Segmental Tibial Fractures Research Articles

Cerebral Fat Embolism Diagnosed by Cognitive Disorder

Fat embolism syndrome is a rarely seen complication of skeletal trauma, and it is seen at a rate of 2-5% after fractures of the long bones of the lower extremities. Its classic triad-+consists of hypoxemia, petechial bleedings on the skin and neurological findings. These neurological findings are highly variable and non-specific, and they can present with lethargy, irritability, delirium, stupor, convulsion or coma. In this report, a male case is presented who was diagnosed with cerebral embolism due to acute cognitive disorder after a segmental tibial fracture.

Assessment & Evaluation of the Outcome for Closed and Open Method in Treatment of Segmental Tibial Fracture

Segmental tibial fractures are considered to be a special type of injury associated with high complication rates and are defined by the presence of two or more distinct fracture lines with completely isolating an intermediary segment і.е interruption of bone integrity at two levels(majority) or moreand are usually caused by a high-energy direct trauma with important soft tissue damage effect the both intramedullary and periosteal vascularization, which are predisposed to slow healing with creation of unsuitable biological conditions for fracture union. The aim of our study was to evaluate and assess the outcome of our policy on dealing with closed segmental fracture of the tibia treated by (closed or open) application of external tubular device fixator (AO group of ASIF) .Within the period between October 1, 1998 and September 30, 2010 in Al Nasiriya military hospital, AL Amara military hospital and Al Husain teaching hospital, we collect 38 patients with displaced and minimally displaced closed segmental tibial fractures. We exclude the multiply injured patients died after surgical treatment in the course of further management, open fractures, and all the patients lost for follow up. The minimally or undisplaced fractures were treated by closed application of the external device, while those with significantly displaced fractures, firstly managed by calcaneal continuous traction for a few days as an attempt for reduction, some of them were reduced to minimally displaced or acceptable position which were treated also by closed method, and some are remain significantly displaced, treated by open reposition and external fixation with the help of X-ray control for all cases. A range of motion exercise of ankle and knee joints post operatively were encouraged. The mean age was 38.81 years. We collect and study 38 closed segmental tibial fractures i.e. (two fractures focuses for one bone), so we are dealing with 76 fractures in 38 patients. All the patients were treated by AO unilateral external fixator arranged in multiplanartechnique for more rigid fixation and regarded as a definitive procedure for holding the fractures until clinical& radiological union.Once a considerable callus seen, a loosening of the distal clamps and a very graduated weight bearing started, with the help of the crutches to permit an axial compression on the fractures sites until a secure union of the bone. Then the external fixation was removed and a partial weight bearing was continued with the help of the crutches until consolidation. Healing of the bone occurred in 52 fracture focuses (68.42%) patients, and 24 fractures (31.57%) patients reported significant complications in the course of treatment that required further surgical management, 18 of them delayed union (23.68%) patients and 6 of the fracture focuses(7.89)patients go to nonunion.The delayed union treated simply by dianamyzation with chips bone graft and sometimes rearrangement of the external fixator particularly the loose pines, all of them healed completely, while the nonunited were treated by (Revision procedure):(revision of the external fixator with wider pins and extensive refreshment of the fracture ends and added a considerable amount of bone graft), so all of them were united successfully. We conclude that the external fixation is a suitable method for the treatment of segmental tibial fractures with an acceptable rate of

Complex Tibial Fractures: Tips and Tricks for Intramedullary Nail Fixation

Intramedullary nailing of metaphyseal and segmental tibia fractures can be technically challenging for a variety of reasons. Restoring length, alignment and rotation of the injured limb requires careful preoperative planning and meticulous attention to surgical technique, while avoiding common pitfalls. Understanding the deforming forces on the fracture segments and normal tibial osteology provides a background for recognizing the most common pitfalls when nailing these fractures. Many adjuncts for obtaining and maintaining fracture reduction while nailing have been described, including extended positioning, use of the femoral distractor, blocking screws, and provisional plating. We discuss these techniques as well as the role of intramedullary fixation for treating metaphyseal fractures with articular extension. The purpose of this paper is to describe the background and technique for a variety of operative tips and tricks to facilitate intramedullary nailing of metaphyseal and segmental tibia fractures.

External Fixation in the Management of Closed Segmental Tibial Fractures

Summary Segmental fractures represent the interruption of bone integrity at two or more levels. In these fractures, a wide zone of injury (damage of all structures of the lower leg) creates very unsuitable biological conditions for healing of the fracture. Because of the damage of both intramedullary and periostal vascularization, segmental fractures are predisposed to slow healing and development of pseudoarthrosis. The aim of the paper was to present the results of treatment of patients with closed segmental tibial fractures treated by external fixation. Within the period between January 1, 1998 and June 31, 2012 in the Clinical Center Niš, 26 patients with closed segmental fractures of the tibia were treated. The assessment of outcomes of treatment of closed segmental tibial fractures by external fixation was performed on a series of 24 patients. The mean age was 43.57 years. All the patients were treated by Mitković unilateral external fixator produced by “Trafix” firm. Fracture healing occurred in 20 (83.33%) patients; four (16.67%) patients reported significant complications in the course of treatment that required further surgical treatment. By applying the method of external fixation in the treatment of closed segmental tibial fractures, reposition of fragments is achieved through a small incision, with pins of exteranal fixator placed outside the fracture zone to prevent further damage of intramedullary and periosteal bone vascularisation, which is very important for fracture healing.

Outcomes and Analysis of Factors Affecting Bone Union after Interlocking Intramedullary Nailing in Segmental Tibia Fractures

275 Copyright c 2013 The Korean Fracture Society. All rights reserved. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Received January 18, 2013 Revised (1st) May 9, 2013, (2nd) July 25, 2013 Accepted August 7, 2013 Address reprint requests to: Jun-Young Lee, M.D. Department of Orthopaedic Surgery, Chosun University Hospital, 365 Pilmun-daero, Dong-gu, Gwangju 501-717, Korea Tel: 82-62-220-3147ᆞFax: 82-62-226-3379 E-mail: leejy88@chosun.ac.kr 경골 분절 골절에서 교합성 골수강 내 금속정 내고정술 후 결과 및 골유합에 영향을 미치는 인자 분석

Segmental Tibial Fractures: An Infrequent but Demanding Injury

Segmental tibial fractures are considered to be a special injury type associated with high complication rates. However, it is unclear whether healing of these fractures truly differs from that of nonsegmental fractures. We therefore asked (1) does the time to union in segmental tibial fractures differ from that of nonsegmental fractures; and (2) does the complication rate of segmental fractures differ from that of nonsegmental fractures? We retrospectively studied 30 patients with segmental tibial fractures treated at a Level I trauma center from January 2000 to December 2008 and compared healing and complications with a matched control group of 30 nonsegmental tibial fractures. In followup we determined time to union, delayed and nonunion, and overall complication rates. Patients were followed at least until union was attained. The minimum followup was 5 months (median, 15 months; range, 5-54 months). Median time to union was 34 weeks (range, 12-122 weeks). Segmental fractures took longer to heal than nonsegmental fractures (median, 34 weeks; range, 12-122 weeks and median, 24 weeks; range, 11-39 weeks, respectively). The overall rate of complications was higher in segmental fractures as was the necessity for reoperation to attain healing. Healing of segmental tibial fractures is characterized by substantially more complications and longer healing times than nonsegmental fractures and should be considered as a special type of injury. We believe these should be treated in specialized trauma centers.

Open segmental fractures of the tibia treated by external fixation

Open segmental fractures of the tibia are rare but severe injuries. In these fractures the wide zone of injury (damage of all structures of the lower leg) creates very unsuitable biological conditions for healing of the fracture. The aim of our work was to present the results of treatment of patients with segmental open fractures of the tibia treated by external fixation. We analyzed treatment results of 21 patients with open segmental tibial fractures who were treated using the method of external fixation at the Clinical Center Nis from January 1, 1995 to July 31, 2010. The average age of the patients was 53 years; the youngest patient was 27 years and the oldest one 80 years. According to the Gustilo open fracture classification, there were 3 (14.3%) type 1, 6 (28.6%) type 11, 8 (38.1%) type IIIA, and 4 (19.0%) type IIIB. All the patients were treated by a unilateral type Mitković external fixator by Traffix Company. Union was attained in 16 (76.2%) fractures without severe complications (pseudoarthrosis, chronic osteitis and angular deformities of over 10 degrees). Among severe complications associated with open segmental tibial fractures, in two cases we registered septic pseudoarthrosis, in one aseptic pseudoarthrosis and in two large angular deformities of the tibia after union, with a valgus of over 10 degrees and extremity shortening of over 2 cm which required additional surgery. External fixation by the use of Mitković external fixator is one of the methods of choice in the treatment of open segmental tibial fractures, which incorporated with antibiotic therapy provides good biomehanical conditions for segmental fracture healing that enables good stability of the segmental tibial fracture and decreases the risk of deep infections.

Intramedulläre Nagelung von proximalen Tibiafrakturen

Restoration of axis, length, and rotation of the lower leg. Sufficient primary stability of the osteosynthesis for early functional aftercare. Maintaining mobility of knee joint. Bone healing in closed and open fractures. Closed and open isolated proximal tibia and lower leg fractures (AO 42). Extraarticular fractures of the proximal tibia (AO 41 A2/A3). Intraarticular fractures of the proximal tibia (AO 41 C1/C2) in combination with other implants. Segmental tibia fractures (AO 42 C1/C2) with short proximal fragment. Comminuted tibia shaft fractures (AO 42 C3) with short proximal fragment. Very poor general condition (e.g., bedridden). Flexion of knee less than 90°. Infection in the nail's and bolt's insertion area. Infection of the tibia intramedullary canal. Complex fractures of the tibia plateau (AO 41 C3). Open physis. Closed reduction of the fracture. If necessary, use of reduction clamps through additional stab incisions or open surgical procedures. In some cases, additional osteosynthesis procedures are necessary (e.g., compression screws). Positioning of the patient on a radiolucent table or a traction table. Opening of the proximal tibia in line with the medullary canal. Cannulated or noncannulated insertion of the nail with or without reaming of the medullary canal. Control of axis, length, and rotation of the lower leg. Triple proximal interlocking in three different planes with the targeting device. Double distal interlocking. Immediate mobilization of the knee joint. Depending on the type of fracture, mobilization with 20kg partial weight bearing or pain-dependent full weight bearing with crutches. X-ray controls after 3, 6, and 12 weeks and increase of weight bearing depending on the fracture status. In a prospective multicenter study on the stabilization of tibia fractures with the Expert Tibial Nail, 22 patients with proximal third tibia fractures were documented. Seventeen patients could be reviewed clinically and radiologically after 1year. A non-union was registered in 1patient (5.9%), a malalignment in any plane above 5° in 3fractures (17.6%).

Using External and Internal Locking Plates in a Two-Stage Protocol for Treatment of Segmental Tibial Fractures

The tibial segmental fractures usually follow high-energy trauma and are often associated with many complications. We designed a two-stage protocol for these complex injuries. The aim of this study was to assess the outcome of tibial segmental fractures treated according to this protocol. A prospective series of 25 consecutive segmental tibial fractures were treated using a two-stage procedure. In the first stage, a low-profile locking plate was applied as an external fixator to temporarily immobilize the fractures after anatomic reduction had been achieved followed by soft-tissue reconstruction. The second stage involved definitive internal fixation with a locking plate using a minimally invasive percutaneous plate osteosynthesis technique. The median follow-up was 32 months (range, 20-44 months). All fractures achieved union. The median time for the proximal fracture union was 23 weeks (range, 12-30 weeks) and that for distal fracture union was 27 weeks (range, 12-46 weeks; p = 0.08). Functional results were excellent in 21 patients and good in 4 patients. There were three cases of delayed union of distal fracture. Valgus malunion >5 degrees occurred in two patients, and length discrepancy >1 cm was observed in two patients. Pin tract infection occurred in three patients. Use of the two-stage procedure for treatment of segmental tibial fractures is recommended. Surgeons can achieve good reduction with stable temporary fixation, soft-tissue reconstruction, ease of subsequent definitive fixation, and high union rates. Our patients obtained excellent knee and ankle joint motion, good functional outcomes, and a comfortable clinical course.

Segmental tibial fractures stabilized with the Less Invasive Stabilization System. Study of twenty-three consecutive acute segmental tibial fractures

Segmental tibial fractures stabilized with the Less Invasive Stabilization System. Study of twenty-three consecutive acute segmental tibial fractures

The Ilizarov method for the treatment of segmental tibial fractures

The Ilizarov method for the treatment of segmental tibial fractures

Open acute segmental tibial fracture fixation using the Less Invasive Stabilisation System (LISS): Study of 23 consecutive cases

Aim To evaluate the Less Invasive Stabilisation System (LISS) in the treatment of segmental tibial fractures. Methods A prospective series of 23 consecutive open acute segmental tibial fractures were treated with a long LISS plate, in a university hospital. All but three fractures were temporarily fixed with a unilateral external frame. The minimal follow-up was 2 years. Results Mean age of the casualties was 34 (17–72) years, all but two were male and all were involved in high-energy accidents, had multiple injuries and open fractures. Of the fractures, 4 were grade IIIA, 16 grade IIIB and 3 grade IIIC. It was possible to span the distal fracture with the LISS plate in 20 cases; of these, 3 developed compartment syndrome. Two people with trifocal fractures required additional distal plates, one of which became loose and infected, resulting in a malunion of 8°. Dermatofasciotomy was performed in 13 cases, in 10 of these as a preventive measure and in 3 because of impending compartment syndrome. In five cases a post-fixation neural palsy of the extensor hallucis longus was observed. All except three fractures healed; mean time for union for the proximal fractures was 16 (10–24) weeks and for the distal fractures was 22 (16–44) weeks. Conclusion Use of the LISS plate in fixing these difficult fractures is commended, but immediate fixation should be avoided. A staged sequential procedure with a temporary spanning external fixation and definitive treatment after soft-tissue healing is preferred.

Withdrawal of a paper

A paper entitled “Recombinant human morphogenetic protein-2 for type grade III open segmental tibial fractures from combat injuries in Iraq” was submitted to the JBJS[Br] with a covering letter dated 9 October 2007 which was signed by the authors. The corresponding author was Dr. T. Kukla. The

Acute treatment of segmental tibial fractures with the Ilizarov method

Objectives We evaluated the results of acute application of the Ilizarov external fixator for segmental tibial fractures and also examined the experience with these special type fractures. Methods Twenty-four patients (19 males, 5 females) with a mean age of 37.8 years (range 22–66) with segmental tibial fractures were treated with the use of an Ilizarov type circular fixator. According to the categorisation of Melis et al., the fractures were types I, II, III and IV in seven, nine, five and three patients, respectively. Seven fractures were closed and 17 were open (9 grade IIIa, 5 grade IIIb, 2 grade II, 1 grade I according to the Gustilo classification). The mean time from the injury to surgery was 14 h (range 4–36). Eight patients with partial-thickness soft-tissue defects with no bone exposure were managed by split thickness skin grafting. Flap procedures were performed in four patients. All patients had good lower leg viability with a MESS score 6 and below. No patients had bone defects of 3 cm or more at the fracture level. Functional and bone results were made using the criteria proposed by ASAMI. The mean follow-up 28 months (range 12–70). Results We obtained excellent results in 20 and good results in 4 patients in terms of bone assessment. Functional results were excellent in 19 and good in 5 patients. All radiological evaluations showed normal alignment except in two patients. Both united with a residual procurvatum deformity. No rotational deformity was seen. Bone grafting was performed in one patient with a distal fracture. Complete union was achieved in all patients. None of the patients required amputation. There were no refractures after frame removal. Pin-tract infection occurred in 13 of the 24 patients. There were no incidents of chronic osteomyelitis secondary to pin-tract infection. The mean time for proximal fracture union was 36.4 weeks (range 10–78) and 39.8 weeks (range 12–80) for the distal fractures ( p > 0.05). Callus and consolidation occurred earlier posterolaterally. There were no implant failures. Conclusion Ilizarov external fixator is a successful method in the acute management of segmental tibial fractures. This method is particularly effective in the treatment of distal segmental fractures of the tibia when the distal segment is short. This method allows for control of complications by decreasing the need for new operations even in the presence of infection.

The significance of segmental fibular fractures in the management of associated tibial fractures

One hundred seventy-six patients with 179 tibial shaft fractures (between March 2003 and August 2007) with a minimum of 4 months follow up were retrospectively reviewed by the author. Twenty-nine of these fractures were found to have segmental fibular fractures. These 29 fractures were analysed and compared with the total of 179 tibial fractures. Segmental tibial fractures with and without segmental tibial comminution were also analysed and compared. The segmental fibular fracture group had a greater incidence of associated injuries, associated fractures, open tibial fractures, Gustilo III B type fractures, major flap procedures, bony infection and bone grafting procedures which was statistically significant. The coincidence of segmental fibular fractures and segmental tibial fracture with segmental comminution indicated a bad prognosis. Segmental fibular fracture (associated with tibial fracture) appear more severe injury than segmental tibial fracture.

Recombinant human bone morphogenetic protein-2 for grade III open segmental tibial fractures from combat injuries in Iraq

This is a retrospective consecutive case series of 138 Gustillo-Anderson type IIIB and IIIC segmental tibial fractures treated at Walter Reed Army Medical Center in soldiers injured in Iraq between March 2003 and March 2005. Five patients with a head injury and four who were lost to follow-up were excluded. The patients were treated definitively with either a ringed external fixator or a reamed intramedullary nail, evaluated in terms of supplementary bone grafting with either autogenous bone (group 1, 67 patients) or recombinant human bone morphogenetic protein-2 at 1.50 mg/ml applied to an absorbable collagen sponge (group 2, 62 patients). The mechanism of injury, defect size and classification, associated injuries, presence of infection, preliminary treatment/fixation, number of procedures before definitive management, time to and details of definitive management, subsequent infection, re-operation, smoking history and other complications were noted. Radiographs were assessed for union, delayed union or nonunion by an independent investigator. All the patients were male. Their mean age was 26.6 years (20 to 42) and the mean follow-up was for 15.6 months (12 to 32). Group 2 had a slightly higher profile of concomitant injuries and a slightly worse fracture classification, but these were not significant. The rate of union was 76% (51 of 67) for group 1 and 92% for group 2 (57 of 62; p = 0.015). There was also a higher rate of subsequent infection in group 1 (14.9%) compared with group 2 (3.2%; p = 0.001) and a higher rate of re-operation (28%) in group 1 (p = 0.003). There were no observed hypersensitivity reactions to the recombinant human bone morphogenetic protein-2 implant.

Versorgung der komplikationsbelasteten proximalen Tibia-Etagenfraktur mit dem winkelstabilen Less-invasive-stabilization-System

Proximal segmental tibia fractures are rare injuries. Concomitant soft tissue injury, additional articular involvement and ligament injuries, secondary displacement, infection and pseudarthrosis present high demands for the implant and the surgeon. This clinical study was designed to clarify whether Tibia-LISS is a suitable implant for this type of fracture. From January 2002 to June 2005, 24 consecutive patients with proximal segmental tibia fractures were evaluated prospectively. All fractures were treated with Tibia-LISS. Follow-up examination was every 4 weeks until fracture healing. The final follow-up examination was at least 1 year after surgery and the average time was 23 months. Of the 24 patients, 23 could be considered for the follow up examination. On average 3.4 operations per patient were necessary, in 19 patients the fractures (82.6%) healed within 6 months after surgery, 2 deep-seated infections and 5 postoperative misalignments occurred. No patient suffered from secondary loss of reduction but 11 patients (47.8%) suffered from a complicated healing process. Tibia-LISS is a suitable implant for the treatment of proximal segmental tibia fractures with an acceptable rate of complications.

Distraction osteogenesis in a segmental tibial delayed union

The treatment of open segmental tibia fracture associated with bone loss is very demanding. Despite the fact that the principles of the distraction osteogenesis are being followed commonly in these fractures, there is not a single technique that fits all situations. In this article, we report a case where the initial fractures were stabilized with a monolateral bridging external fixator with no evidence of callus formation 6 weeks later. The proximal fracture was used as “an osteotomy” for bone transport after a latent period of 6 weeks of compression. The successful outcome in this patient, confirms that distraction of a delayed union even when it is mobile, can lead to bone formation and healing of the delayed union.

Segmental Tibia Fractures

Debate exists regarding the treatment of segmental tibia fractures. We report a large series of segmental fractures treated with a single technique of nonreamed nailing and report the time to union, reoperation rate, and associated complications. Emphasis was placed on achieving an anatomic reduction with good interfragmentary contact. We prospectively followed 62 consecutive patients with closed and open segmental tibia fractures (Orthopaedic Trauma Association Type 42-C2). Three patients died and eight were lost to followup, leaving 51 patients followed to union. Forty-six of the 51 fractures (91%) united with one operation (average time to union 138 days in closed fractures and 178 days in open fractures). Five patients had secondary procedures before achieving union. Type 3B fractures and those associated with compartment syndrome had the longest time to union, averaging 294 days. Full weightbearing was achieved within 3 months for all closed fractures and 74% of open fractures. There were no deep infections or nail or screw breakages in the series and knee pain occurred in 14 patients (27%). Nonreamed nailing is associated with high union rates, few complications, and limited indications for secondary procedures in the management of segmental tibia fractures.

Provisional Unicortical Plating With Reamed Intramedullary Nailing in Segmental Tibial Fractures Involving the High Proximal Metaphysis

This simple procedure for treating segmental tibial fractures involving the high proximal petaphysis decrease complications such as malalignement, nonunion, and postoperative infection by avoiding latrogenic devascularization of the fracture site.