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
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