Fractures of the Tibia & Fibula.pptttttt

FRACTURES OF THE TIBIA AND FIBULA
 Important for 2 reasons
o Common
o Controversial
 Incidence
o 492,000 per year
o 77,000 hospitalization

 ANATOMY
o Long bones
o Tibia palpable subcut.
o 3 compartments
I. Anterior compartment
 Muscles
• T A, EHL, EDL, FT

 Artery
 Anterior Tibial
 Nerve
 Deep peroneal
II. Lateral Compartment
 Muscles
 P.brevis and longus

 Nerve
 Superficial peroneal
III. Posterior Compartment
A) Superficial
 Muscles
 Gastrocnemius, Soleus
 Popliteus, plantaries

 Nerve
 Sural nerve
 Vein
 Long and short saphenous
B) Deep
 Muscles
 TP, FDL, FHL

 Nerve
 Posterior tibial
 Artery
 Posterior tibial and peroneal
 Blood Supply
1) Nutrient(posterior tibial)
2) Periosteal(anterior tibial)

 Venous Drainage
 Greater and lesser saphenous
 Anterior and posterior tibial
 Peroneal veins
 Mechanism
1) Fatigue/stress
2) Low energy
3) High ennergy

Classification
Various types
• Simple( stable – unstable )
• Detailed alphanumeric
Morphological variables
Anatomic location
Pattern of # lines
Degree of displacement
Soft tissue injury

Sign and symptoms
 Pain
 Inability of unrestricted wt bearing
 Deformity
 Local swelling/ edema
 Look for :
 Wound
 Vascular/ neurologic damage
 Ipsilateral femur, hip, knee, ankle, foot injuries

 Investigation
 Radiology
 2 views
 Include knee and ankle
 Control
 Fracture Description
1) Closed or open #
2) Anatomic location( prox.,mid.,dist.)

3)Fracture configuration
 Transverse
 Oblique
 Spiral
 Comminuted
4)Angulation
 In reference to distal fragment
5)Displacement

 6)Degree of shortening or distraction
 7)Rotation
TREATMENT
Types
1. Closed( non-operative)
2. Operative methods
 Plate and screw
 IMN
3. External fixation

 Best Rx depends on:
Morphology of #
Amount of energy imparted
Mech. Characterstics of the bone
Age and general condition
Soft tissue status

 I. Closed Rx
Indications
 Low energy closed #
 Minimally displaced #
 Longitudinal spiral #
Methods
• LLC for 6-8 weeks
• PTB FOR 6-8 weeks

 Initial posterior gutter
 Control x-ray
 Cast care instruction
 Physiotherapy
Advantages
• Allow early wt bearing
• Minimize hospitalization
• Stimulate bone healing

 No risk of infection
 No sophisticated instruments
 Cast failure easier to correct than implant failure
Disadvantage
• Require compliant pt
• ↑rate of subtalar motion loss
• Malunion
• Shortening
• Delayed and nonunion

 External Fixator
• Indication
• Acute stabilization of open fractures
• Closed unstable # complicated by com.synd., head
injury,burns, impaired sensation
 Methods
1) Pins and plaster
2) Ext. Fixators
 Pin fixators
 Ring fixators

 Complications
• Pin tract infection
• Pin loosening
• Mal-, delayed, non-union
• Bulky
• Require frequent adjutment

II. Internal Fixation
Indication
• Failure of closed Rx
• Displaced, unstable #
• Bilateral #
• Segmental#
• Intra-articular extension
• Pathological#

 Methods
1) Plate and screw
 Indications
 # with displaced intra-articular
 Malunions
 Nonunions
 Complications
 Skin necrosis and infections

 2)IMN
 Open
 Closed
 Locking/without
 Reamed/ unreamed
 Preservation of periosteal soft tissue
 Medullary canal diam. >8mm
Advantages of ORIF
• Restoration of bony anatomy
• Early joint mobilization

Disadvantage
 Further soft tissue damage
 Wound dehiscence and infection
 Delayed wt bearing
 Implant failure
 Refracture
Complications of tibiofibular #
o Common
o R/d to # or Mx

 Delayed and non-union
 Infection( osteomyelitis/infected non-union)
 Bone defect
 Mal-union and shortening
 Skin loss
 Amputation
 Vascular injury
 Compartment syndrome

 Nerve injury
 Joint stiffness and ankylosis
 Traumatic artritis
 Reflex symp. Dystrophy( sudek’s atrophy)
 Claw toe deformity
 Fat embolism
 refracture

 Prognosis
 Time to union
10-13wks closed low energy
13-20wks closed high energy
16-26wks open (type I)
30-50wks open(type ii.iii)
 Poor px factors
• Infection, distraction, bone loss

 Long term result depends on
• Length restoration
• Knee ankle motion
 OPEN FRACTURES
 Classification( Gustilo)
 Type I,II,III A,B,C
 Teatment
1) Radical debridement and pulsed lavage

2)stabilization
3)antibiotics
4)Soft tissue coverage ( with in 4-7 days)
5)Functional rehabilitation and preemptive bone grafting
(6-12 wks)
 Method of stabilization
• Controversial
1) Cast immobilization ; low enegy stable open #

2)External fixator ; intra articular,metaphyseal shaft #s ,
markedly contaminated or extensive soft tissue loss
3)non reamed interlocking IMN; contraindicated in
contaminated wounds

Fractures of the Tibia & Fibula.pptttttt

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