What are the treatments for tibia fractures? When is minimally invasive surgery appropriate?

Author: Wang Qiwei, attending physician at Peking University First Hospital

Reviewer: Li Jun, deputy chief physician, Peking University First Hospital

The tibia is a long bone on the inner side of the lower leg, divided into two ends. The proximal end of the tibia is enlarged and protrudes to both sides to form the medial condyle and lateral condyle.

Figure 1 Original copyright image, no permission to reprint

The tibia is the main trunk of the human leg, connecting the knee joint above and the ankle joint below. The middle section is directly under the skin and is more susceptible to injury and fracture. In terms of anatomical location, tibial fractures are divided into tibial shaft fractures, distal tibial fractures, and proximal tibial fractures (that is, tibial metaphysis fractures). Tibial fractures are more common in the middle part of the lower leg, that is, tibial shaft fractures.

Today we will talk about the treatment of tibial fractures.

Tibial fractures are not significantly displaced, or the articular surface injury is not very serious, and are transverse or short oblique, and are mainly fixed with plaster.

For some unstable tibial fractures, manual reduction is required first, followed by plaster fixation. Simply put, the more obvious tibial fractures that can be reduced manually are those where the fracture site is not close to the joint and the fracture displacement is relatively small. During manual reduction, traction and rotation operations are performed according to the specific morphology of the fracture, displacement trend, fracture displacement and injury mechanism to adjust the direction of fracture displacement and achieve the purpose of manual reduction.

The displacement of the tibial fracture is relatively serious; the fracture involves the articular surface, affecting the accurate reduction of the articular surface; it is a partial open fracture, the fracture penetrates the skin or the outside world punctures the soft tissue and skin covering the fracture, exposing the bone to the outside; the fracture causes damage to the blood vessels and nerves, these situations require surgical treatment.

Currently, tibial fracture surgery is divided into open surgery, limited incision surgery, and percutaneous semi-open surgery.

What are the minimally invasive surgical treatments for tibial fractures?

Conceptually, minimally invasive surgery for tibial fractures is to achieve the most stable and best treatment effect with minimal surgical damage, but it is impossible to be non-invasive. For example, the surgical incision should be small, which is conducive to healing and aesthetics; the scope of surgical exposure should be small to reduce the risk during the operation, so that the patient can shorten the recovery period and achieve the best treatment effect. This is minimally invasive treatment for tibial fractures.

At present, there are three types of minimally invasive treatments for tibial fractures: the first is small incision intramedullary nail fixation; the second is small incision or limited incision plate reduction; the third is percutaneous pinning external fixator fixation. The most commonly used of these three is the interlocking intramedullary nail fixation technique.

Figure 2 Original copyright image, no permission to reprint

Most closed tibial fractures can now be treated with minimally invasive plating or intramedullary nailing.

In addition, open tibial fractures can also be treated with minimally invasive surgery. The fracture is from the inside to the outside, and the fracture ends pierce the soft tissue and skin. The severity of this open fracture is relatively low. Another type is that external violence not only breaks and crushes the bones, but also destroys the surrounding soft tissues, exposing the fracture ends, which is an open fracture from the outside to the inside.

For these two types of open fractures, especially those from outside to inside, due to their openness and serious contamination, traditional treatment methods tend to avoid the use of internal fixation devices such as steel plates or intramedullary nails. Because the fracture ends are in contact with the outside world, the possibility of infection is relatively high. Putting in steel plates and intramedullary nails will increase the probability of infection. Once infection occurs, the internal fixation device must be removed, which increases the cost and difficulty of treatment.

However, with the development of treatment technology, if the debridement can be carried out promptly and thoroughly and the bacteria can be effectively removed, then intramedullary nail fixation can be considered in certain cases. Even so, the application of intramedullary nails still needs to be cautious. In most cases, external fixator fixation technology is recommended for fixation.