Tibia fractures

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1. TIBIA FRACTURES Presented by: Bimal Pokharel MBBS 4 TH BATCH INTERN

2. Tibial Plateau The tibial plateau is the proximal end of the tibia including the metaphyseal and epiphyseal regions as well as articular surfaces made up of hyaline cartilage. It is one of the most critical load bearing areas in human body ; fractures of the plateau affect knee alignment, stability and motion.

3. TIBIAL PLATEAU FRACTURES Tibial plateau fractures comprises 1% of all fractures and 8% of all fractures of elderly Most of these fractures are associated with: Neurological and vascular injuries Compartment syndrome Contusion and crush injuries of soft tissue

4. Mechanism of injury Caused by valgus or varus forces combined with axial loading Fall from a height in which the knee is forced into valgus and varus . The tibial condyle is crushed or split by the opposing femoral condyle, which remains intact

5. Classification of tibial plateau fractures

6. Associated injuries 90% of these fractures are associated with soft tissue injuries Meniscal injuries occurs in 50% of these fractures Associated ligamentous injuries ( cruciate or collateral ligaments) occurs in 30% of these fractures Others: common peroneal nerve injuries popliteal artery injury

7. Evaluation of injury Clinical evaluation: 1) Neurovascular examination to rule out any neurological or vascular injury 2) Assessment for any ligament injury 3) Assessment for compartment syndrome 4) Assessment for haemarthrosis

8. Radiographic evaluation X-Ray: AP view b) Lateral view c) 40 degree internal rotation view ( lateral plateau) d) 40 degree external rotation view ( medial plateau) CT: provides information on: Location of main fracture lines The site and size of the portion of condyle that is depressed Position of major parts of articular surface that have been displaced

9. MRI: Useful for evaluating the injuries of menisci and cruciate and collateral ligaments injuries

10. Treatment Type I fractures: Undisplaced type 1 fractures can be treated conservatively. Haemarthrosis is aspirated and compression bandage is applied. As soon as acute pain and swelling subsides, a hinged-cast brace is applied; however weight bearing is not allowed for another 3 weeks. Thereafter partial weightbearing is permitted but full weight bearing is delayed until the bone has fully healed ( 8 weeks) Displaced fractures are treated by ORIF method. Two lag screws or buttress plate are usually sufficient for fixation.

11. Type II fractures If the depression is slight ( less than 5 mm) and the knee is stable or if the patient is old, the fracture is treated by skeletal traction. After 3 to 4 weeks, traction pin is removed and a hinged- cast brace is applied and patient is allowed to move on crutches. Full weight bearing is restricted for another 6 weeks If the depression is more ( more than 5 mm), in younger patients and with central depression, ORIF is preferred

12. Tibial shaft fractures

13. TIBIAL SHAFT FRACTURES Mechanism of injury: Direct injury: RTA are the commonest cause of these fractures, mostly due to direct violence. Frequently the object causing the fracture lacerates the skin over it, resulting in open fracture. Indirect injury: A bending or torsional force on the tibia may result in an oblique or spiral fracture. The sharp edge of fracture fragment may pierce the skin from within, resulting in an open fracture.

14. Patho -anatomy May be closed or open May occur at various levels ( upper, middle or lower thirds ) Displacements may be sideways, angulatory or rotational.

15. Imaging Diagnosis usually cofirmed by x- rays CT MRI Arteriography or venography

16. Acceptable Fracture Reduction Less than 5 degrees of valgus/ varus angulation is recommended Less than 10 degrees of anterior/ posterior angulation is recommended ( < 5 degrees preferred) Less than 10 degrees of rotational deformity is and less than 1 cm of shortening. More than 50% of cortical contact is recommended.

17. NON-OPERATIVE MANAGEMENT Fracture reduction followed by application of a long leg cast with progressive weight bearing can be used for fractures with minimal displacement Cast with the knee in 0 to 5 degrees of flexon to allow for weight bearing with crutches as soon as tolerated by patient with full weight bearing by 2 nd to 4 th week

18. Operative treatment Intramedullary ( IM) nailing: Method of choice for internal fixation IM nailing carries the advantage of preservation of periosteal blood supply and limited soft tissue damage. Fracture is reduced under x ray control, proximal end of tibia is exposed ; a guide wire is passed down the medullary canal and the canal is reamed A nail of appropriate size and shape is then introduced from the proximal end across the fracture site. Transverse locking screws are inserted at the proximal and distal ends Postoperatively, partial weightbearing is started early.

19. Plate Fixation: Plating is suitable for metaphyseal fractures that are not suitable for nailing. External Fixation: Primarily used to treat severe open fractures, it can also be used in closed fractures complicated by compartment syndrome. Union rates : 90% with about 4-6 months for union.

20. Plates and Screws Suitable for fractures extending into the metaphysis or epiphysis.

21. Complications Delayed union and non union Malunion Infections Compartment syndrome Injury to major vessels and nerves

22. Fracture of the malleolus Fractures and fracture dislocations of the ankle is common.