Master Techniques in Orthopaedic Surgery: Fractures
2nd Edition

28
Tibial Shaft Fractures: Open Reduction Internal Fixation
Brett R. Bolhofner
Indications/Contraindications
Open reduction internal fixation (ORIF) through use of plates and screws may be carried out for any fracture of the tibia in which soft-tissue conditions are satisfactory. Although intramedullary interlocking nails have become popular for the treatment of many tibial-shaft fractures, plating remains a viable alternative (1). Compared with an intramedullary implant, plating of the tibia requires greater attention to the condition of the soft tissues, more preoperative planning, and greater attention to surgical detail during the procedure.
Strong indications for plate osteosynthesis of tibial-shaft fractures are the presence of compartment syndrome, neurovascular injury, compromised medullary canal, or compromised access to the medullary canal due to associated injury (2,3).
Relative indications for ORIF include the following conditions: polytraumatized patients, open fractures, late loss of reduction with closed treatment, segmental injury, fractures that extend into either the knee or ankle joint, fractures of the proximal and distal one third of the shaft, and fractures in patients whose livelihood or recreational habits demand perfect restoration of length and rotation (2,3). Certain fracture patterns may be better anatomically restored by plating. For example, a distal, spiral, oblique fracture or a simple oblique fracture with a relatively steep fracture plane may be best treated with a plate as will fractures that extend to the ankle joint.
Relative contraindications to plate osteosynthesis include isolated, displaced, diaphyseal fractures, which may be better treated with a locked intramedullary nail. Grossly contaminated open fractures, which will require serial débridements, are best treated with an external fixator.
A careful assessment of the soft-tissue envelope at the time of injury and at the time of surgery is essential because its condition influences the timing of the surgical procedure. The Tscherne classification may be helpful in evaluating and assessing the soft-tissue
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injury associated with a particular fracture pattern (4). In patients whose soft tissue does not permit early internal fixation because of swelling, abrasions, or blisters, may benefit from a 10 to 14 day waiting period. The skin should have a very fine wrinkled texture or appearance before plate osteosynthesis is undertaken.
When soft-tissue conditions are satisfactory, the tibia is well suited to plate fixation. It has a large subcutaneous surface that may be used for stabilization without the muscles being stripped (5). Because no muscle needs to be stripped from it, the medial face of the tibia is, in fact, an ideal plating surface. Most of the poor results and subsequent criticisms of tibial plating were due to poor soft-tissue technique, inappropriate implant use, and poor reductions.
Preoperative Planning
The initial assessment of the soft tissues and the radiographic pattern of the fracture is carried out immediately. Attention to the neurovascular status as well as the status of the muscle compartments is mandatory. The presence of soft-tissue contusion, skin necrosis, swelling, compartment syndrome, skin abrasion, or any wounds is carefully documented. Anteroposterior (AP) and lateral views of the tibia, to include both knee and ankle joint, must be obtained (Fig. 28.1).
The timing of the internal fixation is based primarily on the condition of the soft tissues. ORIF of the tibia should only be carried out when satisfactory skin and wound conditions permit a tension-free soft-tissue closure at the conclusion of the procedure. If these conditions do not exist, then internal fixation should be postponed. The extremity should be splinted, casted, or a temporary, spanning, external fixator applied until more favorable conditions exist. If surgery is delayed, the limb should be elevated to help resolve any swelling. Necrotic soft tissue should be well demarcated and excised at the time of surgery. A gastrocnemius, rotational, muscle flap will be required for proximal tibia fractures. In the distal tibia, a free tissue transfer or a fasciocutaneous rotational flap may be needed. When satisfactory soft-tissue conditions are present, the procedure may be carried out with a well-conceived preoperative plan and a surgical tactic.
AP and lateral radiographs of the injured extremity should be obtained. If the fracture is complex or if deformity is significant, an AP and lateral radiograph of the unaffected side or an AP and lateral radiograph of the affected extremity in traction may help the surgeon better conceptualize the fracture pattern. The preoperative drawings, which need not be of artistic quality, should be fashioned so that a step-by-step procedure from start to finish is outlined in a simple fashion (Fig. 28.2). Because the preoperative plans are displayed in the operating room at the time of the surgery, they should list any equipment that might be required. The steps of the procedure are indicated directly on the preoperative plan in numeric order.
The equipment required to carry out the procedure will be AO/ASIF screws and plates including the limited-contact dynamic compression (LCDC) plate with combination holes (Synthes, Paoli, PA). Basic instruments, an AO drill, bone forceps, and associated small soft-tissue retractors and elevators are also required.
Locking the screws to a plate may be an advantage when bone quality is poor due to osteoporosis or when the distal fragment is relatively short. Using a locked construct will allow the creation of a fixed angle device, and when applied to one or the other major fragments, it will allow the plate to be used to facilitate the reduction (i.e., indirect technique). Precontoured plates are available for some fracture patterns and applications. A locked plate must be accurately contoured if it is to be used as a reduction tool because a locked screw will not pull the plate and bone together. In some instances, a more stable construct can be created with locking screws. Preoperative planning may be more difficult because of the uncertainty of the locked screw projections after plate contouring.
Assumption of basic AO technique as well as the use of locking screws is assumed. A complete discussion of locking technique is beyond the scope of this chapter.
Figure 28.1. AP (A) and lateral (B) radiographs of the tibia and fibula showing an oblique fracture pattern with butterfly fragments that are mildly displaced. Nondisplaced fracture lines extend toward the ankle joint. C. A nondisplaced, medial, malleolar fracture is shown.
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Surgery
When the soft tissues are satisfactory for surgery and a preoperative plan has been established, the procedure may be initiated (Fig. 28.3). Intraoperative findings (such as nondisplaced fracture lines or unrecognized comminution) may contradict the preoperative plan for trauma reconstruction (such as for an osteotomy). In such cases, the order of the preoperative plan may need to be altered.
The patient is placed in the supine position on a regular operating-room table. A tourniquet is not required for the procedure but may be used if desired. Use of either general or spinal anesthesia is satisfactory. The entire leg is prepped from the toes to the groin. Prophylactic intravenous antibiotics, usually a single preoperative dose of cephalosporin, is
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recommended. The location and length of the incision is drawn on the skin before application of an adhesive iodine-impregnated drape (Fig. 28.4). I prefer to carry out the procedure in the seated position at the foot of the table with the surgical assistant also seated.
Figure 28.2. A–D. AP and lateral preoperative drawings illustrate the fracture pattern and subsequent definitive fixation. This is helpful in selecting a plate of proper length to contour. The plate may be used to achieve reduction followed by lag screw fixation or vice versa. The articulating tension device may be used to load the construct if the pattern allows. Preoperative plan: Step 1: Indicate joint axis. Step 2: Reduce and secure butterfly fragments. Step 3: Precontour plate and apply to distal fragment. Step 4: Not shown; push/pull screw may be inserted proximally. Step 5: Adjust reduction. Step 6: Additional lag screws if necessary. Step 7: Additional plate screws to balance fixation.
Surgical Approach
A long anterior incision is placed 1 cm lateral to the tibial crest and corresponding to Langer’s lines (Fig. 28.5) (1). The incision is curved gently at its distal portion at the level of the metaphyseal flare in the supramalleolar region. A long surgical incision is preferred because it allows satisfactory exposure of the tibia and allows the surgeon to avoid unnecessary, vigorous, skin retraction, particularly on the medial skin flap (Fig. 28.6A) (6). The saphenous vein or nerves need not be sacrificed in the distal portion of the incision because the plate may be placed beneath these structures, leaving them completely intact (see Fig. 28.6B). They should be dissected only enough to allow passage
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of the plate beneath them. In addition, the sheath of the tibialis anterior tendon need not be entered.
Figure 28.3. The condition of the skin is ascertained before undertaking ORIF. In this case, no ecchymosis or fracture blisters are found. A minimal amount of edema is present and a fine wrinkle pattern can be noted on the skin 10 days after the initial injury.
Figure 28.4. Planned surgical incision is indicated on the skin with a marker to assist in the surgical approach as well as wound closure. The operative area is draped with adhesive iodine.
Figure 28.5. The surgical incision is anterior and curvilinear. It begins 1 cm lateral to the tibial crest and curves medially in the distal portion.
Figure 28.6. A. The surgical incision is carried through the skin and subcutaneous tissue. B. The small dental instrument indicates the location of the distal saphenous structures, which are preserved during the surgical approach and the procedure. C. The small dental instrument indicates the presence of fracture hematoma, which is removed for exposure of the fracture.
The skin and subcutaneous flap are raised in a medial direction just enough to allow exposure of the posteromedial border of the tibia and the butterfly fragment, which are seen after removal of the fracture hematoma. The dissection remains extraperiosteal. The periosteum is frequently noted to be stripped at the fracture edges as a result of fracture displacement. If any additional periosteal elevation is necessary to evaluate reduction, then not more than 1 or 2 mm at the immediate fracture edge should be elevated. The remainder of the procedure should be carried out entirely extraperiosteally (Fig. 28.7) (1).
Figure 28.7. After evacuation of the fracture hematoma, the fracture, including the minimally displaced posteromedial butterfly, can be seen. The edges of the fracture are compared to the surrounding hemorrhagic periosteum and are noted to be white. This indicates the amount of periosteum that was stripped by the injury itself. The stripping done by the injury allows for sufficient visualization of the fracture edges and subsequent reduction. No further periosteal stripping should be necessary for reduction and fixation of this fracture. The periosteum is hemorrhagic because of the injury and also because no tourniquet is used.
Figure 28.8. The posteromedial butterfly is directly reduced with bone forceps. Even though the butterfly is directly reduced, the bone forceps is applied extraperiosteally; no soft-tissue stripping is necessary to accomplish the reduction. The small elevator indicates the location of the posteromedial butterfly fragment.
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Internal Fixation
Once the surgical approach has been completed and satisfactory exposure of the fracture site and the medial surface of the tibia has been achieved, then the preoperative plan is followed in order for reduction and fixation of the fracture (see Fig. 28.2).
The ankle-joint axis is initially marked with a reference Kirschner (K) wire placed by hand in the soft tissues at the level of the ankle joint (step1, Fig. 28.2B). The butterfly fragment in the nondisplaced fracture lines are reduced and secured with bone forceps placed without stripping additional periosteum. If significant displacement of the butterfly fragment exists, an indirect reduction technique is preferable to manual manipulations, which generate risk of soft-tissue stripping and devascularization of the fragment (Fig. 28.8). The butterfly fragment in nondisplaced fracture lines is then secured with lag screws (Fig. 28.9); this is the direct reduction portion of the case.
The remainder of the fixation is achieved using a 4.5-mm combination-hole plate. Because locked screws will not pull the plate to the bone, a locked place should be contoured anatomically (Fig. 28.10). The plate is secured to the distal fragment with locking screws. The bone or undersurface of this particular plate has small undulations so that the plate contacts the bone or periosteum only at intermittent alternating points, allowing (as much as possible) preservation of the periosteal circulation. However, standard stainless-steel plates without the limited-contact feature and without the locking feature are also satisfactory choices. An experienced surgeon can bend and twist the plate during the procedure. Less experienced surgeons can precontour the plate by using a bone model or skeleton before the procedure and then sterilizing it (step 3).
In an alternate procedure, the locking plate may be applied initially on the distal fragment with a standard 4.5-mm cortical screw, which will pull the plate to the bone. Then a second locking screw can be placed to protect the initial screw. Any of the distal fragment holes can be used for the preliminary screw insertion.
A push-pull screw is then inserted 1 or 2 cm proximal to the plate. The AO articulating tension device is then applied at the proximal end of the plate and distracted (step 4, Fig. 28.2C). If the plate is properly contoured, the plate need not be clamped to the shaft proximally. However, if necessary, the surgeon can carefully apply a bone clamp by making a small incision and laterally placing it with minimal stripping of soft tissue.
Figure 28.9. An intraoperative image demonstrates lag screw fixation of the butterfly and nondisplaced fracture fragments. The lag screws are placed through the periosteum with care not to strip additional bone. They should be placed so that they do interfere with plate placement. Note the nondisplaced, medial, malleolar fragment that will be secured with the plate.
Figure 28.10. A 4.5-mm tibial LCDC plate with combination holes is contoured for the distal-tibial medial surface with a distal bend and a proximal medial twist.
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The fracture is then distracted (step 5, Fig. 28.2D), and reduction is adjusted for angulation and rotation with small position changes in the extremity or with reduction clamps placed extraperiosteally (Fig. 28.11). This is the indirect reduction portion of the case (5).
Once the fracture has been reduced, the articulating tension device is placed in the compression mode and compressed to approximately 60 kPa (step 6, Fig. 28.2D) (7). This construct, with only one screw and the articulating tension device, is usually quite stable. This is a good time to obtain intraoperative radiographs for assessing fracture reduction and alignment. Standard overhead films or c-Arm images are obtained to assess the overall axial alignment and preliminary fixation (Fig. 28.12). At this point in the procedure, any step is easily reversed.
If the reduction is satisfactory, then the major fragments should be secured with lag screws placed through or outside the plate. Additional screws are inserted into the plate to enhance stability (Fig. 28.13) (step 7, Fig. 28.2D). The exact number of screws is cannot be precisely predicted, but the surgeon should balance the fixation by dispersing the screws
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equally on either side of the plate. Intraoperative radiographs are obtained and final fixation adjustments are carried out (Fig. 28.14). The final radiograph should correspond closely with the preoperative drawing.
Figure 28.11. A. The contoured plate is slipped beneath the distal neurovascular structures and applied to the distal fragment with a single locked screw to create a fixed-angle plate. B. The ATD is then placed off a proximal push-pull screw and can be used to achieve distraction if necessary and to fine-tune the reduction. Clamps are used extraperiosteally to secure and fine-tune the reduction as well as to protect the lag screws during distraction and compression. Note the distal drill sleeve for insertion of a second, more distal, locking screw. The ATD creates a load-sharing construct between the implant and bone.
The wound is irrigated with antibiotic solution and closed over a small drain. The skin itself is approximated with interrupted, horizontal, mattress sutures of 4-0 nylon. No tension should be present at the skin edges at the time of closure (Fig. 28.15). If tension-free closure cannot be obtained after osteosynthesis, then I prefer to make multiple, small, relaxing incisions with a no.10 blade on both sides of the surgical incision; this pie-crusting technique frequently allows closure without tension. If wound closure without tension is not possible, then only the portion of the wound that can be closed without tension is carried out, and the remainder of the wound is left open. The patient may then be returned to the operating room in several days for delayed primary closure or flap coverage if necessary.
A sterile nonadhesive dressing is applied over the wound, followed by application of a bulky Jones-type dressing. A splint may be incorporated into the Jones dressing if desired, particularly if more distal injuries are present (Fig. 28.16); the splint also helps to prevent equinus deformity. Postoperatively, the limb is elevated on a Bohler-Braun frame for 1 to 3 days.
Diaphyseal tibial fractures are frequently accompanied by an associated fibular fracture, which usually does not require repair. However, if the tibia fracture is proximal or distal, plate osteosynthesis may be carried out at the time of tibial stabilization to enhance fracture stability. If the fracture results in excessive shortening, fibular osteosynthesis carried out before the tibial osteosynthesis may be additionally helpful. Care must be taken in preoperative planning to allow for satisfactory skin bridges between the tibial and fibular incisions, which should be kept to a minimum of 8 cm.
Postoperative Care
If his/her condition permits, the patient is mobilized on the first postoperative day with partial weight bearing (20 kg) on the affected side. The use of locking screws does not affect the weight-bearing capability of the construct, and full weight bearing on the plate should not be permitted merely because the screws are locked.
Figure 28.12. AP (A) and lateral (B) intraoperative images after removal of the ATD. The proximal screws are standard, 4.5-mm, cortical screws and the distal screws are 5.0-mm locked screws. Due to fracture configuration, additional lag screws through or outside the plate were not necessary.
Figure 28.13. Final clinical appearance of extraperiosteal locked plate. Distally (left) the plate is beneath the saphenous structures.
Figure 28.14. AP (A) and lateral (B) radiographs of the final osteosynthesis are made at the conclusion of the case.
Figure 28.15. Skin closure is carried out with interrupted, horizontal, mattress sutures of 4-0 nylon. No tension should be present in the skin at the time of closure.
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The drain is usually removed between 2 and 4 days after surgery, followed by removal of the surgical dressing the next day. Active and active-assisted range of motion of the ankle, hip, and knee is then initiated. A light dry dressing may be required for several days for any subsequent wound drainage. Depending on the clinical situation, any portion of the postoperative regimen may be carried out on an outpatient basis.
The patient is followed up at 4-week intervals with clinical examination and radiographs. Weight bearing is advanced based on the clinical examination of discomfort or localized tenderness and the radiographic appearance of the fracture at follow-up. Typically, weight bearing will be advanced to partial (50 kg) by 6 to 8 weeks and to full by 8 to 12 weeks.
Figure 28.16. Bulky soft-tissue dressing is applied at the conclusion of the operation.
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Complications
Of primary concern after ORIF of a tibial fracture is that the incision heals uneventfully. Even with the utmost care, minimal skin and wound-edge necrosis of 1 to 2 mm may be found on occasion; it usually requires nothing more than observation. More extended skin and wound-edge necrosis may require surgical excision with irrigation, debridement, and reclosure of the wound (occasionally with flap advancement). Significant loss of skin and soft tissue in the postoperative period may require flap coverage.
Deep infection, occurring in the first 6 to 8 weeks after ORIF, should be treated with wound irrigation and reclosure over drains with or without antibiotic beads if the fixation remains intact and secure. Late infection in the presence of loosened hardware will require irrigation, debridement, removal of the hardware, and external fixation of the tibia until satisfactory wound and soft-tissue conditions can be obtained.
Treatment of delayed union and nonunion of a tibial shaft fracture after ORIF depends on whether the hardware remains intact or has failed, either by loosening or breakage. If the fixation remains intact and the soft-tissue conditions are satisfactory, then delayed union or nonunion may be treated with bone grafting and maintenance of protected weight bearing. If the internal fixation shows signs of failure, then the hardware must be removed and the internal fixation repeated with the addition of bone graft and an additional period of protected weight-bearing ambulation. Locking plates are not more difficult to revise than standard plates, and old locking holes can be reused for new locking screws.
Recommended Readings
1. Perren SM. Physical and biological aspects of fracture healing with special reference to internal fixation. Clin Orthop 1979;138:175–196.
2. Muller MR, Allgower M, Schneider R, et al. Manual of internal fixation. 2nd ed. New York: Springer-Verlag; 1979.
3. Ruedi T, Webb JK, Allgower M. Experience with the dynamic compression plate (DCP) in 418 recent fractures of the tibial shaft. Injury 1976;7:265.
4. Oestern HJ, Tscherne H. Pathophysiology and classification of soft tissue injuries associated with fractures. In: Tscherne H, Gotzen L, eds. Fractures with soft tissue injuries. Berlin: Springer-Verlag; 1984.
5. Borrelli J Jr, Prickett W, Song E, et al. Extraosseous blood supply of the tibia and the effects of different plating techniques: a human cadaveric study. J Orthop Trauma 2002;16(10): 691–695.
6. Ruedi T, Webb JK, Algower M. Experience with the dynamic compression plate (DCP) in 418 recent fractures of the tibial shaft. Injury 1976;7:265.
7. Mast J, Jakob R, Ganz R. Planning and reduction technique in fracture surgery. Berlin: Springer-Verlag; 1989.