Books on the topic 'Tibia fracture'

Bone 470Skeletal muscle 472Classification of fractures 474Treatment of fractures 476Management of a child with a fractured femur 478Fractured tibia and fibula 480Supracondylar fracture of humerus 482Fractured radius and ulna 484Fractures of metacarpals and metatarsals 486External fixation ...

♦ Tibial plafond fractures demand respect, largely due to the fragile soft tissue envelope that surrounds the distal tibia♦ Careful preoperative planning followed by meticulous operative handling of the soft tissues is required to avoid devastating complications.

The ankle and distal tibia can often be damaged through inversion injuries, or from twisting trauma at the foot. Fractures to the tibial plateau will reduce the functioning of the limb and articulation of the knee. It is often the lateral side of the plateau that is damaged, the fixation of which will be covered in this chapter, reviewing a selection of orthopaedic procedures involving the tibia and ankle, covering tibial plateau screws; tibial plating; tibial intramedullary nailing; and fixation of the medial, lateral, and posterior malleolus of the ankle. Each procedure includes images that demonstrate the position of the C-arm, patient, and surgical equipment, with accompanying radiographs demonstrating the resulting images.

♦ Split depression pattern lateral plateau most common type♦ Bicondylar and medial plateau fractures high energy injuries♦ Compartment syndrome, vascular injury, and common peroneal palsy may occur with high energy patterns♦ Internal fixation preferred treatment with good soft tissue envelope♦ Limited internal fixation suitable for many simple patterns♦ Plate fixation preferred for medial and bicondylar fractures♦ External fixation used with poor soft tissues♦ Fine wire external fixation should be considered for most complex patterns.

♦ The tibia is the most commonly fractured long bone♦ The orthopaedic surgeon needs to be familiar with all of the management options available in order to effectively manage the simple and complex cases♦ Problems associated with the soft tissue envelope are frequently encountered.

♦ After forearm and digital injuries, tibial and ankle fractures are the commonest fractures in the immature skeleton and the majority of these involve the diaphysis or ankle♦ Compared to the morbidity seen in adults these are relatively forgiving injuries in children as the healing rate of bone and soft tissues is rapid and remodelling will occur♦ It is wise, however, to guard against overconfidence in the remodelling potential of certain injuries; for example, angulated mid-diaphyseal fractures, rotational malalignment, and metaphyseal fractures within 2 years of skeletal maturity♦ Children will tolerate manipulative/cast treatment better than adults as the duration of treatment is usually shorter and rapid rehabilitation is almost the norm with or without physiotherapy♦ Postfracture overgrowth does occur but is less than that following femoral fractures and seldom clinically significant (over 10mm)♦ Isolated fibular fractures are of minor importance but need to be taken into account in managing complex injuries involving the distal tibia♦ It is convenient to discuss injuries according to three anatomical sections: proximal, diaphyseal, and distal.

♦ Stress fractures are fractures occurring as the result of repetitive, submaximal loads, in the absence of a specific precipitating traumatic event.♦ These fractures can be subdivided into two groups on the basis of aetiology. Whereas ‘fatigue fractures’ result from the excessive repetitive (i.e. abnormal) loading of normal bone, ‘insufficiency fractures’ are fractures resulting from normal forces acting on abnormal bone.♦ Early diagnosis allows the initiation of effective treatment that can prevent prolonged pain and disability, as well as avoiding the progression to displacement or a non-union.♦ While management decisions are generally focused on activity modification, protection of weight bearing, and immobilization, there is a subset of fractures at high risk for progression to complete fracture, non-union, or delayed union. These high-risk stress fractures, including tension-side femoral neck fractures and anterior tibial cortex fractures, require aggressive treatment to prevent the sequelae of poor healing.

The lower leg is one of the most common sites of injury in sport, particularly involving acute and chronic injuries to muscle and bone. For example, almost 50% of stress fractures are seen in the tibia, and over 6% affect the fibula (Matheson et al...

This chapter begins by discussing the basic principles of musculoskeletal physiology, fracture assessment, and fracture management, before focusing on the key areas of knowledge, namely congenital and developmental conditions, the foot, the ankle, the knee, the femoral and tibial shaft, the proximal femur, the pelvis, the shoulder, the upper limb, degenerative and inflammatory arthritis, bone and joint infection, crystal arthropathies, musculoskeletal tumours, and metabolic bone conditions. The chapter concludes with relevant case-based discussions.

♦ 81–89% overall patient satisfaction following total knee replacement♦ 1 in 8 patients experience unexplained postoperative pain♦ Obesity, increasing age, and medical comorbidities increase the risk of postoperative complications♦ Prosthetic infection rate at 1 year is 1–2%♦ Preoperative range of movement often determines postoperative range♦ Low risk of acute vascular event and neurological and ligamentous injury♦ Duration and method of venous thromboprophylaxis remains controversial♦ Periprosthetic femoral and tibial fractures require stabilisation. Fixation of periprosthetic patella fractures is not recommended♦ New surgical techniques and innovations require long term evaluation.

Bones are multifunctional passive organs of movement that supports soft tissue and directly attached muscles. They also protect internal organs and are a reserve of calcium, phosphorus and magnesium. Each bone is covered with periosteum, and the adjacent bone surfaces are covered by articular cartilage. Histologically, the bone is an organ composed of many different tissues. The main component is bone tissue (cortical and spongy) composed of a set of bone cells and intercellular substance (mineral and organic), it also contains fat, hematopoietic (bone marrow) and cartilaginous tissue. Bones are a tissue that even in adult life retains the ability to change shape and structure depending on changes in their mechanical and hormonal environment, as well as self-renewal and repair capabilities. This process is called bone turnover. The basic processes of bone turnover are: • bone modeling (incessantly changes in bone shape during individual growth) following resorption and tissue formation at various locations (e.g. bone marrow formation) to increase mass and skeletal morphology. This process occurs in the bones of growing individuals and stops after reaching puberty • bone remodeling (processes involve in maintaining bone tissue by resorbing and replacing old bone tissue with new tissue in the same place, e.g. repairing micro fractures). It is a process involving the removal and internal remodeling of existing bone and is responsible for maintaining tissue mass and architecture of mature bones. Bone turnover is regulated by two types of transformation: • osteoclastogenesis, i.e. formation of cells responsible for bone resorption • osteoblastogenesis, i.e. formation of cells responsible for bone formation (bone matrix synthesis and mineralization) Bone maturity can be defined as the completion of basic structural development and mineralization leading to maximum mass and optimal mechanical strength. The highest rate of increase in pig bone mass is observed in the first twelve weeks after birth. This period of growth is considered crucial for optimizing the growth of the skeleton of pigs, because the degree of bone mineralization in later life stages (adulthood) depends largely on the amount of bone minerals accumulated in the early stages of their growth. The development of the technique allows to determine the condition of the skeletal system (or individual bones) in living animals by methods used in human medicine, or after their slaughter. For in vivo determination of bone properties, Abstract 10 double energy X-ray absorptiometry or computed tomography scanning techniques are used. Both methods allow the quantification of mineral content and bone mineral density. The most important property from a practical point of view is the bone’s bending strength, which is directly determined by the maximum bending force. The most important factors affecting bone strength are: • age (growth period), • gender and the associated hormonal balance, • genotype and modification of genes responsible for bone growth • chemical composition of the body (protein and fat content, and the proportion between these components), • physical activity and related bone load, • nutritional factors: – protein intake influencing synthesis of organic matrix of bone, – content of minerals in the feed (CA, P, Zn, Ca/P, Mg, Mn, Na, Cl, K, Cu ratio) influencing synthesis of the inorganic matrix of bone, – mineral/protein ratio in the diet (Ca/protein, P/protein, Zn/protein) – feed energy concentration, – energy source (content of saturated fatty acids - SFA, content of polyun saturated fatty acids - PUFA, in particular ALA, EPA, DPA, DHA), – feed additives, in particular: enzymes (e.g. phytase releasing of minerals bounded in phytin complexes), probiotics and prebiotics (e.g. inulin improving the function of the digestive tract by increasing absorption of nutrients), – vitamin content that regulate metabolism and biochemical changes occurring in bone tissue (e.g. vitamin D3, B6, C and K). This study was based on the results of research experiments from available literature, and studies on growing pigs carried out at the Kielanowski Institute of Animal Physiology and Nutrition, Polish Academy of Sciences. The tests were performed in total on 300 pigs of Duroc, Pietrain, Puławska breeds, line 990 and hybrids (Great White × Duroc, Great White × Landrace), PIC pigs, slaughtered at different body weight during the growth period from 15 to 130 kg. Bones for biomechanical tests were collected after slaughter from each pig. Their length, mass and volume were determined. Based on these measurements, the specific weight (density, g/cm3) was calculated. Then each bone was cut in the middle of the shaft and the outer and inner diameters were measured both horizontally and vertically. Based on these measurements, the following indicators were calculated: • cortical thickness, • cortical surface, • cortical index. Abstract 11 Bone strength was tested by a three-point bending test. The obtained data enabled the determination of: • bending force (the magnitude of the maximum force at which disintegration and disruption of bone structure occurs), • strength (the amount of maximum force needed to break/crack of bone), • stiffness (quotient of the force acting on the bone and the amount of displacement occurring under the influence of this force). Investigation of changes in physical and biomechanical features of bones during growth was performed on pigs of the synthetic 990 line growing from 15 to 130 kg body weight. The animals were slaughtered successively at a body weight of 15, 30, 40, 50, 70, 90, 110 and 130 kg. After slaughter, the following bones were separated from the right half-carcass: humerus, 3rd and 4th metatarsal bone, femur, tibia and fibula as well as 3rd and 4th metatarsal bone. The features of bones were determined using methods described in the methodology. Describing bone growth with the Gompertz equation, it was found that the earliest slowdown of bone growth curve was observed for metacarpal and metatarsal bones. This means that these bones matured the most quickly. The established data also indicate that the rib is the slowest maturing bone. The femur, humerus, tibia and fibula were between the values of these features for the metatarsal, metacarpal and rib bones. The rate of increase in bone mass and length differed significantly between the examined bones, but in all cases it was lower (coefficient b <1) than the growth rate of the whole body of the animal. The fastest growth rate was estimated for the rib mass (coefficient b = 0.93). Among the long bones, the humerus (coefficient b = 0.81) was characterized by the fastest rate of weight gain, however femur the smallest (coefficient b = 0.71). The lowest rate of bone mass increase was observed in the foot bones, with the metacarpal bones having a slightly higher value of coefficient b than the metatarsal bones (0.67 vs 0.62). The third bone had a lower growth rate than the fourth bone, regardless of whether they were metatarsal or metacarpal. The value of the bending force increased as the animals grew. Regardless of the growth point tested, the highest values were observed for the humerus, tibia and femur, smaller for the metatarsal and metacarpal bone, and the lowest for the fibula and rib. The rate of change in the value of this indicator increased at a similar rate as the body weight changes of the animals in the case of the fibula and the fourth metacarpal bone (b value = 0.98), and more slowly in the case of the metatarsal bone, the third metacarpal bone, and the tibia bone (values of the b ratio 0.81–0.85), and the slowest femur, humerus and rib (value of b = 0.60–0.66). Bone stiffness increased as animals grew. Regardless of the growth point tested, the highest values were observed for the humerus, tibia and femur, smaller for the metatarsal and metacarpal bone, and the lowest for the fibula and rib. Abstract 12 The rate of change in the value of this indicator changed at a faster rate than the increase in weight of pigs in the case of metacarpal and metatarsal bones (coefficient b = 1.01–1.22), slightly slower in the case of fibula (coefficient b = 0.92), definitely slower in the case of the tibia (b = 0.73), ribs (b = 0.66), femur (b = 0.59) and humerus (b = 0.50). Bone strength increased as animals grew. Regardless of the growth point tested, bone strength was as follows femur > tibia > humerus > 4 metacarpal> 3 metacarpal> 3 metatarsal > 4 metatarsal > rib> fibula. The rate of increase in strength of all examined bones was greater than the rate of weight gain of pigs (value of the coefficient b = 2.04–3.26). As the animals grew, the bone density increased. However, the growth rate of this indicator for the majority of bones was slower than the rate of weight gain (the value of the coefficient b ranged from 0.37 – humerus to 0.84 – fibula). The exception was the rib, whose density increased at a similar pace increasing the body weight of animals (value of the coefficient b = 0.97). The study on the influence of the breed and the feeding intensity on bone characteristics (physical and biomechanical) was performed on pigs of the breeds Duroc, Pietrain, and synthetic 990 during a growth period of 15 to 70 kg body weight. Animals were fed ad libitum or dosed system. After slaughter at a body weight of 70 kg, three bones were taken from the right half-carcass: femur, three metatarsal, and three metacarpal and subjected to the determinations described in the methodology. The weight of bones of animals fed aa libitum was significantly lower than in pigs fed restrictively All bones of Duroc breed were significantly heavier and longer than Pietrain and 990 pig bones. The average values of bending force for the examined bones took the following order: III metatarsal bone (63.5 kg) <III metacarpal bone (77.9 kg) <femur (271.5 kg). The feeding system and breed of pigs had no significant effect on the value of this indicator. The average values of the bones strength took the following order: III metatarsal bone (92.6 kg) <III metacarpal (107.2 kg) <femur (353.1 kg). Feeding intensity and breed of animals had no significant effect on the value of this feature of the bones tested. The average bone density took the following order: femur (1.23 g/cm3) <III metatarsal bone (1.26 g/cm3) <III metacarpal bone (1.34 g / cm3). The density of bones of animals fed aa libitum was higher (P<0.01) than in animals fed with a dosing system. The density of examined bones within the breeds took the following order: Pietrain race> line 990> Duroc race. The differences between the “extreme” breeds were: 7.2% (III metatarsal bone), 8.3% (III metacarpal bone), 8.4% (femur). Abstract 13 The average bone stiffness took the following order: III metatarsal bone (35.1 kg/mm) <III metacarpus (41.5 kg/mm) <femur (60.5 kg/mm). This indicator did not differ between the groups of pigs fed at different intensity, except for the metacarpal bone, which was more stiffer in pigs fed aa libitum (P<0.05). The femur of animals fed ad libitum showed a tendency (P<0.09) to be more stiffer and a force of 4.5 kg required for its displacement by 1 mm. Breed differences in stiffness were found for the femur (P <0.05) and III metacarpal bone (P <0.05). For femur, the highest value of this indicator was found in Pietrain pigs (64.5 kg/mm), lower in pigs of 990 line (61.6 kg/mm) and the lowest in Duroc pigs (55.3 kg/mm). In turn, the 3rd metacarpal bone of Duroc and Pietrain pigs had similar stiffness (39.0 and 40.0 kg/mm respectively) and was smaller than that of line 990 pigs (45.4 kg/mm). The thickness of the cortical bone layer took the following order: III metatarsal bone (2.25 mm) <III metacarpal bone (2.41 mm) <femur (5.12 mm). The feeding system did not affect this indicator. Breed differences (P <0.05) for this trait were found only for the femur bone: Duroc (5.42 mm)> line 990 (5.13 mm)> Pietrain (4.81 mm). The cross sectional area of the examined bones was arranged in the following order: III metatarsal bone (84 mm2) <III metacarpal bone (90 mm2) <femur (286 mm2). The feeding system had no effect on the value of this bone trait, with the exception of the femur, which in animals fed the dosing system was 4.7% higher (P<0.05) than in pigs fed ad libitum. Breed differences (P<0.01) in the coross sectional area were found only in femur and III metatarsal bone. The value of this indicator was the highest in Duroc pigs, lower in 990 animals and the lowest in Pietrain pigs. The cortical index of individual bones was in the following order: III metatarsal bone (31.86) <III metacarpal bone (33.86) <femur (44.75). However, its value did not significantly depend on the intensity of feeding or the breed of pigs.