Tibial Shaft Fracture Casting 27750

CPT	Technique
Indications	Complications
Contraindications	Follow-up Care / Rehab Protocol
Alternatives	Outcomes
Pre-op Planning / Case Card	Review References

synonyms:closed treatment tibial shaft fracture

Tibial Shaft Fracture Casting CPT

• 27750
• 27752

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