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Tibial Shaft Fracture Casting

 

synonyms:

Tibial Shaft Fracture Casting CPT

Tibial Shaft Fracture Casting Indications

  • Low energy, stable pattern(spiral) tibial shaft fracture
    <1cm shortening, <5° angulation, <5° rotation, competent soft tissues (Tornetta ICL JBJS 2003 85A:352).

Tibial Shaft Fracture Casting Contraindications

  • Open fracture
  • Soft tissue injury (Tsherne Type 2 and greater)
  • Inability to weight bear in a cast or functional brace
  • Intact fibula (relative, 25% incidence of varus malunion with cast treatment).  Teitz CC,JBJS 1980 Jul;62A(5):770-6
  • Fibula fracture at same level
  • High energy fracture
  • Compartment syndrome

Tibial Shaft Fracture Casting Alternatives

  • IM nail
  • External Fixation
  • Amputation

Tibial Shaft Fracture Casting Pre-op Planning

  • Treatment Options = casting (negligible infection, no knee pain, no HWR) , Ex Fix(no disruption of soft tissue envelope), ORIF, IM nail (better alignment, early ROM, improved mobility, less frequent f/u, earlier return to work)-treatment remains controversial
  • Beware of intact fibula as tibia tends to heal in varus(Teitz&Frankel), external rotation deformity is more easily tolerated than internal rotation, as the level of deromity approaches the distal third of the tibia even a minor degree of malalignment can affect the ankle joint..

Tibial Shaft Fracture Casting Technique

  • Initial treatment = long leg splint or bivalned cast for 7-10 days to avoid compartment syndrome. If splinting / bi-valved casting an acute fracture strongly consider admission and observation for compartment syndrome.
  • Place in LLC at 7-10 days.
  • Exchange LLC for patellar tendon bearing cast or fracture brace at 2-4 weeks. Start WBAT.
  • F/u xrays are required frequently. Any angulation should be addressed the cast wedging or cast reapplication with 3 point molding. Shortening >1cm requires surgical fixation.

Tibial Shaft Fracture Casting Complications

Tibial Shaft Fracture Casting Follow-up care

  • Post-op: Long leg cast, weight bearing as tolerated
  • 7-10 Days: Review xrays to ensure alignment is maintained
  • 3 Weeks: Review xrays to ensure alignment is maintained
  • 6 Weeks: Review xrays to ensure alignment is maintained, Place in funciton brace at 4-6weeks.
  • 3 Months: Review xrays for union. Continue function brace until union.
  • 6 Months: Return to sport / full activity
  • 1Yr: follow-up xrays, assess outcomes.

Tibial Shaft Fracture Casting Outcomes

  • Hooper et all prospective randomized-IM nail healed 15.7wks, cast=18.3wks, >angular deformity, >shortening, <hindfoot motion. 
  • Sarmiento (CORR 1995 315:8) initial degree of displacement predictive of final deformity.  Functional bracing indicated for transverse fx that could be reduced or if they had <15mm of initial shortening.  LLC(WBAT) @3.7wks followed by functional brace.  Frequent follow-up.  Fx healed at mean of 18.1 wks.  1.1% nonunion.  90% shortened <10mm, mean shortening=4.28mm.  33% no frontal plane deformity.  48% varus deformity, 90% <6 degrees varus deformity, mean varus =4.8 degrees.  19% valgus deformity, 95% <5degrees. Mean valgus=4.0degrees41% no sagittal plane deformity.  29% ant, 95% <6degress, mean ant=4.7.  30% post, 95% <7, mean post = 4.5

Tibial Shaft Fracture Casting Review References

  • Rockwood and Green's Fractures in Adults: 2009
  • Hooper GJ, JBJS 73B:83-85, 1991
  • Sarmiento A. et al.  Factors influencing the outcome of closed tibial fractures treated with functional bracing.  Clin. Orthop.  1995; 315:pp. 8-24.
  • Teitz CC, Carter DR, Frankel VH. Problems associated with tibial fractures with intact fibulae. J Bone Joint Surg Am. 1980 Jul;62(5):770-6
  • Gicquel P, Giacomelli MC, Basic B, Karger C, Clavert JM. Problems of operative and non-operative treatment and healing in tibial fractures. Injury. 2005 Feb;36 Suppl 1:A44-50
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