TIBIA FRACTURES : AN OVERVIEW OF EVALUATION

AND TREATMENT

MOHANAASHVINI RAJALINGAM ( c11108761)

DIBAWAKAN DALAM RANGKA TUGAS KEPANITERAAN KLINIK PADA BAGIAN ILMU BEDAH FAKULTAS KEDOKTERAN UNIVERSITAS HASANUDDIN MAKASSAR

EPIDEMIOLOGY
Occurrence rate for tibia, fibula, and ankle fractures is 492,000 per year in the United States (Praemer, Furner, & Rice, 1992). Tibia and fibula fractures in the same time period resulted in 77,000 hospitalizations, Tibial fractures are the most common long bone fractures

MECHANISM OF INJURY
Has two categories - First is low-energy injuries, such as household falls or athletic injuries -Second is high-energy injuries, such as motor cycle and car crashes and pedestrians struck by motor vehicles There are rare mechanisms of injury such as tibial insufficiency fractures. Insufficiency fractures are fractures from normal load (walking, using steps, bending, sitting) on abnormal bone (osteopenic or underlying disease) that result in pathologic fractures

CLASSIFICATION OF FRACTURE
CLOSED TIBIA FRACTURE closed fracture to the tibia is more common, whereas an open fracture is thought to be higher risk for complications. Closed tibia fractures in young patients are commonly sports-related injuries. Closed tibia fractures in the elderly are commonly caused by ground level falls. Fracture pattern of closed tibia fractures is usually simple, with less severe soft tissue injury High-energy fractures are caused by motorized vehicle crashes. More complex, soft tissue injury patterns are also frequently seen In older, less fit patients with osteoporotic bone

CLASSIFICATION OF CLOSED TIBIA FRACTURE

OPEN TIBIA FRACTURE

Less common compared to the closed fracture of the tibial bone Scoring system to classify open tibia fracture is developed by Gustillo and Andereson which divides the fracture in three major grades

CONSIDERATION TO COMORBIDITIES

Definitive treatment of fractures may also be delayed until life threatening injuries, such as lung contusions, brain injury or hemodynamic instability elderly patient and those with medical problems requiring comprehensive work up and clearance prior to treatment of the fractures. Dehydration, hypertension, infections (urinary tract infection, pneumonia) or renal nsufficiency should be resolved. Patients taking anticoagulants require reversal, usually to international normalized ratio INR < 1.4. Consideration to chronic renal failure, congestive heart failure, chronic obstructive pulmonary disease an age greater than 70 years are critical risk factors for inpatient mortality

TREATMENT : CLOSED TIBIAL FRACTURE

Treatment for closed tibial fractures can include : cast application, (minimal soft tissue injury, stable fracture pattern, and ability to bear weight in a cast or functional brace.) functional bracing, or plate fixation; however intramedullary (IM) nailing is the preferred treatment alternative for high energy fractures especially with more severe soft tissue injuries

TREATMENT: CLOSED TIBIA FRACTURE

Advantages of cast application over IM nailing are low risk of infection, less knee pain, and no need for hardware removal. However, advantages of IM nailing include better alignment, earlier range of motion of knee and ankle,better mobility of patient, less frequent follow up visits, and earlier return to work

TREATMENT: OPEN TIBIA FRACTURE

Involves attention to the wound and appropriate time to close the wound Treatment for closed tibial fracture may include: -Vacuum-assisted closure (wound vac) device (VAC)
-Plate fixation (most commonly used on the proximal and distal tibia fractures. Plate fixation for the treatment of acute, isolated tibial fractures) - IM nailing (depends risk of infection, extent of soft tissue injury or vascular injury)

POSTOPERATIVE CARE

Pain Management
Elevation of the extremity to the level of the heart and the application of ice help to decrease swelling. The length of time for ice application should continue untildependent painful swelling subsides. Tolerance to pain,reaction to narcotics, and progression of diet can effect the postoperative period.

Neurovascular assesment
Nerve assesment : Check of sensation and range of movement Vascular assessment includes checking color, temperature, capillary refill, and palpation of dorsalis pedis and posterior tibial pulses if accessible. T o avoid Compartment Syndome

PREOPERATIVE CARE
COMPARTMENT SYNDROME Internal pressure or external confinement or restriction can proceed to the point at which cellular exchange is diminished ischemic environment that, when left untreated, can cause irreversible damage to tissue and nerves Assess the six Ps: pain out of proportion to the injury, pain with passive stretch of the toes, pallor, pulselessness, paresthesia, and paralysis;

POSTOPERATIVE CARE

Activity
Physical therapy and occupational therapy consults are ordered to evaluate and treat mobility and self-care abilities.

Plan for discharge

Discharge plans can include the following: home with home health or outpatient physical therapy, skilled nursing facility for increased strengthening and independence training before returning home, or an inpatient stay in the rehabilitation unit.

COMPLICATIONS
Compartment syndrome Non union, or broken hardware, with loss of alignment. Infection in patients especially patients with an open tibia fracture Deep Vein Thrombosis Pulmonary Embolism

CONCLUSION
Tibial fracture is one of the most common long bone injury in the world The goal of treatment is alignment and function, along with a positive and empowering experience for the patient. The patients functional life status will be affected while healing, and coping mechanisms will be challenged.