Beruflich Dokumente
Kultur Dokumente
MINI-SYMPOSIUM:TIBIAL FRACTURES
KEYWORDS
tibial fractures, fractures,
malunited, osteoarthritis,
compartment syndrome,
outcome assessment
(healthcare)
Abstract The main long-term complications of tibial shaft fractures are ankle osteoarthritis and subtalar stiness, postphlebitic limb, foot and ankle deformities due to
acute compartment syndrome, chronic osteomyelitis, and local discomfort related to
metal implants. Fracture malunion may theoretically result in an increased risk of osteoarthritis but clinically the association is not clear, probably because malunion does
not necessarily move overall lower limb alignment outside of the normal range, and
c 2003
therefore not result in important changes in loading of the knee and ankle joints.
Published by Elsevier Science Ltd.
INTRODUCTION
Fracture of the tibial shaft is the most common long
bone fracture, and there is a large volume of literature
about dierent treatments and short- to medium-termoutcomes. Nicolls paper on cast-treated tibial shaft
fractures, published in 1964, is perhaps the best-known
historical study.1 He studied 705 subjects with tibial shaft
fractures and showed that fracture outcome was predicted by what he called the personality of the fracture,
determined by the severity of fracture, displacement,
comminution and associated soft-tissue injury. He
concluded that the good results obtained with cast
treatment meant that routine operative xation of tibial
shaft fractures was not justied.
Over the succeeding decades, there has been a gradual move away from cast treatment towards operative
intervention, mainly due to the development of interlocking nail systems which can be used to stabilise a wide
range of fracture types. Such devices are undoubtedly a
major advance over cast treatment in the management
of high-energy tibial shaft fractures, because skeletal stability allows optimum management of the associated
soft-tissue injury. However, the majority of tibial shaft
fractures are caused by a lower energy mechanism, and
are associated with a less severe soft-tissue injury. Operative treatment of such fractures usually produces
good results, but cast or brace treatment also produces
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general population. The commonest pattern of osteoarthritis is isolated patello-femoral disease. Many patients
with radiographic evidence of osteoarthritis report knee
pain and mild impairment of everyday physical activities.
The cause of osteoarthritis is multifactorial, including
genetic predisposition, direct injury to the knee, and abnormal loading as a result of injuries such as a meniscal
tear or anterior cruciate ligament rupture.The inuence
of tibial shaft fracture malunion on the development of
knee osteoarthritis remains uncertain.
Unlike the knee, there is a signicant excess of osteoarthritis of the ankle on the side of a previous tibial shaft
fracture. Ipsilateral ankle osteoarthritis aects around
10% of subjects,4 whereas contralateral ankle osteoarthritis is rare, and when present is almost always associated
with another injury such as fracture. Ankle osteoarthritis
is usually associated with pain and stiness, but symptoms
do not seem to have as much eect on function.
While ipsilateral subtalar osteoarthritis is seen in 6%
of subjects after a tibial shaft fracture, ipsilateral subtalar
stiness aects 32% of subjects.4 Operative xation of
tibial fractures, followed by early, non-weight-bearing
joint mobilisation may reduce the prevalence of subtalar
stiness.5
Figure 1 Anteroposterior radiograph of a tibial fracture malunion taken 30 years after the original injury.The coronal plane
malunion measures 12.51 varus. The joints are well preserved,
and the patient reported no knee pain, ankle pain or functional
limitation.
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CURRENT ORTHOPAEDICS
203
451
4101
451
4101
4101
4201
410 mm
420 mm
433%
13^32
6^9
10^30
1^6
0^4
2
4^12
2^3
14
0^2
0
3
0^2
4^14
0
1
0
2
POSTPHLEBITIC LIMB
Several long-term follow-up studies of tibial fracture subjects have looked at the prevalence of osteoarthritis in
relation to malunion and other fracture factors.4, 8 ^12
Such studies have a number of limitations. With longterm follow-up, it becomes dicult to trace a good proportion of the original cohort, and this may result in a
biased sample. In addition, the number of subjects with
overall lower limb malalignment will be relatively small
because it is uncommon, even after cast treatment.
Comparisons in these circumstances may be subject to
type 2 statistical error (i.e. failure to show a statistically
signicant dierence when one does exist, owing to insucient subject numbers). With increasing subject age
at the time of follow-up, one would expect a parallel increase in the prevalence of idiopathic osteoarthritis of
susceptible joints such as the knees which might obscure
a small number of cases of osteoarthritis due to malunion, if such exist.
Overall, the published studies suggest that malunions
of the severity usually seen after cast treatment of tibial
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and this was more common in subjects with a calf thrombosis, those who were not adequately anticoagulated,
and those with recurrent thromboses.17
Postphlebitic limb is not recognised as a major problem by many orthopaedic surgeons, probably because
it tends to present years after the causal thrombosis,
and most frequently in vascular surgery or dermatology
clinics. Fractures of the femur and the tibia are said to be
associated with subsequent postphlebitic changes in approximately 50% of subjects where no antithrombotic
prophylaxis is given,18 although the majority would probably be stage I and therefore not a cause of appreciable
morbidity. Signs and symptoms of postphlebitic limb may
not appear until more than15 years after a DVT, and this
means that it is hard to attribute them with certainty to
a previous tibial shaft fracture. Some subjects may have
developed a DVT for other, unrelated reasons. Thus, the
role of tibial shaft fractures in producing appreciable
long-term morbidity as a result of an associated DVT
may have been overstated.
LONG-TERM EFFECTS OF
COMPARTMENT SYNDROME
Compartment syndrome is anincreased pressure within
a closed fascial compartment causing local tissue ischaemia. The reported incidence of compartment syndrome
after a tibial shaft fracture is 1^9%, and tibial shaft fractures account for more cases of compartment syndrome
than any other injury. The type of fracture, and the
means by which it is treated, do not seem to aect
the incidence of compartment syndrome.19 Men under
the age of 35 years are at highest risk of developing
compartment syndrome after tibial shaft fracture.
In spite of heightened awareness of compartment syndrome, cases continue to be diagnosed late or missed altogether. Failure of early diagnosis and treatment of
acute compartment syndrome results in ischaemic muscle damage, which in turn may result in nerve damage,
renal failure, infection, amputation, or even death. Damaged muscle heals by brosis, causing shortening of
the musculo-tendinous unit.This may result in ankle stiness or cavus foot deformity with clawing of the toes,
depending on the compartments aected. Such deformities appear within the rst year after injury. Muscle damage associated with the tibial fracture itself will also
heal by brosis; it is important not to assume that the
presence of foot deformities after a tibial shaft fracture
means that a compartment syndrome must have been
missed.
In one series of tibial shaft fractures treated in casts,
6% of subjects at review had foot and ankle stiness, and
in one-third of these stiness was attributed to ischaemic muscle damage.20 The treatment of ischaemic contractures is dicult, although good functional results
CURRENT ORTHOPAEDICS
have been reported following lengthening of exor hallucis longus and exor digitorum longus for clawing of the
toes after a tibial fracture.21
CHRONIC INFECTION
The main determinant of infection after a tibial fracture
is whether or not the original injury was open or closed.
With closed fractures treated in plaster, the infection
rate is negligible. Operative treatment of closed fractures does result in a small but denite infection rate, in
the range 0 ^15% for AO plate xation and 0 ^1% for intramedullary nailing.3 The infection rate after open fractures depends on the severity of the soft-tissue injury.
Using the Gustilo and Anderson classication, infection
is seen after 0 ^2% of grade I injuries, 2^7% of grade II injuries, 7% of grade IIIa injuries, 10 ^50% of grade IIIb injuries and 25^50% of grade IIIc injuries.22 Plate xation of
open tibial fractures seems to give a higher rate of infection than intramedullary nailing or external xation.
Most infections after a tibial fracture are acute, respond to aggressive surgical treatment, and do not lead
to chronic bone infection. Overall, approximately 10% of
deep infections lead to chronic osteomyelitis. Treatment
of this is dicult, involving removal of infected metalwork, excision of dead bone, stable re-xation and antibiotics. Complex reconstructive procedures are often
necessary to treat the resulting bony and soft-tissue defects. If treatment for infection is unsuccessful, belowknee amputation may give the best functional outcome;
however, circular frame techniques have greatly increased the potential for limb salvage in these dicult
cases. Unresolved infection persisting for many years
has a small risk of amyloidosis.
LOCAL SYMPTOMS
Many patients report intermittent aching symptoms at
the site of a previous tibial shaft fracture, whether the
fracture has been treated by operative or non-operative
means. These symptoms probably lessen with time.
Symptoms seem to be worse when the weather is cold,
although the mechanism for this is not known.
Intramedullary nails have a more denite association
with local symptoms. Up to 40% of patients who have a
tibial nail inserted complain subsequently of anterior
knee pain, although this improves with time in half of
these patients. The use of a patellar tendon-splitting approach, and leaving the tibial nail proud of the bone are
two factors that may increase the incidence and severity
of anterior knee pain after tibial nailing. However, a wellburied nail inserted through a medial para-patellar approach still carries a risk of anterior knee pain, and only
about one-half of aected individuals will get better
following nail removal. Residual tenderness may be related to the presence of a scar on the front of the knee.
PRACTICE POINTS
K Tibial shaft fracture is associated with subsequent ankle osteoarthritis and subtalar stiness of unknown cause
K Angular malunion which does not cause overall lower limb
malalignment does not have a deleterious eect
K Asymptomatic deep vein thrombosis after a tibial shaft fracture is one possible cause of postphlebitic limb many years
later
K Inadequate treatment of acute compartment syndrome
after a tibial shaft fracture results in foot and ankle stiness
and deformities
K Persistent infection after tibial xation carries a risk of amputation
RESEARCH DIRECTIONS
K Long-term follow-up study of young adults to dene the
range of lower limb alignment that can be tolerated without leading to osteoarthritis
K Elucidation of the mechanism by which tibial shaft fractures
lead to ankle osteoarthritis
K Ecacy of strategies to prevent deep vein thrombosis on
the long-term prevalence of postphlebitic limb
REFERENCES
1. Nicoll E A. Fractures of the tibial shaft. J Bone Joint Surg Br 1964;
46B: 373387.
2. Sarmiento A, Sharpe F E, Ebramzadeh E, Normand P, Shankwiler J.
Factors influencing the outcome of closed tibial fractures treated
with functional bracing. Clin Orthop 1995; 315: 824.
3. Littenberg B, Weinstein L P, McCarren M. et al. Closed fractures
of the tibial shaft. A meta-analysis of three methods of treatment.
J Bone Joint Surg Am 1998; 80A: 174183.
4. Milner S A, Davis T R C, Muir K R, Greenwood D C, Doherty M.
Long term outcome after tibial shaft fracture: is malunion
important? J Bone Joint Surg Am 2002; 84A: 971980.
5. Merriam W F, Porter K M. Hindfoot disability after a tibial shaft
fracture treated by internal fixation. J Bone Joint Surg Br 1983;
65B: 326328.
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