Download Tibial shaft Fractures - Peggers Super Summaries

Peggers’ Super Summary Tibial Shaft Fractures
Indications:
NAILING
 Tibial Diaphyseal Fractures
PLATING
 Tibial Diaphyseal Fractures
 Non-unions and mal-unions
 Comminuted fractures
Operative Room Planning
INTRODUCTION
 Confirm Consent / Mark / WHO form / Abx at
induction
POSITION SUPINE
 Bolsters to position knee at 90 0
DRAPING
 Antiseptic solution from midthigh to include whole
of foot
 Perforate drape around midthigh
Anatomy:
 The entry point can damage the proximal tibia,
menisci, intermeniscal ligament and articular
cartilage
 Geniculate nerves
Associated injuries
 Detailed neurological nad vascular assessment
included ABPI
 Compartment syndrome
 Intra-articular extension especially with spiral
fracture patterns – CT if there is any concern
 Tibial compartments
o Anterior – Tibialis anterior, EHL, EDL,
peroneus tertius Deep peroneal and anterior
tibial artery
o Lateral – Peroneals and superficial peroneal
nerve
o Posterior – Gastrocnemius, soleus, Plantaris,
sural cutaneous nerve
o Deep Posterior – (TDH) Tib post, Flexor
digitorum, FHL, tibial nerve and posterior
tibial nerve
Preoperative Planning:
 Often flexed and in varus
 Review imaging to see fracture extension
o Extension or second fracture of the femoral
neck
 Femoral properties
o Femoral length
o Canal diameter
o Neck shaft diameter
Equipment
 Prosthesis
o Intramedullay
 Tibial nail
o Extramedullary
 Plate (LCDCP or MIPPO)
 radiolucent table
 Bolsters to position knee straight and at 900
 II
 Reduction tool such as Haygroves, Schanz, femoral
distracter
Surgical Approach
NAILING
 Longitudinal approach
o Vertical incision from tibial tuberosity to
patella
o Poorer healing from crossing Langer’s line
o Risk of damage to lateral geniculate nerve
o Easier exposure
 Transverse approach
o 6-8 cm incision horizontal midway between
knee joint and tibial tuberosity
o Uses Langer’s lines and no nerve damage
 Subcutaneous dissection via medial or lateral parapatella approach
 Place the bone awl on the anterior ridge of the tibia
1cm below joint line in line with the canal.
 Push the awl through the cortex making sure the awl
is parallel with the tibia (to avoid damaging the
posterior cortex)
 Use a hand reamer in the proximal canal
 Pass a tipped wire into the canal and guide it past the
fracture site
 Failure of closed reduction consider opening;
o Provisional plating
o Reduction tools
o Schanz pins to joystick the fragments
together
o Femoral distractor
o Poller screws placed across the canal to
direct the guide wire or reamer
 Distally the guide wire should be central on AP / Lat
II
REAMING
 Use a tissue protector when reaming
 Ream sequentially until chatter at the isthmus
 Careful not to blow the fracture apart
 Reaming slowly and with sharp reamers to avoid
thermal necrosis
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Peggers’ Super Summary Tibial Shaft Fractures
NAILING
 Measure the nail length
 Check that the fracture is reduced before the nail is
passed
 Introduce the nail and careful not to rotate the nail
 Check distal and proximal positions on II and as the
nail passes the fracture site
 Bury the proximal nail but not too much in case it
needs removing
 Check rotation before inserting screws
DISTAL SCREW INSERTION
 Align C arm 900 to the leg
 Adjust the leg or c arm so that the screw holes are
‘perfectly round’
 Make a 1cm skin incision over the hole
 Use a drill piece and align with the hole
 During drilling if in doubt remove drill but leave drill
piece in situ to check positioning
 Drill through both cortex’s and measure before
inserting correct
PLATING
 Use a tourniquet
 Spiral fracture need lag screws and neutralisation
plates. Whilst comminuted fractures need plates in
bridging mode
 Low compression dynamic compression plate (LCDCP) or (Minimally Invasive Percutaneous Plate
Osteosynthesis) MIPPO technique to minimally
disturb periosteal tissues and blood supply
 Cortical screws 4.5, cancellous screws 6.5mm
 Compression side of plate with open tension side of
bone, can be overcome with bending at the fracture
site
 Approach is via a 1-2cm lateral incision to the crest
of the tibia
 Incise deep fascia
 Plate can be placed on the medial or lateral tibia, if
medially use sharp dissection to raise flat extraperiosteally.
 Lateral place placement is preferable as there is less
skin irritation
 Plates are placed extraperiosteally
Closure
 Irrigate ++
 Haemostasis
 Fascia not closed
 2/0 vicryl for fat and subcutaneous
 3/0 caprosyn for subcuticular
 3/0 nylon or vicryl rapide for the skin
 Dressings
Evidence:
>50 angulation in any plan has a 25% risk of loss of
fixation. Lang GJ et al. Clin Orthop Related Research 1995.
Trans patella approach no different in pain or movement
than para-patella. Vaisto O et al. J Trauma 2008.
Complications:
Early
 Infection
 Periprosthetic fracture
 Knee pain
Late
 Knee pain – only eason to remove nail
 Non or Malunion
 Nail breakage
Finishing off:
 Check alignment
o Rotation and < 50 acceptable
 Check knee ligaments
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