Proximal Tibial Fractures

Definition

 

Metaphysical / extra-articular

 

Deformity

- abductors/hamstrings (pes) = varus of proximal fragment = valgus of fracture

- patella tendon = extension of proximal fragment = procurvatum of fracture

 

Prox tibia 1Prox tibia lateral

Characteristic valgus deformity with extension of the proximal fragment

 

Treatment options

 

IMN

Plate

 

Results

 

Jindal et al. Indian J Orthop 2020

- systematic review

- no different in malunion

- infection more common in plate

- anterior knee pain more common with nail

- faster time to weight bearing and union with nail

 

Meena et al. J Orthop Traumatol 2015

- RCT plate v IMN for proximal tibial fractures

- 58 patients

- reduced time to union and weight bearing IMN
- no significant different for infection / nonunion / malunion

 

IMN Proximal tibial fractures

 

Issue

 

High incidence malunion

- coronal plane valgus 

- saggital plane flexion / procurvatum

- posterior translation of distal segment

 

Proximal Tibial Fracture Poorly NailedProximal Tibial MalunionProximal Tibial Malunion

Residual proximal tibial fragment flexion - entry point too anterior

 

Valgus 1Valgus 2

Residual valgus - entry point too medial

 

Reason

 

Standard medial and anterior entry points

- mismatch to distal canal 

- canal becomes triangular

- pushes fracture into the above deformities

 

Techniques

 

1.  Change entry point

- match entry point to distal IM canal

- lateral in line with lateral tibial spine

- posterior

 

2.  Blocking screws

- also lateral and posterior

- functionally narrow IM canal

- on concave side of deformity at the level of the fracture

- same positions as entry point

- posterior in proximal segment adjacent to fracture

- lateral in proximal segment adjacent to fracture

 

Smith and Nephew Tibial Meta Nail with Blocking Screws

 

3.  Supra-patellar approach with leg semi-extended

- flexed tibia tends to accentuate the deformity

- semi-extended reduces the deformity

- also easier to get lateral and posterior entry point

 

Smith & Nephew Semi-extended nail

 

Vumedi Proximal Tibial Nailing Presentation

 

Results

 

Kulkarni et al. Injury 2020

- series of 43 proximal tibial fractures

- treated with suprapatella nail in semi-extended position

- malunion in 4/43 (9%)

- nonunion in 1/43 (2%)

 

Plate Proximal Tibia Fractures

 

Proximal tibia fracture 1Proximal Tibial Fracture

 

Proximal Tibial PlateProximal tibial plate

 

Nail + Plate fixation

 

Proximal tibia #Nail plate construct

 

Indications

 

Elderly

Allow early weight bearing

 

Technique

 

Surgical technique PDF