Diaphyseal fractures of the tibia moderated interactive session

$Diaphyseal fractures of the tibia moderated interactive session AOTrauma Advances Course$

Diaphyseal fractures of the tibia moderated interactive session AOTrauma Advances Course

Learning outcomes • List indications for use of an external fixator as temporary and/or definitive stabilization of tibial shaft fractures • Outline indications and technique for plating of tibial fractures • Discuss tips and tricks for nailing of difficult tibial fractures • Contrast the three possible fixation methods for treating closed or open tibial midshaft fractures • Appreciate that conditions of soft-tissues are crucial for decisionmaking

$Closed mid-shaft tibial fracture Your treatment of choice is? 1. Intramedullary nailing 2. ORIF$

Closed mid-shaft tibial fracture Your treatment of choice is? 1. Intramedullary nailing 2. ORIF with plate 3. Minimally invasive plating 4. Nonoperative, set in cast 5. External fixation (including ring fixation)

$Closed mid-shaft tibia fracture Your treatment of choice is? 1. Intramedullary nailing 2. ORIF$

Closed mid-shaft tibia fracture Your treatment of choice is? 1. Intramedullary nailing 2. ORIF with plate 3. Minimally invasive plating 4. External fixation as definitive treatment (including ring fixation) 5. Temporizing external fixation and secondary definitive treatment

$Key points from lectures Tibial shaft fractures—plate fixation • Soft-tissue care is key for$

Key points from lectures Tibial shaft fractures—plate fixation • Soft-tissue care is key for success • Indicated in meta/diaphyseal fractures, combination shaft plus proximal or distal articular fracture, open growth plates, small canals, periprosthetic fractures, nonunions, and malunions • Locked implants in periarticular and periprosthetic fractures

$Key points from lectures Tibial shaft fractures—external fixation • Can be used temporary as$

Key points from lectures Tibial shaft fractures—external fixation • Can be used temporary as a stabilization method: damage control (patient and soft tissues) while everything settles down • Temporary use of external fixation does not burn any bridges and allows time to plan • Conversion as soon as possible, preferable within 2 weeks • As a definitive treatment can be used in severe soft-tissue injuries, bone loss, reconstruction, complex injuries

$Key points from lectures Tibial shaft fractures—nail fixation • Reamed nailing is the gold$

Key points from lectures Tibial shaft fractures—nail fixation • Reamed nailing is the gold standard in midshaft tibial fractures • In proximal and distal tibia: reduce the fracture and keep it reduced until insert the nail and lock it • Insertion point is key for proximal tibia nailing • Several reduction techniques have evolved that can help you with reduction: poller screws, monocortical plate, femoral distractor, fixing the fibula

Controversies • Cast • Plate—open reduction, MIPO technique • IM nailing • External fixation/ring/hybrid

32 -year-old male, motor vehicle accident • Closed injury • Neurovascular structure intact • No other injury

Your treatment of choice? 1. IM nailing 2. ORIF Plate 3. Minimally invasive plating 4. External fixation (including ring)

32 -year-old male, motor vehicle accident • Closed injury • Neurovascular structure intact • No other injury

Your treatment of choice? 1. IM nailing 2. ORIF Plate 3. Minimally invasive plating 4. External fixation (including ring)

Final result

16 -year-old male fell from 10 m • Open wound • Distal neurovascular status is normal • Irrigated and debrided

Your treatment of choice? 1. IM nailing 2. Plate 3. External/ring fixation 4. Temporary fixation with external fixation, then definitive treatment 5. Cast

Definitive treatment?

Summary • Soft tissues! closed vs open tibial injury • There are indications for use of each implant: – IM nail – Plate – External fixation • Rules for temporary fixation and then converting to definitive fixation