Tibial shaft fracture extending into the plafond—plate fixation

 

 

 

1. Case description

    

   A 26-year-old man fell from a height of 3 m into a hole sustaining an injury to his right lower extremity. He was initially admitted to a hospital where x-rays revealed a displaced tibial shaft fracture extending into the plafond, with articular involvement (Fig 2.1-1).

    

   Clinical examination revealed a closed fracture and an acute compartment syndrome of the leg. The patient underwent an immediate 4-compartment fasciotomy, at the initial hospital, through two longitudinal skin and fascia incisions. At the same time, temporary external fixation for stabilization of bone and soft tissues was applied.

   The following day, he was transferred to another hospital for further care. The patient required revision of the external fixator to change the location of the calcaneal pin due to tibial nerve irritation. After external fixation x-rays and computed tomographic (CT) scan with 3D reconstruction revealed a displaced multifragmentary, oblique fracture of the midshaft of the tibia extending into the plafond. None of the anterolateral, medial, and posterior articular fragments were in continuity with the shaft (AO/OTA 43C3.3). Impac-tion of the distal tibial articular surface was also noted (Fig 2.1-2 and Fig 2.1-3).

    

   a

   b

   a

   b

    

    

   Fig 2.1-1a–b Immediate postinjury x-rays.

   1. AP view showing the tibial shaft fracture extending into the plafond.

   2. Lateral view revealing the multifragmentary fracture of the plafond (AO/OTA 43C3.3).

   Fig 2.1-2a–b Initial fracture stabilization with spanning external fixator. Fasciotomy wounds are outlined by skin staples.

    

   a

   b

   c

   d

    

    

   Fig 2.1-3a–d Computed tomographic scans with 3D reconstruction.

   a–c Coronal, sagittal, and axial images demonstrating plafond comminution and displacement, particularly of the anterolateral fragment resulting in intraarticular step and gap. There is an incarcerated fragment at the center of the plafond.

   d 3D reconstructed image showing the external fracture anatomy and general alignment.

    

    

2. Preoperative planning

    

   Indications for surgery

   Displaced lower limb fractures require restoration of anatomy, specifically length, alignment, and rotation. Intraarticular fractures require open reduction and internal fixation (ORIF) to restore and support the articular surface.

    

   Approach

   When selecting the definitive approach, the preexisting medial and lateral fasciotomy incisions must be considered (Fig 2.1-4). For this patient, the entire fracture from shaft to joint was accessed with a single incision, using the extensile approach. This was done by extending the lateral fasciotomy wound distally and medially.

    

   Where possible, the placement of the fasciotomy incisions should be where they will not interfere and indeed facilitate proper ORIF approach. The external fixator should be placed with the pins far enough apart to remain out of the surgical field of definitive surgery.

    

   Plate positioning

   In this case due to concerns about medial soft-tissue coverage, a lateral plate was preferred for fixation of the shaft fracture. As an aid for reduction the first step was to anatomically reconnect the shaft to the lateral column of the distal tibia (converting AO/OTA 43C to a 43B). This was performed by use of a 4-hole straight locking compression plate (LCP) placed anteriorly so as not to disturb future plate

   placement. A long anterolateral plate was then used to buttress the entire fracture. The vertical limb was of sufficient length to overlap the previously applied tibial shaft plate. This avoids creating a stress-riser with a fracture between the plates. Additionally, the plate augments the fixation of the shaft. The medial distal tibia was buttressed with a short low-profile medial plate.

    

   Order of fixation

   1. Reduce and stabilize the shaft component of the fracture.

   2. Reconstruct the articular surface.

   3. Connect the articular surface to the shaft.

    

   External fixator in situ

   Surgery was performed with the external fixator left in place to aid in maintaining limb alignment, length, and rotation. The external fixator is prepared into the field in its entirety using betadine paint. This maintains alignment that has been achieved when the external fixator was assembled, aiding in the reconstruction. It also helps in distraction and visualization of the ankle joint. Small adjustments to the external fixator are often necessary during the surgery. Any time a part is removed or adjusted, betadine must be applied to the newly exposed portion of the external fixator as it is not possible to disinfect under the clamps at the beginning of the operative case.

    

   a

    

    

   b

    

    

   Fig 2.1-4a–b Fasciotomy wounds are progressively approximated to achieve primary wound closure using the “shoelace technique”.

    

    

3. Operating room setup

    

    

   Patient positioning • Supine on a radiolucent table.

   • The patient is positioned so the foot is at the end of the operative table for easy access to the fracture.

      

     Anesthesia options • General, often supplemented with a regional

     nerve block

      

     C-arm location • Positioned on the contralateral side with the

     monitor placed near the head of the operative table.

      

     Tourniquet • Used at surgeon’s discretion.

   • Improves the ability to see the joint surface and the reduction.

      

     Tips • Placing a bump under the ipsilateral hip internally rotates the leg to neutral allowing improved access to the lateral part of the plafond.

      

      

     For illustrations and overview of anesthetic considerations, see chapter 1.

      

     Equipment

     • LCP 3.5 (for fixation of midshaft tibial fracture)

     • Anterolateral LCP 2.7/3.5 (for fixation of anterolateral plafond fragment)

     • LCP 2.4/2.7 (for fixation of medial plafond fragment)

     • K-wires

     • Point-to-point reduction (Weber) clamps

     • Smooth and sharp elevators

      

     Size of system, instruments, and implants may vary according to anatomy of the fracture and the patient. Conventional compression plates can be used in good bone quality, while locking plates are preferred in osteopenic bone and in fractures with comminution.

      

      

4. Surgical procedure

    

   The first step is fixation of the oblique fracture of the tibial shaft, which will restore length, rotation, and alignment. Fixation of the shaft provides a template for reduction and fixation of the plafond articular fragments, which is the second part of the operation.

   When selecting the approach, careful consideration must be given to the preexisting fasciotomy wounds and to the width and length of skin bridge, neurovascular damage, excessive soft-tissue stripping, adequacy of soft-tissue coverage especially on the medial side of the tibia, and the strategy for wound closure.

    

   The extensile approach is used as it permits complete and direct visualization of the distal tibial articular surface and planned placement of medial and anterolateral plates. Thus, it provides ideal access for this AO/OTA type C pilon fracture. The lateral incision of the fasciotomy is extended distally and medially and ends 10 mm below the tip of the medial malleolus (Fig 2.1-5). The incision is carried out down to the subcutaneous tissue avoiding dissection of the superficial layers. The extensor retinaculum is carefully incised leaving the tibialis anterior tendon undisturbed in its sheath. The full-thickness subcutaneous flap is retracted medially while the tibialis anterior tendon is retracted laterally. The flap is handled atraumatically without strong retraction or the use of forceps. Nylon stay sutures in the skin may be used to retract soft tissues. At the level of the ankle, the capsule is opened longitudinally, exposing the talus. Subperiosteal dissection exposes the distal tibia fracture, and extending the dissection proximally clearly exposes the fractured shaft.

    

   The shaft fracture is first reduced anatomically and fixed using a short straight 4-hole, locking compression 3.5 plate (Fig 2.1-6). Retraction of tissues laterally exposes the entire anterolateral articular fragment of Chaput. The anterolateral fragment is reduced and fixed anatomically to the previously fixed shaft with its nondisplaced posterior articular fragment. The external fixator aids in alignment and visualization during this reduction.

    

   Finally, the medial fragment is reduced to the anterolateral and posterior fragments and temporarily stabilized with K-wires. For definitive fixation, the anterolateral fragment and tibial shaft are fixed with a long anterolateral plate overlapping the already applied short tibial shaft plate, and the medial fragment is buttressed with a medial plate. If the plates are longer than the incision, they can be slid proximally deep to the soft tissues, and screws inserted using a minimally invasive technique.

    

   Large metaphyseal defects should be bone grafted. The wounds are closed primarily. The external fixator is left in situ temporarily to facilitate wound healing (Fig 2.1-7). In this patient, it was removed after 1 week (Fig 2.1-8).

    

   a

   b

    

    

   Fig 2.1-5 Distal and medial extension of lateral fasciotomy wound, as marked on skin, to gain access to the plafond.

   Fig 2.1-6 Plating of the shaft fracture improves limb stability and alignment by converting

   a segmental fracture into an isolated pilon fracture.

   Fig 2.1-7a–b Immediate postoperative x-rays show the external fixator left in place to facilitate soft-tissue healing.

   1. AP view.

   2. Lateral view.

    

   a

   b

   c

   d

    

    

   Fig 2.1-8a–d The external fixator was removed 1 week postoperatively (a–b) and the ankle was immobilized in a cast (c–d).

    

    

   Principles of fracture fixation

   The shaft fracture was anatomically reduced under direct vision and fixed using a straight 4-hole plate. Plates used in fixation of pilon fractures usually function as buttress plates. Therefore, a fracture that is primarily in varus should be buttressed with a medial plate, and conversely, a fracture that is primarily in valgus should be buttressed with an anterolateral plate.

    

   Considerations for shaft fixation

   In cases of a tibial shaft fracture that extends into the plafond, fixing the diaphysis before the plafond potentially

5. Pitfalls and complications

    

   Pitfalls

   Soft-tissue problems

   Soft-tissue problem are a major pitfall when treating pilon fractures, owing to the inherently thin soft-tissue envelope around the distal tibia, the fragility of soft tissues after high-energy trauma, and the necessity for multiple incisions to approach different parts of this complex fracture (Table 2.1-1).

    

    

   Pitfall Tip

    

   simplifies the fixation by converting a segmental fracture into an isolated pilon fracture. The timing of initial shaft fixation is controversial. The shaft fracture can be plated at initial surgery when the external fixation is applied or at definitive ORIF. Careful planning is necessary to ensure the hardware and incision will not interfere with definitive fixation of the articular injury.

    

   The authors prefer to initially stabilize both the shaft fracture and the pilon injury temporarily with an external fixator, and fix the shaft and plafond together during definitive ORIF after soft-tissue edema has resolved and preoperative planning has been performed.

    

   In general, posteromedial or anterolateral approaches offer

   Insufficient

    

   resolution of soft-tissue edema

   Rough soft-tissue handling

    

    

    

   Inadequate skin bridge between incisions

   Contracted and unstable soft tissues

    

    

   Subcutaneous medial border of tibia

   • Wait for wrinkle sign before definitive surgery

     (may require waiting 14–21 days or more, postinjury)

   • Gentle atraumatic retraction

   • Avoid desiccation of tendons or flap during surgery by repeated irrigation

   • Maximize distance between incisions and keep parallel (5 cm)

      

   • Early application of the external fixator not only stabilizes the fracture but also stabilizes and prevents contracture of soft tissues while waiting for definitive fixation.

   • Plating on the lateral side of the tibial shaft if appropriate where the soft-tissue coverage is more robust

   a more robust musculocutaneous soft-tissue cover for the

   plates, while the medial approach carries a higher risk of wound breakdown and exposed implants due to the thin medial soft-tissue envelope.

    

   Table 2.1-1 Major pitfalls pertaining to soft-tissue care.

    

   Inadequate fracture visualization

   In most articular fractures, visualization of and access to the entire articular surface is often necessary. Selection of an approach that is suboptimal for a fracture pattern may result in excessive traction being used for reduction. An external fixator is frequently used to aid visualization of the articular surface by distracting the tibiotalar joint.

    

   Irreducible or non-fixable articular fragments

   Small or comminuted articular surface fragments that are impossible to anatomically reduce or fix are at risk of affecting joint congruency by displacing into the joint as loose fragments. Removal of these fragments is recommended.

    

   Inadequate diagnosis and fixation

   A simple extension of a distal tibial shaft spiral fracture into the joint may be overlooked on plain x-rays. Secondary joint displacement may be the consequence.

    

    

   Complications

   Flap necrosis

   The incidence of flap necrosis can be decreased through appropriate timing of definitive ORIF, meticulous and gentle soft-tissue handling, and repair of extensor retinaculum to prevent tibialis anterior tendon from bowstringing which exerts pressure on the overlying soft tissues.

    

   Infection

   The risk is decreased through a combination of prophylactic antibiotics, extreme care with soft tissues, and reducing duration of surgery.

    

   Loss of fixation

   Incidence can be decreased through use of locking plates in comminuted fractures, correct placement of plates, and correct principle of buttress plating.

    

   Malunion

   Malunion is decreased by anatomical reduction of articular surface, and functional reduction of tibial length, rotation, and varus/valgus alignment.

    

   In the case of osteoporotic bone or noncompliant patients, the external fixator may be left in place postoperatively for 1–6 weeks as an additional support for the fracture.

    

   Nonunion

   Nonunion is best prevented by fixation of shaft fracture in compression, bone grafting of large metaphyseal defects, preserving soft-tissue attachments to fracture fragments, and by providing adequate stability.

    

   Patients should also be advised on nutritional support (ie, multivitamins and calcium) and cessation of tobacco use.

    

   Posttraumatic arthritis

   While severity of injury and quality of reduction play a role in the development of posttraumatic arthritis, the most important factor is primary articular cartilage damage that occurs at the time of the initial injury

6. Alternative techniques

    

   Selecting appropriate incisions is dependent on the fracture pattern and the soft-tissue envelope. Traumatized soft tissue, prior incisions, or preexisting scars require incisions to be placed away from the area of concern.

    

   In cases of a tibial shaft fracture extending distally resulting in a nondisplaced intraarticular split of the plafond, the plafond should first be fixed with two percutaneous interfrag-mentary partially threaded screws. With the articular block restored, the tibial shaft fracture can then be fixed with a standard intramedullary nail.

    

    

7. Postoperative management and rehabilitation

    

   In the first 6 weeks, the patient should be maintained on toe-touch weight-bearing with early gentle range of motion (ROM) of the ankle and hindfoot. In the subsequent 6 weeks, the patient should gradually increase to full weight bearing as tolerated in a removable orthosis and increase ROM exercises and gentle resistance training.

    

   After 12 weeks, the patient can begin neuromuscular retraining which focuses on coordination, balance, and gait. Serial postoperative x-rays are done beginning in the immediate postoperative period until 2 years postoperative. X-rays are evaluated for healing in the initial months and for signs of posttraumatic arthrosis beyond 1 year.

    

   Implant removal

   Removal of implants is not mandatory but recommended if implants are prominent under the subcutaneous envelope of the distal tibia. Implant removal should be undertaken only after healing is complete, ie, after 12–18 months at the earliest.

    

   This patient showed good radiographic and functional healing at the 6-month postoperative review (Fig 2.1-9 and Fig 2.1-10).

    

   a

   b

    

    

   Fig 2.1-9a–b Postoperative x-rays at 6 months showing progress in fracture healing.

   1. AP view.

   2. Lateral view.

    

   a

   b

    

    

   Fig 2.1-10a–b Good functional recovery at 6 months postoperative, demonstrated by active dorsiflexion of 10° and active plantarflexion of 30°.

    

    

    

8. Recommended reading

 

Assal M, Ray A, Stern R. Strategies for surgical approaches in open reduction internal fixation of pilon fractures. J Orthop Trauma.

2015 Feb;29(2):69–79.

Assal M, Ray A, Stern R. The extensile approach for the operative treatment of high-energy pilon fractures: surgical technique and soft-tissue healing. J Orthop Trauma. 2007 Mar;21(3):198–206.

Berman SS, Schilling JD, McIntyre KE, et al. Shoelace technique for delayed primary closure of fasciotomies. Am J Surg. 1994 Apr;167(4):435–436.

Sands A, Grujic L, Byck DC, et al. Clinical and functional outcomes of internal fixation of displaced pilon fractures. Clin Orthop Relat Res. 1998 Feb(347):131–137.