for about six weeks , though walking with crutches may be allowed earlier. Madam Ruth 51

52. Standard method of conservative treatment… The plaster is retained until the tibial fracture is firmly united as shown by clinical and radiological examination – usually after 12-16 weeks (3-4 months). Thereafter, active exercises are carried out to restore a full range of knee, ankle and foot movements and to redevelop the muscles. Madam Ruth 52

53. Standard method of conservative treatment… Functional bracing: With transverse fractures which are relatively stable, the full length cast may be changed after 3-4 weeks to functional below knee cast or brace which is carefully moulded to bear upon the upper tibia and patella tendon. This sets the knee free and allows full weight bearing. Madam Ruth 53

54. Skeletal traction Could be used if follow up X-rays show unsatisfactory fracture alignment with POP. Fractures with severe soft tissue damage or vascular injury and severe comminution are better treated by skeletal traction. Skeletal traction could also be used if a patient is confined to bed by other injuries The limb is supported upon a Braun’s frame and traction is applied through a transfixion pin in the lower end of tibia. Madam Ruth 54

55. External fixation Is used for: Unstable fractures Long oblique or spiral fractures Severely comminuted fractures In all these weight bearing is delayed. Madam Ruth 55

56. Operative treatment (Internal fixation) Internal fixation is required mainly when the fracture cannot be reduced adequately by manipulation, or when plaster alone fails to maintain an acceptable position of the fragments. Operation is required much more often for oblique or spiral fractures, which always tend to be unstable, than for transverse fractures. Madam Ruth 56

57. Operative treatment (Internal fixation)… Plate and screws: Often used for fixation of tibial shaft fracture Afterwards a plaster cast is applied to support the limb until union is evident radiographically. Intramedullary nail: This offers the advantage of stronger fixation than that provided by other methods of internal fixation. Additional support by plaster is seldom required Early weight bearing may be encouraged. Madam Ruth 57

58. Operative treatment (Internal fixation)… Oblique transfixion screws: Are required for long oblique or spiral fractures, which are notoriously difficult to control by plaster. Additional support is required till union is well advanced. Interfragmentary lag screws: Are good for holding a long spiral fracture. Madam Ruth 58

59. Post operative care After the nailing of a transverse fracture or short oblique fracture, weight bearing can be started within a few days, progressing gradually to full weight bearing. Once the fracture is healed the metal work is removed.  The IM nail will be removed after 3-6 months or sometimes longer.  After plating, partial weight bearing only is permitted. 6-8 weeks thereafter full weight bearing is permitted. After external fixation, only partial weight is allowed until some callus is seen on check X-rays. Madam Ruth 59

60. Post operative care… After 6-8 weeks external fixator is replaced with an above knee POP until full callus is formed. Madam Ruth 60

61. Treatment of open fractures The management of open fractures is embodied in the following words: Antibiotics and tetanus toxoid Debridement Stabilization Delayed closure Rehabilitation Madam Ruth 61

62. Treatment of open fractures… Antibiotics and tetanus toxoid are started immediately. The wound is debrided and thoroughly cleaned with copious amounts of normal saline in minor theatre. Gustilo type I injuries can be closed primarily and then treated as for closed fractures More severe wounds are left open and inspected after 3 days; if necessary a further debridement is carried out. Madam Ruth 62

63. Treatment of open fractures… Stabilization of the fracture is achieved by applying an external fixator , leaving the wound free to be inspected and treated as necessary, including dressing. As soon as it is certain that the wound is clean and is granulating, it can be closed either by direct suture (without tension) or a skin graft . Madam Ruth 63

64. Treatment of open fractures… The external fixator is retained until the fracture is sticky , and then is replaced by a cast . Partial weight bearing is then allowed. The cast is removed only when callus is abundant. Madam Ruth 64

65. External fixation Madam Ruth 65

66. External fixation Madam Ruth 66

67. External fixation Madam Ruth 67

68. External fixation Madam Ruth 68

69. External fixation Madam Ruth 69

70. External fixation Madam Ruth 70

71. Complications of tibia/fibula fracture Early complications: Infection Vascular injury Damage to major branch of popliteal artery Compartment syndrome Injury to a major nerve Tibial nerve Common peroneal nerve Madam Ruth 71

72. Complications… Late complications: Mal-union Delayed union Non-union Joint stiffness Of the knee and the ankle due to prolonged splintage, neglect, prolonged infection. Osteoporosis Due to disuse of the distal fragment and sometimes also the tarsal bones. Madam Ruth 72

73. Complications… Compartment syndrome: Proximal 1/3 fractures of the tibia are inclined to cause bleeding and progressive soft tissue expansion within the fascial compartments of the leg, thus precipitating muscle ischaemia. A tight POP on a swollen leg may have the same effect. Operative decompression of all the affected compartments is mandatory at this level. The fracture is then treated as a grade III open fracture requiring an external fixator and delayed wound closure. _ Madam Ruth 73

74. Complications… Malunion: Slight shortening of up to 1.5cm is usually of little consequence, but rotation and angulation deformity, apart from being ugly are disabling, because the knee and the ankle no longer move in the same plane. In the long run the deformity may predispose to secondary osteoarthritis of the knee and ankle. _ Madam Ruth 74

75. Complications… Delayed union: This is common when the fracture is open, especially: With infection If the initial displacement was considerable If the tibia is fractured in two places or If the fracture is comminuted Union is hastened by: Weight bearing Bone grafting Intramedullary nailing. _ Madam Ruth 75

76. Complications… Non-union: May follow bone loss or deep infection May also follow faulty treatment It could also be due to the intact fibula acting as a strut, thus preventing the tibial fragments from coming close together and therefore preventing union of the tibia. Non-union should be managed by intramedullary nailing and also bone grafting. _ Madam Ruth 76

77. Fractures and fracture-dislocations about the ankle Pott’s fracture Madam Ruth 77

78. Mechanisms of injury Three types of injury: Abduction or lateral rotation force or combination of both – commonest Adduction force Vertical compression force Madam Ruth 78

79. Groups of fractures or fracture-dislocations that may result Isolated fracture of the lateral malleolus Isolated fracture of the medial malleolus Fracture of lateral malleolus with lateral shift of the talus Fractures of both malleoli with displacement of the talus Tibio -fibular diastasis Posterior marginal fracture of the tibia with posterior displacement of the talus Vertical compression fracture of the lower articular surface of the tibia. Madam Ruth 79

80. Management of #s and #-dislocations about the ankle General principles of treatment: In fractures without displacement it is usually sufficient to protect the ankle in a below-knee walking plaster for 3-6 weeks, depending upon the nature of the injury. Usually for the relief of pain. Madam Ruth 80

81. Management of #s and #-dislocations about the ankle.. In fractures with displacement: Ensure that the tibia and fibula are in normal relationship to one another at their lower ends, to form the ankle mortise Ensure that the talus is restored to its normal relationship with the tibio -fibular mortise. Madam Ruth 81

82. Treatment… Fractures with displacement… Reduction is effected by manipulation under anaesthesia The talus and the displaced malleolar fragment or fragments are restored to position by firm pressure in a direction opposite to the direction of displacement. Maintain the reduction until union is well advanced, usually 8-10 weeks. Madam Ruth 82

83. Treatment… Sufficient immobilization is achieved by a closely fitting plaster. However, because in these unstable fractures there is always a risk of redisplacement within the plaster, check X-rays should be done a week after the initial reduction to see if satisfactory reduction is maintained. Madam Ruth 83

84. Treatment… Operative treatment: When normal relationships between tibia, fibula and talus cannot be maintained by plaster alone, operative fixation is required. Secure the fragments in perfect position by screws or a plate. Post-operatively, for the first two (2) weeks allow the ankle to remain free for mobilizing exercises and elevation to reduce swelling. Thereafter, apply below-knee plaster to protect the ankle for 6-8 weeks. Madam Ruth 84

85. Complications Stiffness of the ankle Persistent swelling of the ankle from oedema of the soft tissues Reflex sympathetic dystrophy (Sudeck’s post-traumatic osteodystrophy) Osteoarthritis (later) All these complications are most likely to occur when the articular surface of the ankle mortise has been damaged by the fracture, or when there is persistent displacement of the talus. Madam Ruth 85

86. Complications… Persistent swelling and stiffness of the ankle Tendency to gravitational oedema when the plaster is first removed Oedema may be controlled by: Exercises to restore muscle tone Elevation of the limb when at rest Crepe bandage or an elastic sock Oedema and stiffness are usually more troublesome in elderly patients than in the young. Madam Ruth 86

87. Complications… Reflex sympathetic dystrophy Possibly related to sympathetic overaction Severe oedema with glazing of the overlying skin is associated with pain and obstinate stiffness of the ankle and joints of the foot. Treatment by elevation and intensive exercises under the supervision of a physiotherapist must be prolonged. In an intractable case, sympathetic blockade by intravenous guanethidine infusions is useful . Madam Ruth 87

88. Complications… Osteoarthritis Due to imperfect reduction and irregularity of joint surface. The greater the irregularity of the tibial articular surface, the more rapidly will degenerative changes occur. Osteoarthritis of the ankle does not respond well to conservative treatment. Arthrodesis is the most satisfactory treatment (if disability is severe) . Madam Ruth 88