^DEFINITION

^{A fracture of the proximal or distal tibial metaphysis can occur from a variety of high- and low-energy trauma.}

^{Fractures may be confined to the metaphysis or extend into the articular surface.}

^{Simple fractures suggest lower energy injuries, whereas comminution signifies a greater amount of energy and a higher velocity mechanism.}

 

 

^ANATOMY

 

 

^{Proximal metaphyseal fractures of the tibia are those that occur proximal to the isthmus of the tibia (FIG 1A). Distal metaphyseal fractures of the tibia are those that occur distal to the isthmus of the tibia (FIG 1B).}

^PATHOGENESIS

 

^{Common causes of tibial fractures include high-energy collisions (pedestrian vs. car bumper) such as an automobile or motorcycle crash.}

 

 

 

^{FIG 1 • A. AP view of synthetic tibia model. Shading of the proximal tibial metaphysis is shown. B. AP view of synthetic tibia model. Shading of the distal tibial metaphysis is shown.}

 

 

^{Lower energy injuries, such as certain sports injuries or falls, can also cause fractures of both the proximal or distal tibial metaphysis.}

 

^{NATURAL HISTORY}

 

^{Fractures of the tibia can occur in all age groups and from a variety of mechanisms.}

 

^{Goals of treatment should include restoration of length, rotation, and alignment of the tibia with a return to previous level of activity and function.}

 

^{Recognition and treatment of associated injuries including those to nerves, blood vessels, or compartment syndrome should be an integral part of the assessment and treatment to prevent complications.}

 

^{PATIENT HISTORY AND PHYSICAL FINDINGS}

 

 

^{Patients will often present with a recent history of trauma. Tibial fractures may present with a variety of findings:}

 

^{Pain in the affected extremity with an inability to bear weight}

 

^{Leg length inequality}

 

 

^{Visual deformity including tenting of the skin Contusions/abrasions}

 

 

^{Nerve injury Open fractures}

 

^{Compartment syndrome}

 

^{Sensory deficits in the foot (less common)}

 

^{IMAGING AND OTHER DIAGNOSTIC STUDIES}

 

^{Diagnosis of a proximal or distal tibia (FIG 2A,B) fracture can usually be made with standard orthogonal anteroposterior (AP) and lateral x-rays.}

 

 

^{Dedicated knee and ankle x-rays are necessary to decrease the chance of missing a fracture at the articular surface.}

 

^{Fractures that extend proximally or distally into the articular surface may require a computed tomography (CT) scan to evaluate joint involvement and/or displacement to aid in preoperative planning (FIG 3A,B).}

 

^{DIFFERENTIAL DIAGNOSIS}

^Trauma

^{Fractures of the knee Fractures of the ankle}

^{Soft tissue injury Ankle injury Knee injury}

^{Compartment syndrome Peripheral vascular injury}

^{Pathologic process (tumor/malignancy) Infection}

⁵⁶⁵

 

 

^{FIG 2 • A. AP and lateral x-ray of a proximal tibia fracture. B. AP and lateral x-ray of a distal tibia fracture.}

 

 

 

^{NONOPERATIVE MANAGEMENT}

 

^{Nonoperative management is normally reserved for lower energy injuries with minimal or no displacement.}

 

^{Patients with low functional demands (ie, paraplegic) or significant medical comorbidities can be successfully treated without surgical intervention.}

 

^{Nonoperative management of the proximal or distal tibia often involves a long-leg splint with conversion to a long-leg cast once swelling has resolved.}

 

 

^{Distal fractures may be converted to a short-leg cast or brace once there is radiographic evidence of healing.}

 

^{Non-weight bearing for the first 6 weeks with progression to full weight bearing, with or without a brace, once there is physical evidence of healing (decrease in pain) and/or radiographic evidence of healing (callus formation)}

 

 

 

^{FIG 3 • A. CT of distal tibia with axial cut demonstrating intra-articular extension of distal tibia fracture. B. CT of distal tibia with sagittal cut demonstrating intra-articular extension of distal tibia fracture.}

 

^{SURGICAL MANAGEMENT}

^{Proximal Tibia Fractures}

 

^{The proximal tibia presents a challenge for intramedullary (IM) nailing due to deforming forces from the patella and the eccentric starting point for the IM nail.}

 

^{Flexion of the knee past 60 degrees to allow access to the tibial nail starting point causes the quadriceps, patella, and patellar tendon to extend the proximal fracture fragment leading to an extreme procurvatum deformity.}

 

 

^{In addition, starting the IM nail at the “usual” starting point, just medial to the lateral tibial spine, in the coronal plane will produce a valgus deformity. Techniques to prevent these deformities include the following:}

 

 

 

 

^{Judicious use of blocking screws Suprapatellar IM nailing Semiextended IM nailing}

 

^{Clamps, plates for reduction prior to IM nailing}

 

^{Preoperative Planning}

 

^{A review of all images will help to plan the surgical a pproach.}

 

^{Fractures that extend into the proximal plateau or across the distal plafond may require closed or open reduction and fixation prior to IM nailing.}

 

^{Cancellous screws (6.5 mm) placed posteriorly in the tibial plateau will be out of the way of the tibial nail and its entry site.}

 

^{Depending on the fixation required, small fragment screws and/or plates should be readily available for distal fractures.}

 

^{Obtaining and maintaining the reduction may require additional equipment. Planning ahead of time will avoid unnecessary delays in the operating room.}

 

 

^{Some examples of other items you may wish to have available include (FIG 4A,B) the following:}

 

 

^{Clamps, “spike” pushers, K-wires}

 

^{Small fragment set (for provisional plate fixation)}

 

 

^{Large fragment (6.5, 7.3 mm) cannulated cancellous screws External fixator/universal distractor}

 

^{Skeletal traction tray (calcaneal traction)}

 

 

⁵⁶⁶

 

 

 

^{FIG 4 • A,B. Preoperative planning may include additional equipment. This may include small fragment plates and}

^{screws (Synthes, Paoli, PA), specific clamps, or traction sets.}

 

^Positioning

 

^{Patients are positioned in the supine position on a radiolucent table. A bolster may be placed under the ipsilateral hi}

 

^{Radiolucent triangles may be used to assist with hyperflexion of the knee for standard nailing (FIG 5), whereas smaller bumps may be placed under the knee for semiextended approaches (FIG 6).}

 

 

 

^{FIG 5 • Standard tibial nailing requires hyperflexion of the knee. Radiolucent triangles may help with positioning.}

 

 

 

^{FIG 6 • Patient positioning for semiextended or suprapatellar nailing. Notice a small bump under the knee to provide 30 to 40 degrees of knee flexion. Suprapatellar nailing requires specific instruments seen here.}

 

^Approach

 

^{Standard nailing uses an incision between the inferior pole of the patella and the tibial tubercle (FIG 7).}

 

^{Incision is carried down through skin and subcutaneous tissue and should be carried distally to the proximal tibia.}

 

^{The patellar tendon is identified and an incision can be made medial to the patellar tendon or through the tendon.}

 

 

 

^{Guidewire placement and correct starting point are extremely important, especially with proximal fractures. Avoid an incision too medial which could make it difficult to achieve the correct starting point.}

 

^{Semiextended nailing uses a suprapatellar portal.}

 

 

^{The incision is made from the superior pole of the patella proximally in line with the quadriceps tendon (FIG 8). A deeper incision is then made through the quadriceps tendon.}

 

^{If the knee joint is too tight to enter through this portal, the skin incision can be carried distally and a medial parapatellar arthrotomy can be made to help elevate the patella out of way and provide access to the correct starting point.}

 

^{The semiextended approaches require specific instrumentation (FIG 9) and soft tissue guides to help protect the cartilage in the patellofemoral joint and to avoid unnecessary damage to the joint surface.}

 

 

 

^{FIG 7 • Skin incision for standard tibial nailing from inferior pole of the patella to the tibial tubercle.}

 

 

⁵⁶⁷

 

 

 

^{FIG 8 • Skin incision used for a suprapatellar tibial nail is from the superior pole of the patella proximal approximately 3 cm centered over the quadriceps tendon.}

 

 

^{Guide pin placement and starting point are dependent on whether the tibia fracture is proximal or distal.}

 

 

^{For distal fractures, a starting point just medial to the lateral tibial eminence on the frontal plane and along the proximal anterior portion of the tibia anterior to the cruciate insertion is appropriate.}

 

 

 

^{FIG 9 • Suprapatellar nailing requires specific instrumentation. Specifically, it requires longer cannulas to protect the cartilage of the patellofemoral joint, a longer opening reamer, and longer reamer rods.}

 

 

^{The wire should be aiming down the center of the canal in the AP plane and traversing parallel to the anterior cortex on the lateral view.}

 

^{For proximal fractures, the starting guide pin should be slightly more lateral, in line with the lateral tibial eminence, and parallel to the lateral cortex of the proximal tibia.}

 

^{On the lateral view, a more anterior starting point that is extra-articular but on the flat surface of the proximal tibia, avoiding the meniscus attachments, with the guidewire directed parallel to the anterior cortex of the tibia is optimal.}

 

 

^TECHNIQUES

• ^{Proximal Tibia Fractures}

^{The starting point for IM nailing of fractures of the proximal tibia must be modified from the “classic” entry portal.}

^{The IM nail for proximal fractures is inserted at the “flat” anterior part of the tibial plateau and more lateral, at the lateral tibial spine, in line with the lateral cortex of the proximal tibia.}

^{On the sagittal view, the IM nail should be traversing parallel to the anterior cortex to avoid deformity (TECH FIG 1A).}

^{If, despite proper proximal tibial insertion site technique, deformity still occurs, then the next best intraoperative solution is the application of blocking screws.}

^{These are usually the locking screws from the IM tibial nailset and are placed to prevent the IM nail from going posteriorly and causing the procurvatum deformity.}

^{In the sagittal plane, the blocking screws are placed posterior to the IM nail to force it off of the posterior cortex and parallel to the anterior cortex (TECH FIG 1B).}

^{If the deformity is present with the IM guidewire in place after fracture reduction, then the blocking screw can be placed to “block” the guidewire to a more anterior position prior to reaming.}

^{Sometimes, the guidewire is so far posterior that the blocking screw has to be placed anterior to the wire that lies on the posterior proximal tibial cortex. In this case, the blocking screw is inserted in its proper position and then the guidewire is pulled back and reinserted anterior to the blocking screw prior to reaming.}

^{The reamer must either hit the blocking screw or be forcibly pushed past it for the screw to work.}

^{Similarly, a lateral blocking screw can be added to redirect the nail centered in the proximal fragment on the coronal view (TECH FIG 1C,D). This strategy is most commonly employed when the proximal tibia is}

^{nailed with the knee flexed greater than 60 degrees over a triangle and a too medial starting point has been employed.}

^{Additional Strategies}

 

^{Two other strategies for proper insertion site and trajectory is to perform the IM nailing with the knee in less flexion to prevent the extremes of proximal deformity.}

 

^{The semiextended position allows for a small paramedian arthrotomy, with the knee in only slight flexion, and subluxation of the patella allows for a straight trajectory in the proximal fragment and a more anterior line of insertion.}

 

^{The second option is suprapatellar IM nailing. This has gained popularity lately but requires special extra-long insertion instruments and caution so as not to cause damage to the patellofemoral cartilage.}

 

^{The best insertion angle is between 20 and 50 degrees of knee flexion but up to 22% articular damage has been reported. A small insertion site is created just above the superior pole of the patella and a cannula is inserted in the patellofemoral groove.}

 

^{A guide pin is then placed just proximal on the “flat portion” of the proximal tibia just superior to the anterior slope.}

 

^{This pin is directed in a direction that centers the pin in both planes using the more proximal and lateral starting points previously described.}

 

^{All reaming is done through the cannula to prevent articular damage.}

 

^{Bolsters are used under the knee and, with the knee in only slight flexion, the fracture stays reduced during the IM nailing procedure (TECH FIG 2A-D).}

 

⁵⁶⁸

 

 

 

^{TECH FIG 1 • A. Guidewire positioning for proximal tibia fractures at the flat anterior part of the tibial plateau and more lateral, at the lateral tibial spine, in line with the lateral cortex of the proximal tibia. On the sagittal view, the IM nail should be traversing parallel to the anterior cortex to avoid deformity. B. A blocking}

^{screw in the proximal tibia will help guide the nailinto the right position and aid in reduction of this common deformity. C. An AP radiograph demonstrating common valgus deformity with a medial starting point. D. Correction of the deformity can be seen with a laterally placed blocking screw in the proximal fragment.}

^{The nail will “bounce” off of the nail and center itself in the proximal deformity.}

 

 

^{Finally, direct reduction of the fracture through small incisions can be performed prior to IM nailing.}

 

^{A ball spike “pusher” can be used with a small anterior incision to push the proximal fragment down and inhibit the flexion deformity (TECH FIG 2E).}

 

 

 

^{TECH FIG 2 • A-D. An image depicting the suprapatellar approach. A small incision is made through the quadriceps tendon. Notice the cannula protecting the cartilage and the insertion of the guidewire followed by the opening reamer. (continued)}

 

 

^{Percutaneous clamps (TECH FIG 2F) through very small incisions, without stripping of soft tissues, that are placed to reduce the fracture allow for the surgeon to ream and place the IM nail with the fracture reduced.}

 

⁵⁶⁹

 

 

 

^{TECH FIG 2 • (continued) E. A ball spike centered over the proximal fragment with a posteriorly directed force can hold the reduction during reaming. F. Percutaneous clamps can be used to hold the reduction while the guidewire, reamers, and nail are passed. This requires minimal soft tissue stripping. G. A one-third tubular plate was used to hold the reduction of this proximal tibia fracture. A five-hole plate with two screws on either side of the fracture is usually sufficient. Remember to place the plate anterior so that it}

^{is out of your way. Once the nail is locked, you may remove the plate or leave it in as depicted here.}

 

 

^{A small fragment plate, usually a one-third tubular plate, can be placed safely through a small incision (TECH FIG 2G) to reduce the fracture precisely prior to IM nailing.}

 

^{An anterolateral incision centered over the proximal fracture and under the muscle mass allows for the placement of a five-hole plate with two screws on either side of the fracture line. The screws can be directed into the anterior cortex or placed unicortical to allow the subsequent passage of the IM nail.}

^{These plates can be left in place after IM nailing if adequate soft tissue coverage is present.}

• ^{Distal Fractures}

   

  ^{Similarly to proximal fractures, reduction is the key to IM nailing of distal tibia fractures.}

   

  ^{A closed reduction can be performed but is often difficult with spiral fractures that have an intact fibula or those with a proximal fibula fracture.}

   

  ^{Often, a small, pointed reduction clamp can be placed percutaneously, with minimal soft tissue stripping, and then the ball-tipped guide rod can be placed in a center-center position down to the epiphyseal scar.}

   

  ^{To correct varus or lateral translation, a blocking screw can be inserted just medial to the guidewire in the distal fragment (TECH FIG 3A).}

   

  ^{This is done using the same drill bit and screws from the IM nailing set and should be close enough to the guide rod that the reamers and IM nail will bounce off of it.}

   

  ^{The other option is fixation of the fibula fracture, especially in distal one-third tibia and associated fibula fractures. There are pros and cons to this approach.}

   

  ^{For the pros, the surgeon can get rotation and length correct and make the IM nail procedure much easier.}

   

  ^{The cons relate to the fact that a malreduction of a comminuted fibula can lead to deformity and malunion of the tibia.}

   

  ^{Further, if tibial metaphyseal comminution is present, fixation of the fibula may not allow this area to compress and consolidate and later exchange procedures require an osteotomy of the fibula to allow for tibial compression and subsequent union.}

   

  ^{Adjunctive plating of the distal tibia with subsequent IM nailing is to be avoided as the skin of the distal leg has a limited blood supply as does the tibia; incisions with plate and subsequent IM nail insertion could lead to disastrous skin and bone healing issues.}

   

  ^{For distal fractures, two interlocking screws should be inserted through the IM nail into the distal fragment, preferably with screws at 90 degrees or oblique to each other as these out-ofplane screws allow for early motion and lessen the chance of screw loosening and loss of distal fixation.}

   

  ⁵⁷⁰

   

   

   

  ^{TECH FIG 3 • A. A depiction of varus/lateral translation malreduction and the appropriate placement of a blocking screw to correct the deformity. B-E. Screw placement for a simple intra-articular split. Notice how the screws are placed just above the cartilage to allow the nail to be E seated at the level of the epiphyseal scar.}

• ^{Intra-articular Splits}

   

  ^{Proximal and distal intra-articular splits associated with a metaphyseal fracture can be treated by percutaneous clamp and screw fixation.}

   

  ^{For proximal fractures, these are most commonly sagittal splits, and a cannulated or solid 6.5-mm screw with a washer can be placed across the split from lateral to medial as long as the screw is at the midportion of the plateau or posterior to this line.}

   

  ^{Because the IM nail enters anteriorly, the percutaneously placed screw will not interfere with IM nail passage.}

   

  ^{For distal fractures, the plane of the fracture needs to be identified. If the fracture is not completely visible or understood on plain x-rays, then a CT scan is performed to elucidate the fracture configuration and morphology.}

  ^{Once the fracture is identified, a percutaneous clamp and a partially threaded cancellous screw or fully threaded screw can be inserted perpendicular to the fracture line at the level of the epiphyseal scar.}

  ^{This distal screw insertion site allows for the IM nail placement as far distal as possible up to this screw (TECH FIG 3B-E).}

   

   

  ⁵⁷¹

   

  ^{PEARLS AND PITFALLS}

   

  ^{Proximal tibia fractures behave differently than diaphyseal fractures.}

• ^{Correct starting point is essential to eliminating valgus and flexion deformity. Slightly more lateral and proximal than the conventional starting point.}

   

  ^{The starting point makes all the difference.}

  • ^{“High on the tibia, at the edge of the articular surface of the knee, just medial to the lateral tibial spine.”2}

     

    ^{Reduce and hold the reduction prior to reaming and inserting the nail.}

    • ^{The nail will not reduce the fracture if it is in the proximal or distal metaphysis due to a canal-nail size mismatch. Reduce and hold the reduction, then ream and insert the IM nail. Percutaneous clamps with minimal soft tissue stripping can hold proximal and distal fractures reduced during reaming and nailing.}

     

    ^{Nailing of proximal fractures with the knee in extension may be technically easier.}

• ^{With semiextended position, there is less pull on the proximal fragment through the patellar tendon and less deformity. Suprapatellar nailing requires specialized equipment and there is the possibility of cartilage damage.}

   

  ^{Proximal plate fixation can be extremely helpful.}

  • ^{You can use any variety of plates, just be sure that it is out of the way of your nail. Can be left in, but be cautious of making an incision through the zone of injury.}

     

    ^{Beware of the intra-articular extension.}

    • ^{Any questions about the extent of the fracture should be further investigated with a CT scan. If there is intra-articular involvement, address that first then continue with the IM nail.}

       

      ^{Blocking screws can help direct the nail and alleviate malreductions that come with bone/implant mismatch.}

• ^{They are minimally invasive and you can use the same screws as your interlocking screws. Placed in the right position, they can help redirect your nail and guide it in the right direction.}

 

^{POSTOPERATIVE CARE}

 

 

^{After surgery, immobilization of the limb can be achieved by placement of a splint or boot for soft tissue protection along with elastic bandage compression, ice, and elevation.}

 

 

^{The splint is typically removed prior to discharge once the patient's pain allows range of motion (ROM). This may help avoid an acquired equinus contracture.}

 

^{Antibiotics are generally discontinued after 24 hours but may continue until all wounds are closed in the presence of an open fracture or with fasciotomies performed secondary to compartment syndrome.}

 

^{Although full weight bearing is generally protected until there is radiographic evidence of healing (10 to 12 weeks), aggressive ROM including heel cord stretching and mobilization are essential to provide optimal outcomes.}

 

 

^{Partial weight bearing can be started at 6 weeks, depending on the progression of healing and the inherent stability of the fracture-nail construct.}

 

^{A course of deep venous thrombosis (DVT) prophylaxis is recommended for at least 2 weeks, with longer duration for patients who may have multiple injuries or who are otherwise slow to mobilize.}

 

 

^{Low-molecular-weight heparin is often used in multiply injured patients or those who are high risk, whereas lowdose aspirin may be sufficient for the ambulatory patient.}

 

^{Follow-up is generally at 2 weeks for suture removal, 6 weeks for radiographic follow-up and to assess ROM, and 3 months for advancement to weight bearing as tolerated.}

 

^{Follow-up beyond that may be every 6 to 12 weeks thereafter, depending on healing and return to function.}

^OUTCOMES

^{Closed tibial fractures should be expected to heal by 24 weeks.}

^{There is little information about the long-term, patientreported outcomes of tibial shaft fractures.}

^{Factors such as smoking, comminution, quality of reduction, and whether or not the fracture is open can influence the patient's ability to heal a tibia fracture.}

^{Those fractures associated with intra-articular extension may have decreased joint motion despite aggressive postoperative therapy.}

^{Tibial IM nailing, whether using a medial patellar tendon incision or a midline tendon split, has been shown to cause knee pain in as high as 50% of patients with hardware removal alleviating pain in half of the patients.}

 

 

^{COMPLICATIONS}

^{Similar to other orthopaedic surgery Infection}

^DVT

^{Malunion Nonunion}

^{Hardware irritation/pain (knee pain)}

^{Malunion can be avoided with proper starting point and ensuring that you have appropriate reduction prior}

 

 

^{to IM nailing.}

^{In some instances, leaving intraoperative adjunctive fixation (ie, plate, blocking screws) indefinitely may provide additional stability and aid in healing and prevention of late deformity.}

^{Nonunions are not uncommon in tibia fractures and increase if the fracture is comminuted or is an open fracture with extensive soft tissue stripping.}

^{Recent studies have suggested avoiding reoperations until at least 6 months after surgery in absence of infection or catastrophic failure1 as these fractures may simply require longer to achieve union.}

^{Hypertrophic nonunions are usually a result of a canal-nail mismatch and instability.}

^{These are most readily treated with a dynamic exchange nailing often with a fibular osteotomy to allow for}

⁵⁷²

^{compression at the nonunion site. The nonunion in these cases does not need to be débrided.}

^{IM cultures should be done in all nonunions, open or closed, to rule out infection as a cause of the nonunion.}

^{Atrophic or oligotrophic nonunions may need an increase in stability as well but most require the addition of bone graft.}

^{Options include autograft, allograft, or a combination of these adjuvants to obtain union.}

 

^REFERENCES

1. ^{Bhandari M, Guyatt G, Tornetta P III, et al. Randomized trial of reamed and unreamed intramedullary nailing of tibial shaft fractures. J Bone Joint Surg Am 2008;90:2567-2578.}

    

    

2. ^{Schmidt AH, Templeman DC, Tornetta P, et al. Anatomic assessment of the proper insertion site for a tibial intramedullary nail. J Orthop Trauma 2003;17:75-76.}