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Fractures of the Tibia and Fibula
Fractures of the Tibia and Fibula WILLIAM C. LITHGOW, M.D., F.A.C.S.*
Fractures of the tibia and fibula may be catalogued and classified in many ways. I have chosen to divide these fractures into two groups, childhood and adult; and then to make closing comments about the treatment of compound fractures in both age groups.
CHILDHOOD FRACTURES
Avulsion of the Tibial Spine and its attached anterior cruciate ligament is a common injury in children. The same sort of injury in an adult would produce a tear of the anterior cruciate ligament, but in a child the bone of the tibial spine gives way before the ligament tears. This fact is important to know because a misdiagnosis of a tear of the anterior cruciate ligament can easily be made. The child presents with a painful, swollen knee in which motion is considerably restricted. In examining this knee, one must eliminate the possibility of a simple effusion of the joint from rheumatic fever or other systemic illness. The history is therefore of great importance. To be considered among the conditions which might be of traumatic origin are a torn meniscus, a tear of the anterior cruciate ligament, and traumatic synovitis of the joint. Anteroposterior, lateral and intercondylar radiograms of the knee will frequently be of help, because they will generally show a small flake of bone representing the tibial spine and the attachment of the anterior cruciate ligament. This flake of bone is usually seen best in the intercondylar notch radiogram, but it may also be visualized in the other views. Aspiration of the joint will generally disclose pure blood rather than bloodtinged synovial fluid. This always indicates a traumatic condition of more serious consequence than a synovitis. Once a diagnosis of an avulsion of the tibial spine has been made, the treatment, if the patient is seen within a week to ten days of the original injury, is surgical replacement of the tibial spine and fixation of the flake
* Attending Orthopedic Surgeon, Copley Memorial Hospital, Aurora, Illinois; Associate Surgeon, Shriners' Hospital for Crippled Children, Chicago, Illinois
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of bone into its position. This can be done by making two drill holes through the anterior portion of the tibia and passing a heavy chromic or silk suture through the drill holes and about the distal end of the cruciate ligament (with its attached flake of bone). The suture is tied at the front of the tibia, pulling the tibial spine and attached cruciate ligament down into place. Another simple way to deal with this problem is to use one or two Smillie nails to affix the tibial spine in place. After surgical repair of the ligament, a long leg walking cylinder cast is applied and the patient is kept in plaster for a period of six weeks. He is then allowed moderate exercises for a period of another month. If the patient is seen two weeks or longer after the avulsion of the tibial spine, surgical treatment is generally not indicated, and a walking plaster cylinder cast is applied and maintained for a period of six to eight weeks. In those cases in which the tibial spine is replaced, the child generally has no permanent disability and has good stability of the knee; in the late cases, treated nonoperatively, there may be some laxity of the ligament and minor instability in the anteroposterior plane. Displacement of the Proximal Tibial Epiphysis (Epiphysiolysis), which results from direct trauma to the knee, is the most common injury of the upper end of the tibia in childhood. The entire tibial epiphysis is slid off the metaphysis of the bone, the fracture displacement occurring through the epiphyseal plate. The displacement may be minimal or the upper epiphysis may be completely out of contact with the metaphysis. It is indeed surprising, but true, that a shearing injury of this type at the epiphyseal plate is less likely to cause premature closure and loss of epiphyseal growth than a compression injury in which the epiphyseal plate is crushed in the longitudinal axis of the bone. Nevertheless, great care must be taken in replacing the displaced epiphysis to avoid making the situation worse than it is. With minimal~displacement of the proxima(tibial epiphysis, no attempt to replace the epiphysis should be made; instead, the position is accepted and a long leg plaster cast is applied with the knee in 15 to 20 degrees of flexion, following which the treatment is that of a fracture of the shaft of any long bone. Remodeling of the upper end of the tibia will occur as the epiphyseal fracture heals and generally there will be little residual deformity or loss of length. Of course, the patient must be kept under observation for the full extent of his growing period to make sure that premature closure of the epiphysis does not occur, either in its entirety or on one side or the other, to produce a bowleg or knock-knee deformity. Appropriate measures to correct these residual problems would have to be carried out at a later date. With displacement of 50 per cent (or more) of the width of the epiphysis, closed manipulation of the fracture displacement should be attempted. With gentle manipulation the epiphysis can generally be slid back into its normal location, or at least a severe displacement can be corrected to a
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moderate one. The treatment following reduction is immobilization in a long leg plaster cast for a period of six to 12 weeks. Again remodeling will take care of any residual deformity, but in the cases of severe displacement there is more chance of epiphyseal damage and subsequent loss of linear growth with or without bowleg or knock-knee deformity. Open reduction is rarely, if ever, necessary or indicated and in most cases it is completely contraindicated because of the possibility of further injury to the epiphyseal plate. Fracture8 of the Upper End of the Fibula are of no great importance unless one of two things happened at the time of fracture. If the distal end of the lateral collateral ligament was avulsed from the head of the fibula, taking a flake of bone with it, treatment consisting of the use of a long leg cast must be instituted in order to provide adequate healing of the ligament to insure good stability of the knee. The only other problem sometimes associated with fractures of the upper end of the fibula is involvement of the peroneal nerve. Unless the injury is an open one, involving a laceration in the area of the fibular neck, it may be assumed that the peroneal nerve is contused rather than lacerated. Conservative treatment, consisting of a plaster cast early in the healing phase of the fracture, and a drop-foot brace later to protect the weakened or paralyzed muscles of the anterior compartment should be used. It should be apparent within six weeks whether a contusion or a loss of continuity of the nerve is present. Later repair of the nerve gives end results that are just as good as those of immediate suture; therefore, a conservative approach should be taken and the treatment, as outlined above, instituted. If there is a direct laceration of the nerve with a compound fracture of the neck of the fibula, then primary suture of the nerve may be accomplished if the wound is clean or, if the wound is dirty and contaminated, debridement closure of the wound and late suture of the nerve can be accomplished. Fractures of the Tibial Shaft occur in a number of types determined usually by (1) the mode of injury and (2) the age of the patient. Torsional fractures of the tibial shaft generally occur in infants and in children up to the age of eight to ten years from getting a foot caught in the bars of the crib, high-chair, or other relatively immovable object. There is generally no fracture of the fibula. There is usually no displacement in this type of fracture, except possibly some rotational displacement which can be corrected easily without anesthesia. The fracture is treated by the application of a long leg plaster cast with the knee bent at approximately 90 degrees. Three to six weeks in a cast, depending on the age of the patient, will generally suffice. If there is displacement, closed reduction (under anesthesia) can generally be accomplished and a long leg plaster cast, with the knee at 90 degree, applied. If for some reason a closed reduction is not possible or successful, skeletal traction with a Kirschner wire through the os calcis can be used. Fractures of the tibia (as well as fractures of the femur) routinely overgrow, so one
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should allow approximately 1 cm. of overlap of the fracture fragments to accomodate this overgrowth. Children of five or more years who receive a direct blow to the lower leg generally have a transverse fracture of both bones with or without displacement of the fracture. If the fracture is undisplaced, a long leg cast with the knee bent at 90 degrees and again three to six weeks in plaster, depending on the age of the child, will generally give complete healing with no residual disability. If the fracture is comminuted or segmental, closed reduction should be attempted and a cast applied provided the patient is below 15 years of age. If closed reduction is unsuccessful, skeletal traction can be utilized and, after sufficient callus has been laid down, a long leg cast applied. After the epiphyses have closed (in young adults), if closed reduction does not yield satisfactory results, open reduction with internal fixation can be used. Fractures of the Shaft of the Fibula are of no importance. They usually do not require treatment other than wrapping the leg with an elastic bandage, but if this is insufficient to control discomfort (because of the pull of the muscles on the shaft of the fibula), a long leg cylinder cast can be utilized for a period of three to four weeks, or until the patient is comfortable without it. Fractures of the Distal End of the Tibia and Fibula in children are usually of two types: either a greenstick fracture of one or both bones just above the epiphysis, or an epiphyseal fracture (epiphysiolysis) of the fibular epiphysis. The first type is due to direct trauma; the second is generally due to a twisting force applied to the ankle when the foot is firmly fixed by one means or another. In greenstick fractures through the metaphyseal area with minimal angulation, no attempt to correct the angulation is necessary. A long leg cast is utilized for a period of three to six weeks, depending upon the age of the child. If the greenstick fracture is angulated sufficiently to warrant it, closed manipulation can be done and again a long leg cast applied. Epiphyseal Separations of the Distal Tibia and Fibula look as though they would be difficult to handle, but actually they are quite simple and the closed reduction is generally easy. These fractures rarely lead to premature closure of the epiphysis and generally there is no residual disability. The family should be warned, however, that inasmuch as the fracture has occurred through the epiphyseal plate, the child should be watched through the whole of his growth period to make certain that there will be no change in the rate of growth or deformity from premature closure of one side of the epiphysis or the other. Open reduction of these fractures is never indicated. Fractures of the Malleoli practically never occur in children below the age of nine. In older children they are due to version or rotation of the foot. Usually there is no displacement of the fracture fragments. Treatment consists in the application of a walking cast. Fractures through the fibular epiphysis may occur without displacement and radiograms may show no
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recognizable change until two weeks or so after the injury, when callus will be apparent. It is wise, therefore, when a fracture of the fibular malleolus in the area of the epiphysis is suspected, for the child to have repeat radiograms after a period of two weeks and be treated during that interval as though a fracture were present. This will relieve the symptoms and certainly will do no harm.
ADULT FRACTURES
Fractures of the Tibial Spine are infrequent in adults. Instead, the adult generally tears the anterior cruciate ligament because the bone of the tibial spine is mature and can withstand the avulsion force. If one sees a fracture of the tibial spine in an adult, open reduction and internal fixation of the fracture fragment, with either a wire loop through drill holes in the upper end of the tibia or Smillie nails as indicated, are employed. Fractures of the Tibial Plateaus are seen more frequently in adults. These may involve one or both plateaus. They generally occur from a fall from a height, as from a stepladder or chair. All of the weight is transferred to one plateau or the other; or in the case of fractures of both plateaus, directly downward, equally on the upper end of the tibia. The most severe tibial plateau fracture is one in which either the medial or the lateral plateau is fractured and depressed, the accompanying semilunar cartilage is torn and generally is found between the fracture fragments, and the anterior cruciate ligament may be torn in the bargain. This triad should be recognized, because arthrotomy with removal of the incarcerated meniscus is necessary to elevate the depressed plateau fragment. The anterior cruciate ligament can be repaired at the same time. Minimal displacements of the tibial plateau can generally be accepted and the patient treated in a long leg cast with the knee is slight flexion. Aspiration of the joint may be necessary in order to give the patient freedom from the pain of the joint effusion. Great care must be taken, of course, not to introduce bacteria into the joint at the time of aspiration because the hematoma is a perfect culture medium for the bacteria. Depressed plateau fractures which would obviously lead to knockknee or bowleg deformity will produce additional strain on the collateral ligament and traumatic arthritis of the knee, as sequelae, unless they are reduced as perfectly as possible. While this can sometimes be accomplished by closed means, generally open reduction and internal fixation are necessary. This should be done by an expert surgeon to insure the best possible result. Occasionally the tibial tuberosity, at the attachment of the patellar tendon, may be avulsed, although the patellar or the quadriceps tendon is usually torn instead. If the tendon is avulsed it should be sutured back into place, with sutures through the periosteum, or one screw can be placed
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through the distal end of the tendon (and the accompanying flake of bone) into the tuberosity to hold the tendon at its bony attachment. A long leg plaster cast, with the knee in full extension for a period of eight to ten weeks, will generally give satisfactory results. Transverse Fractures of the Upper End of the Shaft of the Tibia are generally the result of direct trauma, hence are frequently compound. The simple fractures which are seen in this area can generally be manipulated back into position by closed means and adequate fixation in a long leg plaster cast, with the knee in flexion, will give good results. Nonunion in this area is rare. Fractures of the Fibular Head and Neck are of no importance unless there is an accompanying avulsion of the lateral collateral ligament of the knee or an injury to the peroneal nerve. An avulsion fracture, producing laxity of the lateral collateral ligament, can be determined by lateral instability on the physical examination and, of course, by the radiograph. If the avulsed fragment of bone is undisplaced, treatment in a long leg plaster cast is indicated. This is generally the case. Avulsion of the lateral collateral ligament at the fibular head without a flake of bone should be repaired surgically by suture of the distal end of the ligament to its fibular attachment. Injuries to the peroneal nerve, other than direct lacerations, can be assumed to be contusions unless after six to eight weeks of conservative, supportive treatment there is no evidence of return of function. Direct lacerations of the nerve can be sutured primarily if the wound is considered clean and relatively uncontaminated. If it is not, they should be treated conservatively and delayed repair of the nerve performed. Fractures of the Tibial Shaft fall into various categories depending upon their radiographic appearance. A spiral fracture in an adult is generally due to a torsional-rotational strain on the lower leg and is quite common in skiing accidents. These may be relatively undisplaced and may be reduced without general anesthesia by giving the patient a narcotic in sufficient dosage to control the momentary pain, de-rotation of the foot and ankle, and the application of a plaster cast. If the fragments are widely separated or there is considerable shortening, general anesthesia and closed manipulation will generally produce an acceptable result; and the patient, of course, is treated in a long leg plaster cast following the closed reduction. For those spiral fractures of the tibial shaft in which closed reduction cannot be accomplished, probably because of soft tissue interposition, open reduction and the use of internal fixation, generally in the form of one or two screws, will give good results. The metallic internal fixation, of course, does not preclude the need for external plaster support. All metallic internal fixation devices merely serve!las internal splints and do not hasten the time of healing. Transverse Fractures of the Tibial Shaft are generally the result of a direct blow to the shaft and are quite common in the so-called bumper
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injury. This occurs when a pedestrian is caught by the bumpers of a stationary and a moving vehicle. Transverse fractures that have sufficient irregularity of the two fractured surfaces can generally be manipulated back into position under general anesthesia by closed means. The irregularity of the fracture surfaces will keep the bone ends in contact and prevent them from slipping until healing can take place. Healing of fractures of the shaft generally takes 12 weeks. One occasionally sees a transverse fracture in which the fracture fragments are broken so smoothly that they refuse to stay in proper alignment. For this, the use of a Lottes intramedullary rod is ideal treatment. The rod not only prevents displacement of the fracture fragments but produces such efficient immobilization that the time in plaster can be shortened considerably. The patient can begin earlier weight bearing by virtue of the fact that with the internal fixation the transversely fractured fragments will not tend to slide out of place upon the stress of weight bearing. The compression force of weight bearing will assist in healing. Segmental Fractures of the Tibia and fractures of the tibia with large butterfly fragments are often accompanied by massive soft tissue injury as well. If closed treatment is possible, it is best to use it to avoid the possibly serious consequences of open surgery. However, closed treatment is sometimes out of the question and in these cases, after sufficient time is allowed for the soft tissue to recover from the insult, open reduction with internal fixation (either by means of an intramedullary rod or multiple screws) can be done and acceptable results obtained. Again it is necessary to use a long leg plaster cast, which is generally applied with the knee in a flexed position to prevent rotation of the fragments. In segmental fractures or fractures with a butterfly fragment, the nutrient artery as well as the metaphyseal arteries are generally torn. This leaves the central piece of bone without sufficient blood supply and results not infrequently in aseptic necrosis of the central fracture fragment. This is one of the most important complications of this fracture. Prolonged immobilization and protection from weight bearing, and bone grafting or other reconstructive orthopedic procedures may be necessary to correct the difficulty. Markedly Comminuted Fractures of the Shaft of the Tibia are almost always best treated by closed means, provided that the fracture fragments can be brought into reasonable apposition and alignment. If delayed union or nonunion in any of the major fracture lines results, bone grafting procedures with or without additional internal fixation may be necessary. It is important to note at this point that fractures at the junction of the middle and distal one-third of the tibia are more prone to delayed union or nonunion than any other fractures, except those of the carpal navicular bone. Despite expert care and prolonged immobilization, treatment of a nonunion by bone grafting procedures may be necessary. Fractures in this area of the tibia should be protected until radiographic evidence of complete
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healing is seen. It is not unusual for this to take six months. It is well to inform the patient of this prolonged time of immobilization and of the possibility of nonunion and the need for subsequent bone grafting procedures at the time of his original injury, so that he will be prepared for the worst, should it come. Fractures of the Fibular Shaft are unimportant generally, but because the fibular shaft serves as an attachment for the muscles of the lateral compartment of the leg there will be discomfort as the muscles pull on the fracture fragments. Usually wrapping of the leg with an elastic bandage gives sufficient support to make the patient comfortable, but occasionally a long leg walking cylinder cast is necessary for a period of three to four weeks to relieve him of his discomfort. Fractures of the Ankle may be divided into fractures of a single malleolus, both malleoli, and the so-called trimalleolar fracture in which the posterior lip of the tibial joint surface is broken along with the two malleoli. This fracture is usually accompanied by a dislocation of the talus posteriorly. It is this force that fractures the posterior lip of the tibia. Fractures of the Lateral Malleolus can almost always be treated by closed reduction (if reduction is necessary) with the application of a plaster cast onto which a walking heel can be applied within a matter of three to four weeks. Fractures of the Medial Malleolus are quite a different matter. A small avulsion fracture of the tip of the malleolus can safely be treated without the need for reduction by the application of a plaster cast. Even in the unusual case in which nonunion of the tip of the malleolus may result, there is rarely any disability. However, when the fracture is through the waist of the malleolus or at the level of the joint surface with the astragalus, the integrity of the ankle mortise must be Inaintained and nonunion of this fracture produces a stiff and painful ankle. Therefore, it is recommended that fractures in this area of the medial malleolus be internally fixed with a transfixation device, generally a single screw. This routinely produces good results and with the use of a plaster cast for six to twelve weeks, depending on the radiographic appearance of callus, one can expect a good result. Bimalleolar Fractures occur as a result of forced inversion or eversion of the ankle. The tipping of the talus within the ankle mortise causes fracture of the second malleolus. It is my practice in bimalleolar fractures to reduce the medial malleolar fracture and fix it internally with a screw. Then, as the cast is applied, pressure with the heel of the hand over the fractured lateral malleolus will usually produce reduction and restore the integrity of the ankle mortise. With adequately treated bimalleolar fractures, the patient generally has little or no residual disability. Trimalleolar Fracture, so-called, is a serious injury which can lead to stiffness and pain with considerable disability, even with the best of treatment; however, when treatment is adequately carried out, this complication can be minimized. The posterior displacement of the talus can be easily
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reduced by merely lifting the leg, holding onto the toes. This frequently is done by the x-ray technician in moving the patient from the stretcher to the x-ray table. With the reduction of the talus, the posterior lip of the tibia will occasionally fall back into place. The fracture can then be treated as a bimalleolar fracture, employing open reduction and internal fixation of the medial Inalleolus with a screw. A plaster cast is applied with the knee flexed at 90 degrees in order to relieve the pull of the gastrosoleus tendon on the posterior portion of the ankle. If the posterior lip of the tibia does not reduce, one must decide whether the fragment is large enough to be worthy of treatment by either closed or open means or whether it can be ignored. A good rule of thumb is as follows: If the posterior lip fracture fragment constitutes one-third or less of the total of the articulating end of the tibia, its complete reduction is probably not too important. If it conetitutes more than one-third, then it must be reduced because weight bearing at this fracture junction will produce trauInatic arthritis as a late sequela unless the fracture is perfectly aligned. Occasionally the fracture can be reduced satisfactorily by pressure with the thumb on the fragment while the foot is held in plantar flexion and the knee flexed, as a plaster cast is applied. More often it is necessary to perform an open reduction from a posterior approach, slide the posterior fragment down to its nOrInal position, under direct vision, and then hold it in place with a single screw.
COMPOUND FRACTURES IN BOTH CHILDREN AND ADULTS
Compound fractures of the leg in both children and adults should be considered surgical emergencies in the same category as an acute appendix or any other catastrophic condition requiring immediate surgery. The earlier that the wound can be cleansed, debrided and closed the less chance there will be for further contamination. In cleansing of the wound all dirt and foreign material should be removed and the wound cleansed to the depths with soap and water. Remember, however, that the soft tissue has already been injured and do not add to the insult by scrubbing it with a scrubbing brush or something equally as trauInatic. Flooding of the wound with normal saline from an Asepto syringe or by directing a stream of normal saline through the adapter of an intravenous set into the depths will frequently assist in this cleansing process. All devitalized tissue should then be excised and the wound edges debrided to produce clean, clear-cut edges. Devitalized muscle is an excellent culture medium for tetanus and gas-gangrene bacilli. The best prevention of these two catastrophic complications is adequate debridement of the wound. The wound should then be closed without drains after bleeding points have been controlled. Prophylactic antibiotics are important in this type of wound. In children, internal fixation of fracture fragments in a compound
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wound is never necessary and, once the wound is closed, it should be treated by closed means as if it were a simple fracture. In an adult, if the wound was clean and one in which minimal bacterial contamination could be expected, it is occasionally permissible to use some form of internal fixation to hold fracture fragments together at the time of closure of the wound. However, one must realize when one elects to do this that he is playing with fire because the internal fixation device Inay contribute to the later development of draining sinuses and osteomyelitis. Both children and adults with compound fractures should be given tetanus toxoid if one can be certain that they have been immunized for tetanus. If they have not, the use of prophylactic tetanus antitoxin, combined with gas-gangrene antitoxin, is probably to be commended and certainly is indicated in compound fractures occurring on the farm or in other places where clostridium bacteria would be common. The patient should be warned, after being given tetanus antitoxin or gas-gangrene antitoxin, that he will, in all probability, be sensitive to horse serum products in the future. He should be immunized against tetanus_so that another inoculation of antiserum will not be necessary. 330 Weston Avenue Aurora, Illinois
Fractures of the tibia and fibula may be catalogued and classified in many ways. I have chosen to divide these fractures into two groups, childhood and adult; and then to make closing comments about the treatment of compound fractures in both age groups.
CHILDHOOD FRACTURES
Avulsion of the Tibial Spine and its attached anterior cruciate ligament is a common injury in children. The same sort of injury in an adult would produce a tear of the anterior cruciate ligament, but in a child the bone of the tibial spine gives way before the ligament tears. This fact is important to know because a misdiagnosis of a tear of the anterior cruciate ligament can easily be made. The child presents with a painful, swollen knee in which motion is considerably restricted. In examining this knee, one must eliminate the possibility of a simple effusion of the joint from rheumatic fever or other systemic illness. The history is therefore of great importance. To be considered among the conditions which might be of traumatic origin are a torn meniscus, a tear of the anterior cruciate ligament, and traumatic synovitis of the joint. Anteroposterior, lateral and intercondylar radiograms of the knee will frequently be of help, because they will generally show a small flake of bone representing the tibial spine and the attachment of the anterior cruciate ligament. This flake of bone is usually seen best in the intercondylar notch radiogram, but it may also be visualized in the other views. Aspiration of the joint will generally disclose pure blood rather than bloodtinged synovial fluid. This always indicates a traumatic condition of more serious consequence than a synovitis. Once a diagnosis of an avulsion of the tibial spine has been made, the treatment, if the patient is seen within a week to ten days of the original injury, is surgical replacement of the tibial spine and fixation of the flake
* Attending Orthopedic Surgeon, Copley Memorial Hospital, Aurora, Illinois; Associate Surgeon, Shriners' Hospital for Crippled Children, Chicago, Illinois
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of bone into its position. This can be done by making two drill holes through the anterior portion of the tibia and passing a heavy chromic or silk suture through the drill holes and about the distal end of the cruciate ligament (with its attached flake of bone). The suture is tied at the front of the tibia, pulling the tibial spine and attached cruciate ligament down into place. Another simple way to deal with this problem is to use one or two Smillie nails to affix the tibial spine in place. After surgical repair of the ligament, a long leg walking cylinder cast is applied and the patient is kept in plaster for a period of six weeks. He is then allowed moderate exercises for a period of another month. If the patient is seen two weeks or longer after the avulsion of the tibial spine, surgical treatment is generally not indicated, and a walking plaster cylinder cast is applied and maintained for a period of six to eight weeks. In those cases in which the tibial spine is replaced, the child generally has no permanent disability and has good stability of the knee; in the late cases, treated nonoperatively, there may be some laxity of the ligament and minor instability in the anteroposterior plane. Displacement of the Proximal Tibial Epiphysis (Epiphysiolysis), which results from direct trauma to the knee, is the most common injury of the upper end of the tibia in childhood. The entire tibial epiphysis is slid off the metaphysis of the bone, the fracture displacement occurring through the epiphyseal plate. The displacement may be minimal or the upper epiphysis may be completely out of contact with the metaphysis. It is indeed surprising, but true, that a shearing injury of this type at the epiphyseal plate is less likely to cause premature closure and loss of epiphyseal growth than a compression injury in which the epiphyseal plate is crushed in the longitudinal axis of the bone. Nevertheless, great care must be taken in replacing the displaced epiphysis to avoid making the situation worse than it is. With minimal~displacement of the proxima(tibial epiphysis, no attempt to replace the epiphysis should be made; instead, the position is accepted and a long leg plaster cast is applied with the knee in 15 to 20 degrees of flexion, following which the treatment is that of a fracture of the shaft of any long bone. Remodeling of the upper end of the tibia will occur as the epiphyseal fracture heals and generally there will be little residual deformity or loss of length. Of course, the patient must be kept under observation for the full extent of his growing period to make sure that premature closure of the epiphysis does not occur, either in its entirety or on one side or the other, to produce a bowleg or knock-knee deformity. Appropriate measures to correct these residual problems would have to be carried out at a later date. With displacement of 50 per cent (or more) of the width of the epiphysis, closed manipulation of the fracture displacement should be attempted. With gentle manipulation the epiphysis can generally be slid back into its normal location, or at least a severe displacement can be corrected to a
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moderate one. The treatment following reduction is immobilization in a long leg plaster cast for a period of six to 12 weeks. Again remodeling will take care of any residual deformity, but in the cases of severe displacement there is more chance of epiphyseal damage and subsequent loss of linear growth with or without bowleg or knock-knee deformity. Open reduction is rarely, if ever, necessary or indicated and in most cases it is completely contraindicated because of the possibility of further injury to the epiphyseal plate. Fracture8 of the Upper End of the Fibula are of no great importance unless one of two things happened at the time of fracture. If the distal end of the lateral collateral ligament was avulsed from the head of the fibula, taking a flake of bone with it, treatment consisting of the use of a long leg cast must be instituted in order to provide adequate healing of the ligament to insure good stability of the knee. The only other problem sometimes associated with fractures of the upper end of the fibula is involvement of the peroneal nerve. Unless the injury is an open one, involving a laceration in the area of the fibular neck, it may be assumed that the peroneal nerve is contused rather than lacerated. Conservative treatment, consisting of a plaster cast early in the healing phase of the fracture, and a drop-foot brace later to protect the weakened or paralyzed muscles of the anterior compartment should be used. It should be apparent within six weeks whether a contusion or a loss of continuity of the nerve is present. Later repair of the nerve gives end results that are just as good as those of immediate suture; therefore, a conservative approach should be taken and the treatment, as outlined above, instituted. If there is a direct laceration of the nerve with a compound fracture of the neck of the fibula, then primary suture of the nerve may be accomplished if the wound is clean or, if the wound is dirty and contaminated, debridement closure of the wound and late suture of the nerve can be accomplished. Fractures of the Tibial Shaft occur in a number of types determined usually by (1) the mode of injury and (2) the age of the patient. Torsional fractures of the tibial shaft generally occur in infants and in children up to the age of eight to ten years from getting a foot caught in the bars of the crib, high-chair, or other relatively immovable object. There is generally no fracture of the fibula. There is usually no displacement in this type of fracture, except possibly some rotational displacement which can be corrected easily without anesthesia. The fracture is treated by the application of a long leg plaster cast with the knee bent at approximately 90 degrees. Three to six weeks in a cast, depending on the age of the patient, will generally suffice. If there is displacement, closed reduction (under anesthesia) can generally be accomplished and a long leg plaster cast, with the knee at 90 degree, applied. If for some reason a closed reduction is not possible or successful, skeletal traction with a Kirschner wire through the os calcis can be used. Fractures of the tibia (as well as fractures of the femur) routinely overgrow, so one
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should allow approximately 1 cm. of overlap of the fracture fragments to accomodate this overgrowth. Children of five or more years who receive a direct blow to the lower leg generally have a transverse fracture of both bones with or without displacement of the fracture. If the fracture is undisplaced, a long leg cast with the knee bent at 90 degrees and again three to six weeks in plaster, depending on the age of the child, will generally give complete healing with no residual disability. If the fracture is comminuted or segmental, closed reduction should be attempted and a cast applied provided the patient is below 15 years of age. If closed reduction is unsuccessful, skeletal traction can be utilized and, after sufficient callus has been laid down, a long leg cast applied. After the epiphyses have closed (in young adults), if closed reduction does not yield satisfactory results, open reduction with internal fixation can be used. Fractures of the Shaft of the Fibula are of no importance. They usually do not require treatment other than wrapping the leg with an elastic bandage, but if this is insufficient to control discomfort (because of the pull of the muscles on the shaft of the fibula), a long leg cylinder cast can be utilized for a period of three to four weeks, or until the patient is comfortable without it. Fractures of the Distal End of the Tibia and Fibula in children are usually of two types: either a greenstick fracture of one or both bones just above the epiphysis, or an epiphyseal fracture (epiphysiolysis) of the fibular epiphysis. The first type is due to direct trauma; the second is generally due to a twisting force applied to the ankle when the foot is firmly fixed by one means or another. In greenstick fractures through the metaphyseal area with minimal angulation, no attempt to correct the angulation is necessary. A long leg cast is utilized for a period of three to six weeks, depending upon the age of the child. If the greenstick fracture is angulated sufficiently to warrant it, closed manipulation can be done and again a long leg cast applied. Epiphyseal Separations of the Distal Tibia and Fibula look as though they would be difficult to handle, but actually they are quite simple and the closed reduction is generally easy. These fractures rarely lead to premature closure of the epiphysis and generally there is no residual disability. The family should be warned, however, that inasmuch as the fracture has occurred through the epiphyseal plate, the child should be watched through the whole of his growth period to make certain that there will be no change in the rate of growth or deformity from premature closure of one side of the epiphysis or the other. Open reduction of these fractures is never indicated. Fractures of the Malleoli practically never occur in children below the age of nine. In older children they are due to version or rotation of the foot. Usually there is no displacement of the fracture fragments. Treatment consists in the application of a walking cast. Fractures through the fibular epiphysis may occur without displacement and radiograms may show no
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recognizable change until two weeks or so after the injury, when callus will be apparent. It is wise, therefore, when a fracture of the fibular malleolus in the area of the epiphysis is suspected, for the child to have repeat radiograms after a period of two weeks and be treated during that interval as though a fracture were present. This will relieve the symptoms and certainly will do no harm.
ADULT FRACTURES
Fractures of the Tibial Spine are infrequent in adults. Instead, the adult generally tears the anterior cruciate ligament because the bone of the tibial spine is mature and can withstand the avulsion force. If one sees a fracture of the tibial spine in an adult, open reduction and internal fixation of the fracture fragment, with either a wire loop through drill holes in the upper end of the tibia or Smillie nails as indicated, are employed. Fractures of the Tibial Plateaus are seen more frequently in adults. These may involve one or both plateaus. They generally occur from a fall from a height, as from a stepladder or chair. All of the weight is transferred to one plateau or the other; or in the case of fractures of both plateaus, directly downward, equally on the upper end of the tibia. The most severe tibial plateau fracture is one in which either the medial or the lateral plateau is fractured and depressed, the accompanying semilunar cartilage is torn and generally is found between the fracture fragments, and the anterior cruciate ligament may be torn in the bargain. This triad should be recognized, because arthrotomy with removal of the incarcerated meniscus is necessary to elevate the depressed plateau fragment. The anterior cruciate ligament can be repaired at the same time. Minimal displacements of the tibial plateau can generally be accepted and the patient treated in a long leg cast with the knee is slight flexion. Aspiration of the joint may be necessary in order to give the patient freedom from the pain of the joint effusion. Great care must be taken, of course, not to introduce bacteria into the joint at the time of aspiration because the hematoma is a perfect culture medium for the bacteria. Depressed plateau fractures which would obviously lead to knockknee or bowleg deformity will produce additional strain on the collateral ligament and traumatic arthritis of the knee, as sequelae, unless they are reduced as perfectly as possible. While this can sometimes be accomplished by closed means, generally open reduction and internal fixation are necessary. This should be done by an expert surgeon to insure the best possible result. Occasionally the tibial tuberosity, at the attachment of the patellar tendon, may be avulsed, although the patellar or the quadriceps tendon is usually torn instead. If the tendon is avulsed it should be sutured back into place, with sutures through the periosteum, or one screw can be placed
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through the distal end of the tendon (and the accompanying flake of bone) into the tuberosity to hold the tendon at its bony attachment. A long leg plaster cast, with the knee in full extension for a period of eight to ten weeks, will generally give satisfactory results. Transverse Fractures of the Upper End of the Shaft of the Tibia are generally the result of direct trauma, hence are frequently compound. The simple fractures which are seen in this area can generally be manipulated back into position by closed means and adequate fixation in a long leg plaster cast, with the knee in flexion, will give good results. Nonunion in this area is rare. Fractures of the Fibular Head and Neck are of no importance unless there is an accompanying avulsion of the lateral collateral ligament of the knee or an injury to the peroneal nerve. An avulsion fracture, producing laxity of the lateral collateral ligament, can be determined by lateral instability on the physical examination and, of course, by the radiograph. If the avulsed fragment of bone is undisplaced, treatment in a long leg plaster cast is indicated. This is generally the case. Avulsion of the lateral collateral ligament at the fibular head without a flake of bone should be repaired surgically by suture of the distal end of the ligament to its fibular attachment. Injuries to the peroneal nerve, other than direct lacerations, can be assumed to be contusions unless after six to eight weeks of conservative, supportive treatment there is no evidence of return of function. Direct lacerations of the nerve can be sutured primarily if the wound is considered clean and relatively uncontaminated. If it is not, they should be treated conservatively and delayed repair of the nerve performed. Fractures of the Tibial Shaft fall into various categories depending upon their radiographic appearance. A spiral fracture in an adult is generally due to a torsional-rotational strain on the lower leg and is quite common in skiing accidents. These may be relatively undisplaced and may be reduced without general anesthesia by giving the patient a narcotic in sufficient dosage to control the momentary pain, de-rotation of the foot and ankle, and the application of a plaster cast. If the fragments are widely separated or there is considerable shortening, general anesthesia and closed manipulation will generally produce an acceptable result; and the patient, of course, is treated in a long leg plaster cast following the closed reduction. For those spiral fractures of the tibial shaft in which closed reduction cannot be accomplished, probably because of soft tissue interposition, open reduction and the use of internal fixation, generally in the form of one or two screws, will give good results. The metallic internal fixation, of course, does not preclude the need for external plaster support. All metallic internal fixation devices merely serve!las internal splints and do not hasten the time of healing. Transverse Fractures of the Tibial Shaft are generally the result of a direct blow to the shaft and are quite common in the so-called bumper
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injury. This occurs when a pedestrian is caught by the bumpers of a stationary and a moving vehicle. Transverse fractures that have sufficient irregularity of the two fractured surfaces can generally be manipulated back into position under general anesthesia by closed means. The irregularity of the fracture surfaces will keep the bone ends in contact and prevent them from slipping until healing can take place. Healing of fractures of the shaft generally takes 12 weeks. One occasionally sees a transverse fracture in which the fracture fragments are broken so smoothly that they refuse to stay in proper alignment. For this, the use of a Lottes intramedullary rod is ideal treatment. The rod not only prevents displacement of the fracture fragments but produces such efficient immobilization that the time in plaster can be shortened considerably. The patient can begin earlier weight bearing by virtue of the fact that with the internal fixation the transversely fractured fragments will not tend to slide out of place upon the stress of weight bearing. The compression force of weight bearing will assist in healing. Segmental Fractures of the Tibia and fractures of the tibia with large butterfly fragments are often accompanied by massive soft tissue injury as well. If closed treatment is possible, it is best to use it to avoid the possibly serious consequences of open surgery. However, closed treatment is sometimes out of the question and in these cases, after sufficient time is allowed for the soft tissue to recover from the insult, open reduction with internal fixation (either by means of an intramedullary rod or multiple screws) can be done and acceptable results obtained. Again it is necessary to use a long leg plaster cast, which is generally applied with the knee in a flexed position to prevent rotation of the fragments. In segmental fractures or fractures with a butterfly fragment, the nutrient artery as well as the metaphyseal arteries are generally torn. This leaves the central piece of bone without sufficient blood supply and results not infrequently in aseptic necrosis of the central fracture fragment. This is one of the most important complications of this fracture. Prolonged immobilization and protection from weight bearing, and bone grafting or other reconstructive orthopedic procedures may be necessary to correct the difficulty. Markedly Comminuted Fractures of the Shaft of the Tibia are almost always best treated by closed means, provided that the fracture fragments can be brought into reasonable apposition and alignment. If delayed union or nonunion in any of the major fracture lines results, bone grafting procedures with or without additional internal fixation may be necessary. It is important to note at this point that fractures at the junction of the middle and distal one-third of the tibia are more prone to delayed union or nonunion than any other fractures, except those of the carpal navicular bone. Despite expert care and prolonged immobilization, treatment of a nonunion by bone grafting procedures may be necessary. Fractures in this area of the tibia should be protected until radiographic evidence of complete
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healing is seen. It is not unusual for this to take six months. It is well to inform the patient of this prolonged time of immobilization and of the possibility of nonunion and the need for subsequent bone grafting procedures at the time of his original injury, so that he will be prepared for the worst, should it come. Fractures of the Fibular Shaft are unimportant generally, but because the fibular shaft serves as an attachment for the muscles of the lateral compartment of the leg there will be discomfort as the muscles pull on the fracture fragments. Usually wrapping of the leg with an elastic bandage gives sufficient support to make the patient comfortable, but occasionally a long leg walking cylinder cast is necessary for a period of three to four weeks to relieve him of his discomfort. Fractures of the Ankle may be divided into fractures of a single malleolus, both malleoli, and the so-called trimalleolar fracture in which the posterior lip of the tibial joint surface is broken along with the two malleoli. This fracture is usually accompanied by a dislocation of the talus posteriorly. It is this force that fractures the posterior lip of the tibia. Fractures of the Lateral Malleolus can almost always be treated by closed reduction (if reduction is necessary) with the application of a plaster cast onto which a walking heel can be applied within a matter of three to four weeks. Fractures of the Medial Malleolus are quite a different matter. A small avulsion fracture of the tip of the malleolus can safely be treated without the need for reduction by the application of a plaster cast. Even in the unusual case in which nonunion of the tip of the malleolus may result, there is rarely any disability. However, when the fracture is through the waist of the malleolus or at the level of the joint surface with the astragalus, the integrity of the ankle mortise must be Inaintained and nonunion of this fracture produces a stiff and painful ankle. Therefore, it is recommended that fractures in this area of the medial malleolus be internally fixed with a transfixation device, generally a single screw. This routinely produces good results and with the use of a plaster cast for six to twelve weeks, depending on the radiographic appearance of callus, one can expect a good result. Bimalleolar Fractures occur as a result of forced inversion or eversion of the ankle. The tipping of the talus within the ankle mortise causes fracture of the second malleolus. It is my practice in bimalleolar fractures to reduce the medial malleolar fracture and fix it internally with a screw. Then, as the cast is applied, pressure with the heel of the hand over the fractured lateral malleolus will usually produce reduction and restore the integrity of the ankle mortise. With adequately treated bimalleolar fractures, the patient generally has little or no residual disability. Trimalleolar Fracture, so-called, is a serious injury which can lead to stiffness and pain with considerable disability, even with the best of treatment; however, when treatment is adequately carried out, this complication can be minimized. The posterior displacement of the talus can be easily
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reduced by merely lifting the leg, holding onto the toes. This frequently is done by the x-ray technician in moving the patient from the stretcher to the x-ray table. With the reduction of the talus, the posterior lip of the tibia will occasionally fall back into place. The fracture can then be treated as a bimalleolar fracture, employing open reduction and internal fixation of the medial Inalleolus with a screw. A plaster cast is applied with the knee flexed at 90 degrees in order to relieve the pull of the gastrosoleus tendon on the posterior portion of the ankle. If the posterior lip of the tibia does not reduce, one must decide whether the fragment is large enough to be worthy of treatment by either closed or open means or whether it can be ignored. A good rule of thumb is as follows: If the posterior lip fracture fragment constitutes one-third or less of the total of the articulating end of the tibia, its complete reduction is probably not too important. If it conetitutes more than one-third, then it must be reduced because weight bearing at this fracture junction will produce trauInatic arthritis as a late sequela unless the fracture is perfectly aligned. Occasionally the fracture can be reduced satisfactorily by pressure with the thumb on the fragment while the foot is held in plantar flexion and the knee flexed, as a plaster cast is applied. More often it is necessary to perform an open reduction from a posterior approach, slide the posterior fragment down to its nOrInal position, under direct vision, and then hold it in place with a single screw.
COMPOUND FRACTURES IN BOTH CHILDREN AND ADULTS
Compound fractures of the leg in both children and adults should be considered surgical emergencies in the same category as an acute appendix or any other catastrophic condition requiring immediate surgery. The earlier that the wound can be cleansed, debrided and closed the less chance there will be for further contamination. In cleansing of the wound all dirt and foreign material should be removed and the wound cleansed to the depths with soap and water. Remember, however, that the soft tissue has already been injured and do not add to the insult by scrubbing it with a scrubbing brush or something equally as trauInatic. Flooding of the wound with normal saline from an Asepto syringe or by directing a stream of normal saline through the adapter of an intravenous set into the depths will frequently assist in this cleansing process. All devitalized tissue should then be excised and the wound edges debrided to produce clean, clear-cut edges. Devitalized muscle is an excellent culture medium for tetanus and gas-gangrene bacilli. The best prevention of these two catastrophic complications is adequate debridement of the wound. The wound should then be closed without drains after bleeding points have been controlled. Prophylactic antibiotics are important in this type of wound. In children, internal fixation of fracture fragments in a compound
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wound is never necessary and, once the wound is closed, it should be treated by closed means as if it were a simple fracture. In an adult, if the wound was clean and one in which minimal bacterial contamination could be expected, it is occasionally permissible to use some form of internal fixation to hold fracture fragments together at the time of closure of the wound. However, one must realize when one elects to do this that he is playing with fire because the internal fixation device Inay contribute to the later development of draining sinuses and osteomyelitis. Both children and adults with compound fractures should be given tetanus toxoid if one can be certain that they have been immunized for tetanus. If they have not, the use of prophylactic tetanus antitoxin, combined with gas-gangrene antitoxin, is probably to be commended and certainly is indicated in compound fractures occurring on the farm or in other places where clostridium bacteria would be common. The patient should be warned, after being given tetanus antitoxin or gas-gangrene antitoxin, that he will, in all probability, be sensitive to horse serum products in the future. He should be immunized against tetanus_so that another inoculation of antiserum will not be necessary. 330 Weston Avenue Aurora, Illinois