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Plating of Tibial Fractures

- Discussion: 
    - plating techniques and synthese products
    - primarily indication for plates and screws is a displaced intra-articular frx of tibia, involving either knee or ankle;
    - main disadvantage is skin necrosis and resultant infection;
    - malunions and mal-non-unions are other indications; 

- Operative Techniques for Proximal Tibial Fractures:
tibial plateau fractures
   - references:
          - Complications of locking plate fixation in complex proximal tibia injuries
          - Results of polyaxial locked-plate fixation of periarticular fractures of the knee.  

- Operative Technique for Distal Fracture: 
    - see pilon frx and plate fixation of pilon frx
    - oblique distal third fractures:
           - in many cases, low energy distal tibial fractures will have an oblique fracture type with the distal fragment in varus malalignment;
           - this fracture pattern is particularly ammenable to lateral plating, with intial reduction and fixation achieved with a anti-glide screw (placed above the frx);
    - surgical approach: anterolateral incision:
           - proximally incision is made 1 cm lateral to anterior tibial crest which places the  incision over the anterior compartment;
           - incision is carried longitudinally down to the level of the ankle joint, at which point the incision is carried either medially or laterally
                  to allow exposure of the ankle joint;
           - following dissection down to the level of the superficial fascia, the surgeon may dissect medially to created a full thickness medially based flap;
           - muscles of anterior compartment are carefully released from their loose attachments with the bone;
                  - perioseum should be left in place, for it derives it main blood supply from anterior tibial artery and contributes to cortical nutrition;
                  - caution superficial peroneal nerve;
                  - ref: Percutaneous plating of the distal tibia and fibula: risk of injury to the saphenous and superficial peroneal nerves.
           - distal Bohler incision:
                  - extensile approach that allows access to the anterior surface of the distal tibia, the anterior talar dome, talar neck, talonavicular,
                            subtalar, and calcaneocuboid joints by allowing direct visualization of these areas;
                  - ref: Bohler incision: an extensile anterolateral approach to the foot and ankle.  
    - lateral approach:
           - references:
                   - Lateral approach for fixation of the fractures of the distal tibia. Outcome of 20 patients 
                   - The distal approach for anterolateral plate fixation of the tibia: an anatomic study.  
    - plate type and position:
           - synthese products
           - medial and lateral plating options are available:
                  - ref: Surgical Treatment of Distal Tibia Fractures: A Comparison of Medial and Lateral Plating  
           - general principle is that the incision should not be made overlying the proposed position of the plate;
           - standard site for tibial plating is lateral surface of bone, because skin lesions of lower leg occur most frequently on anteromedial side;
           - internal fixation over the anteromedial aspect of the tibia is indicated for far distal tibia fractures; 
           - main complication is wound breakdown; 
           - cautions: watch out for saphenous nerve injury;
    - references for distal fracture:
           - Minimally Invasive Plating of High-Energy Metaphyseal Distal Tibia Fractures.
           - Minimally invasive locking plate osteosynthesis for fractures of the distal tibia--results in 20 patients.
           - Reconstruction of distal tibia fractures using a posterolateral approach and a blade plate.
           - Fractures of the distal tibia treated with closed reduction and minimally invasive plating
           - Percutaneous plating of distal tibial fractures; Preliminary results in 21 patients.
           - Locking compression plate with minimally invasive plate osteosynthesis in diaphyseal and distal tibial fracture: a retrospective study of 32 patients.
           - Radiographic and Clinical Comparisons of Distal Tibia Shaft Fractures (4 to 11 cm Proximal to the Plafond): Plating Versus Intramedullary Nailing.
           - Minimally invasive plating of the distal tibia: do we really sacrifice saphenous vein and nerve? A cadaver study.
           - Minimally Invasive Locked Plating of Distal Tibia Fractures is Safe and Effective
           - Distal tibia fractures: management and complications of 101 cases

                - case example:
                - 53-year-old white male w/ grade I open frx, treated w/ 2 lag screws and a contoured 3.5 DCP applied to medial surface;
                       - there were no complications in this case;
         - case example:
                - this 13-year-old female drifted into varus, despite attempts to maintain the reduction w/ cast wedging;
                - in this case, the patient and physician elected to have plate fixation;


- Post Op Care and Complications:
    - pts should be kept partial weight bearing (20 kg) until fracture healing;
    - delayed union: as absence of clinical and radiographic union within 4 months;
    - non unions: absence of signs of healing at 8 months;
    - hardware failure:
    - wound breakdown:
          - soft tissue coverage
                - plates that are exposed or covered by soft tissue of doubtful viability are often a nidus for infection;
                - thus a suitable soft tissue covering is essential;
    - case example:
          - this 30-year-old male developed both a non union and hardware failure, despite a previous bone grafting procedure;


- Results:
    - Experience with the dynamic compression plate (DCP) in 418 recent fractures of the tibial shaft
            - 323 closed tibial fractures treated w/ dynamic compression plates;
                     - 97% of pts w/ good to excellent results, 1%  of pts w/ infection;
            - 95 open tibial fractures
                     - 88% w/ good to excellent results, 50% of patients received antibiotics, 12% of patients had infection;
    - Classification of tibial shaft fractures and correlation with results after rigid internal fixation.
            - increase in complications as progressively higher energy fractures were treated by open reduction and internal fixation;
            - group A: 9.5% complications
                     - osteitis in 2.5%, good to excellent results: 89%
            - group B: 18.1% complications
                     - osteitis in 3.4%, good to excellent: 88%
            - group C: 48.3% complications
                     - osteitis in 10.3%, good to excellent: 69%
    - open fractures: (versus closed)
            - 2x as many non unions in open fractures
            - 5x as many cases of osteitis

Treatment of failures after plating of tibial fractures.

Plate fixation versus conservative treatment of tibial shaft fractures. A randomized trial.

Medial external fixation with lateral plate internal fixation in metaphyseal tibia fractures. A report of eight cases associated with severe soft-tissue injury.

Compression Plating for Non-Union after Failed External Fixation of Open Tibial Fractures.

Experience with the dynamic compression plate (DCP) in 418 recent fractures of the tibial shaft.
Fractures of the distal tibia: minimally invasive plate osteosynthesis.

Endovascular Treatment of Anterior Tibial Artery Pseudoaneurysm Following Locking Compression Plating of the Tibia.

Extraosseous blood supply of the tibia and the effects of different plating techniques: a human cadaveric study.

Outcomes of minimally invasive plate osteosynthesis for metaphyseal distal tibia fractures

Transsyndesmotic Fibular Plating for Fractures of the Distal Tibia and Fibula with Medial Soft Tissue Injury: Report of 6 Cases and Description of Surgical Technique

Effect of Decortications on Union Rate of Tibial Plating