Post-operative radiographs show excessive procurvatum deformity. Soft tissue compromise can present as a component of the injury, or can result from surgical dissection. Tibial stress syndrome (also known as shin splints) is an overuse injury or repetitive-load injury of the shin area that leads to persistent dull anterior leg pain. From the case: Proximal tibial stress fracture. Proximal third tibia fractures are relatively common fractures of the proximal tibial shaft that are associated with high rates of soft tissue compromise and malunion (valgus and procurvatum). Copyright 2022 Lineage Medical, Inc. All rights reserved. Pediatrics | Proximal Tibia Epiphyseal Fractures - Pediatric. Treatment generally consists of surgical open reduction and internal fixation (ORIF) versus intramedullary nail fixation. Copyright 2022 Lineage Medical, Inc. All rights reserved. Minimally impacted transverse oblique fracture through the medial tibial diametaphysis, with cortical interruption and a faint sclerotic line continuing to reach the lateral cortex. A 75-year-old-male presents after being struck by a vehicle while crossing the street. Diagnosiscan often be made on radiographs alone but MRI studies should be obtained in patients with normal radiographs with a high degree of suspicion for stress fracture. Late valgus deformity generally resolves with observation alone. ORTHO BULLETS Orthopaedic Surgeons & Providers Diagnosis of stress fractures is not difficult, but they can mimic other pathologies at times. Hyperflexion to help prevent apex anterior angulation, A medial parapatellar incision to help prevent valgus angulation, Starting point just lateral to the medial tibial eminence to help prevent valgus angulation, A medially placed blocking screw to help prevent valgus angulation, Suprapatellar nailing technique to help prevent apex anterior angulation. Surgical intramedullary nailing is recommended in the presence of an anterior tibia tension-sided stress fracture ("dreaded black line"). Epidemiology Incidence During surgical treatment of this fracture, which of the following techniques will help facilitate a successful reduction and intramedullary fixation? linear microfractures in trabecular bone from repetitive loading, symptoms initially worse with running, then may develop symptoms with daily activities, periosteal reaction with cortical thickening, focal uptake in cortical and/or trabecular region, T1-weighted images show linear zone of low signal, activity restriction with protected weightbearing, if "dreaded black line" is present, especially if it violates the anterior cortex, fractures of anterior cortex of tibia have highest likelihood of delayed healing or non-union, Spontaneous Osteonecrosis of the Knee (SONK), Osgood Schlatter's Disease (Tibial Tubercle Apophysitis), Anterior Superior Iliac Spine (ASIS) Avulsion, Anterior Inferior Iliac Spine Avulsion (AIIS), Concussions (Mild Traumatic Brain Injury). Type in at least one full word to see suggestions list, Knee & SportsTibial Shaft Stress Fractures. The femoral and tibial plateau fractures are open with no gross contamination, and there is an ipsilateral Morel-Lavelle lesion of the left thigh. Diagnosis is made with orthogonal radiographs of the shoulder. A 22-year-old female is struck by a truck and sustains the injury seen in figure A. Diagnosis is made with orthogonal radiographs of the tibia with CT scan often required to assess for intra-articular extension. (OBQ04.37) A radiograph is provided in Figure A. Which of the following complications has been associated with this fixation construct? The fracture is treated in a minimally invasive manner with a lateral locking plate and percutaneous screw fixation. Reduction and stability are dependent on control of the proximal fragment. A 38-year-old male sustains the closed injury shown in Figures A and B. A 34-year-old man is involved in a motorcycle accident and sustains a closed tibia fracture and multiple rib fractures. The parents should be counseled that a temporary tibial deformity may occur. well-tolerated and less painful than the traditional manual-stress radiograph.33, 34 Fracture Classification The Salter-Harris Classification is the most widely recognized system to describe physeal . Triplane Fractures are traumatic ankle fractures seen in children 10-17 years of age characterized by a complex salter harris IV fracture pattern in multiple planes. Proximal tibia fractures are fairly common lower-leg injuries. A 34-year-old female sustains a proximal third tibia fracture as an isolated injury and elects to undergo operative treatment with intramedullary nailing. Which of the following best describes the potential deformity? This fracture is significant for its tendency to develop alate valgus deformity, known as a Cozen's phenomenon, that must be monitored closely. Diagnosis can often be made on radiographs alone but MRI studies should be obtained in patients with normal radiographs with a high degree of suspicion for stress fracture. His current AP radiograph is shown in Figure A. A radiograph is provided in Figure A. (OBQ09.176) Proximal Tibia Metaphyseal Fractures are fractures of the proximal tibia usually seen in children from 3 to 6 years of age. What technical adjunct could have prevented the operative complication seen in Figure B? Switch to elliptical for lower impact exercise. varus/valgus stress testing. Thank you. What is the most appropriate management? Insufficiency fractures of this area have been reported. (OBQ18.156) His radiograph shows a linear lucency over the anterior tibia. Type I. Coronal split fracture. A 3-year-old boy sustained a minimally displaced proximal metaphyseal tibia fracture of the left leg 6 months ago that was treated with a molded long leg cast. Which of the following techniques has not been shown to prevent valgus angulation during intramedullary nailing of proximal one-third tibia fractures? A post-reduction radiograph is provided in Figure A. Copyright 2022 Lineage Medical, Inc. All rights reserved. The proximal tibia is the upper part of the shinbone that connects to the knee joint. A bone scan is shown in Figure A. He is taken for intramedullary nail (IMN) fixation. Insertion of blocking screws lateral and posterior to the nail, Insertion of blocking screws medial and posterior to the nail, Insertion of blocking screws lateral and anterior to the nail, Insertion of blocking screws medial and anterior to the nail, Insertion of blocking screws medial, lateral, and posterior to the nail. They can result from low-energy injuries or a high-energy injury, ranging from slips and falls to major car accidents. Hohl and Moore Classification of proximal tibia fracture-dislocations. Initial management is often provided by primary care and emergency clinicians, who must therefore be familiar with these injuries. Pediatric proximal femur fractures are rare fractures caused by high-energy trauma and are often associated with polytrauma. Tibial nailing with increased knee flexion, Lateral blocking screw in the proximal fragment, Medial blocking screw in the proximal fragment, Anterior blocking screw in the proximal fragment, Posterior blocking screw in the proximal fragment. Proximal Tibia Epiphyseal Fractures - Pediatric. (OBQ10.140) Because blood vessels, ligaments, muscles, nerves and skin may be injured . This fracture is significant for their tendency to develop a late valgus deformity, known as a Cozen's phenomenon, that mus be monitored closely over time. (SAE07PE.4) weight bearing may be allowed after 2-3 weeks. Ring fixator placement with distraction osteogenesis, Follow-up radiographs in 3 months and placement of knee-ankle-foot (KAFO) orthosis, Type in at least one full word to see suggestions list, PediatricsProximal Tibia Metaphyseal Fractures - Pediatric. A tibial stress fracture is a hairline fracture of the tibia bone. (OBQ11.161) Treatment may be nonoperative or operative depending on the Salter-Harris classification, stability, and displacement of fracture. The MRI is shown. Fractures of the proximal tibia can present unique treatment challenges. Which of the following operative techniques would help to best avoid a procurvatum deformity of the tibia? (SBQ12TR.22) Although the fractures of the epiphyseal cartilage injuries are common in the childhood, epiphyseal fractures involving the proximal tibia entities are very rare and account for 1 to 3% of all physeal injuries [6, 7].Salter-Harris type I to V occur from both indirect and direct mechanism of injury [].In distal tibia, the triplane fracture occurs due to the asymmetrical closure of . (OBQ11.193) Figures A through E are paired diagrams depicting the anteroposterior and lateral profiles of the proximal tibia. What is the next appropriate step in management? When treating this injury with an intramedullary nail, addition of blocking screws into which of the following positions can prevent the characteristic malunion deformity? A 20 year-old distance runner developed proximal tibial pain 6 weeks ago. Treatment is usually closed reduction and casting in extension with a varus mold. (OBQ06.269) Abstract. Diagnosis is made with orthogonal radiographs of the tibia withCT scan often required to assess for intra-articular extension. Copyright 2022 Lineage Medical, Inc. All rights reserved. Entire condylar fracture. There is no knee effusion. Treatment with sling immobilization is indicated for minimally displaced fractures with surgical fixation versus arthroplasty . Radiographs or bone scans may be obtained to rule out stress fractures. (OBQ08.108) (OBQ05.179) . Diagnosis is made clinically with tenderness along the posteromedial distal tibia made worse with plantarflexion. What is the next most appropriate step to quickly return him to play? Treatment is generally nonoperative with NSAIDs, rest and activity modifications. What is the most appropriate initial management of the patient's injuries in addition to debridement and irrigation of the open injuries? may occur as a part of a Type III tibial tubercle fracture, seen in up to 40% of Salter-Harris type III and type IV injuries, closure of proximal tibial epiphysis occurs in a predictable pattern, axial plane - posteromedial to anterolateral, superficial portion extends distal to physis to insert on medial metaphysis, acts as lateral buttress along with fibula, acts as restraint to posterior displacement, distal portion lies close to posterior aspect of proximal tibia, tethered to proximal tibia by firm connective tissue septa, at risk of injury with displaced fractures, divides into anterior tibial and posterior tibial branches beneath arch of soleus, passes over popliteus, anterior to lateral head of gastrocnemius, and underneath LCL, passes along proximal border of popliteus, anterior to medial head of gastrocnemius, to anterior proximal tibia, Usually displaced (>50%) due to buttress effect of tibial tubercle and fibula, Fracture through the physis and exiting through the metaphysis, Most common pattern is medial gapping with lateral Thurston-Holland fragment and proximal fibula fracture, Fracture through the physis and exiting through the epiphysis, Fracture through the physis, metaphysis and epiphysis, may see deformity or have palpable step-off if displaced, may see varus or valgus knee instability on exam, important to perform thorough neurovascular exam, physis is at same level of trifurcation of vessels and there is a risk of vascular compromise with displacement, varus/valgus stress but risk of injury to physis, stable Salter-Harris type I and type II fractures, redisplacement is common without fixation, unstable Salter-Harris type I and type II fractures, redisplacement following closed treatment, usually due to diaphyseal periosteal flap blocking reduction, displaced (> 2mm) Salter-Harris type III and type IV fractures, cannulated compression screws parallel to physis, useful for Salter-Harris type II with large Thurston-Holland fragment, can also be used for Salter-Harris type III or IV, univalved or bivalved long leg cast in slight flexion for 4-6 weeks, midline anterior longitudinal incision from inferior pole of patella to tibial tubercle, consider medial approach if vascular injury, can lead to limb length discrepancy and/or angular deformities, - Proximal Tibia Epiphyseal Fractures - Pediatric, Pediatric Pelvis Trauma Radiographic Evaluation, Pediatric Hip Trauma Radiographic Evaluation, Pediatric Knee Trauma Radiographic Evaluation, Pediatric Ankle Trauma Radiographic Evaluation, Distal Humerus Physeal Separation - Pediatric, Proximal Tibia Metaphyseal FX - Pediatric, Chronic Recurrent Multifocal Osteomyelitis (CRMO), Obstetric Brachial Plexopathy (Erb's, Klumpke's Palsy), Anterolateral Bowing & Congenital Pseudoarthrosis of Tibia, Clubfoot (congenital talipes equinovarus), Flexible Pes Planovalgus (Flexible Flatfoot), Congenital Hallux Varus (Atavistic Great Toe), Cerebral Palsy - Upper Extremity Disorders, Myelodysplasia (myelomeningocele, spinal bifida), Dysplasia Epiphysealis Hemimelica (Trevor's Disease). A tibial shaft stress fracture is an overuse injury where normal or abnormal bone is subjected to repetitive stress, resulting in microfractures. These fractures are the result of bone that is deficient in strength that is loaded under normal physiologic conditions. What is a cotton fracture? The proximal fibula is the insertion point for the biceps femoris posterolaterally, the soleus posteriorly, and the peroneus longus and extensor digitorum longus anteiorly. Treatment may be nonoperative or operative depending on the Salter-Harris classification, stability, and displacement of fracture. Which of the following correctly combines techniques used to decrease the incidence of the most common deformities associated with this fracture pattern? Diagnosis is made clinically with tenderness along the posteromedial distal tibia made worse with plantarflexion. A 45-year-old male sustains a proximal third tibia fracture as an isolated injury and elects to undergo operative treatment with intramedullary nailing. (OBQ06.212) A tibial shaft stress fracture is an overuse injury where normal or abnormal bone is subjected to repetitive stress, resulting in microfractures. You can rate this topic again in 12 months. A 25-year-old man sustains a left leg injury during a motorcycle accident. Discussion. They often result from minor trauma. Moderate medial compartment osteoarthritis, with mild changes within the patellofemoral joint, both advanced for age. torsional injury (spiral oblique fracture), severity of muscle injury has the greatest impact on need for amputation, fracture into apex anterior, or procurvatum, intracompartmental pressure measurement if indicated, proximal fracture extended, apex anterior, varus, varus due to pes anserinus + anterior compartment, question of intra-articular fracture extension, diagnosis confirmed by clinical presentation and radiographs, closed low energy fractures with acceptable alignment, < 10 degrees anterior/posterior angulation, shortening is most difficult to control with nonoperative management, angulation and rotational control are difficult to achieve by closed methods, extent of shortening and translation on injury radiographs should be expected at time of union, fractures with extensive soft-tissue compromise, higher incidence of malalignment than IMN, enough proximal bone to accept two locking screws (5-6 cm), high rates of malunion with improper technique, inadequate proximal fixation for IM nailing, best suited for transverse or oblique fractures, lateral plating with medial comminution can lead to varus collapse, long plates may place superficial peroneal nerve at risk, higher infection rate that IMN for open fractures, place in long leg cast and convert to functional brace at 4 weeks, bi-planar and multiplanar pin fixators are useful, circular frames indicated for very proximal fractures, can be safely converted to IMN within 7-21 days, helps maintain reduction for proximal 1/3 fractures, medial parapatellar approach may lead to valgus deformity, facilitates nailing in semiextended position, proximal to the anterior edge of the articular margin, use of a more lateral starting point may decrease valgus deformity, use of a medial starting point may create valgus deformity, prevents apex anterior (procurvatum) deformity, place in posterior half of proximal fragment, place on lateral concave side of proximal fragment, enhance construct stability if not removed, short one-third tubular plate placed anteriorly, anteromedially, or posteromedially across fracture, secure both proximally and distally with 2 unicortical screws, Schanz pins inserted from medial side, parallel to joint, pin may additionally be used as blocking screws, may help to prevent apex anterior (procurvatum) deformity, neutralizes deforming forces of extensor mechanism, statically lock proximally and distally for rotational stability, no indication for dynamic locking acutely, must use at least two proximal locking screws, straight or hockey stick incision anterolaterally from just proximal to joint line (if intra-articular extenion) to just lateral to the tibial tubercle and extend distally as needed, better soft tissue coverage laterally makes lateral plating safer, superficial peroneal nerve injuy with use of a longer plate, varus collapse if lateral only plate used with medial comminution, occurs in more than 30% of cases treated with IMN, resolves with removal of IMN in 50% of cases, 20-60% rate of malunion following intramedullary nailing (valgus/procurvatum), laterally based starting point and anterior insertion angle, entry of IMN should be in line with the medial border of the lateral tibial eminence, blocking screws placed in metaphyseal segment on the concave side of the deformity, place laterally to prevent valgus and posterior to prevent procurvatum in proximal fragment, this narrows the available space for the IMN, direct the nail toward a more centralized position, High rate of malunion following intramedullary nailing, Adult Knee Trauma Radiographic Evaluation, Proximal Humerus Fracture Nonunion and Malunion, Distal Radial Ulnar Joint (DRUJ) Injuries. A 23-year-old-male was involved in a motorcycle accident. This is an AAOS Self Assessment Exam (SAE) question. Imaging is shown in Figure A. Record of 15 patients, 14 females and one male who underwent one stage long stem TKAfrom the year January 2008 till December 2014 were reviewed retrospectively. The proximal tibia is the upper portion of the bone where it widens to help form the knee joint. It is caused by overuse or repetitive stress. What is the next step in management? Proximal tibial/fibular osteotomy with acute correction and pin fixation, Proximal tibial/fibular osteotomy with gradual correction and external fixation, Medial proximal tibial hemiepiphysiodesis. A post-operative radiograph is provided in Figure B. Anterior to the nail in the proximal segment; medial to the nail in the proximal segment, Anterior to the nail in the proximal segment; lateral to the nail in the proximal segment, Posterior to the nail in the proximal segment; lateral to the nail in the proximal segment, Anterior to the nail in the distal segment; lateral to the nail in the distal segment, Posterior to the nail in the distal segment; medial to the nail in the proximal segment. What technique can be utilized to avoid the characteristic deformity seen in this fracture pattern if an intramedullary nail is used for treatment? In addition to the broken bone, soft tissues (skin, muscle, nerves, blood vessels, and ligaments) may be injured at the time of the fracture. (OBQ11.264) Initially it was only painful while running, but she now has pain with walking. Aiming the nail posteriorly in the proximal segment, Anterior blocking screw in the proximal segment, Medial blocking screw in the proximal segment. proportionately to the proximal tibia in young patients, but in adolescents the proximal tibia growth becomes more rapid and distal tibial . Radiographs or bone scans may be obtained to rule out stress fractures. Radiographs were unremarkable, and an MRI demonstrates increased marrow edema. Which of the following is an advantage of using blocking screws for tibial nailing? A 6-year-old child sustained a closed nondisplaced proximal tibial metaphyseal fracture 1 year ago. The tibia fracture is reduced and placed into a long leg cast in the emergency room. She was treated with a long leg cast with a varus mold, and the fracture healed uneventfully. Diagnosis can be confirmed with plain radiographs of the knee. Which of the following figures has arrows that correspond to the ideal entry point for intramedullary nailing of a proximal third diaphyseal tibial fracture? Which of the following stress fracture locations has the greatest likelihood of delayed healing or developing a nonunion? The radiographs are normal. His injury radiographs are shown in Figure A. He complains of right leg pain, and physical exam reveals no evidence of an open fracture. . Cotton fracture is a fracture of the ankle involving the lateral malleolus, medial malleolus and distal posterior aspect of the tibia (posterior malleolus). What is the proper blocking screw technique to prevent apex anterior and valgus deformity of the fracture? Proximal Tibia Metaphyseal Fractures - Pediatric. Diagnosis can often be made on radiographs alone but MRI studies should be obtained in patients with normal radiographs with a high degree of suspicion for stress fracture. A 17-year-old collegiate female track runner reports left leg pain for 3 months that was insidious in onset. Type in at least one full word to see suggestions list, 2021 California Orthopaedic Association Annual Meeting, Supplementation of Plating - Max Hoshino, MD, 2021 Orthopaedic Trauma & Fracture Care: Pushing the Envelope, Proximal Tibia Fracture Case - Payam Tabrizi, MD, Proximal Tibia Fractures: Reduction - Geoffrey Marecek, MD, TraumaProximal Third Tibia Fractures (ft. Dr. Jan Szatkowski), Open Tibial Shaft Fracture 2/2 GSW in 24M, comminuted proximal tibia (firearm injury)with proximal tibiofibular diastasis. Diagnosis is made with orthogonal radiographs of the tibia with CT scan often required to assess for intra-articular extension. (OBQ12.6) MB BULLETS Step 2 & 3 For 3rd and 4th Year Med Students. Although much less common, the proximal medial tibial condyle has been cited as an area subject to stress fracture. Treatment may be casting or operative depending on the age of the patient and the type of fracture. Lateral blocking screws in proximal tibia fragment, Use of a radiolucent triangle to flex the knee, Anterior blocking screw in the proximal tibia fragment, Medial parapatellar arthrotomy avoiding the patellar tendon. A tibial shaft stress fracture is an overuse injury where normal or abnormal bone is subjected to repetitive stress, resulting in microfractures. Initial radiographs are shown in Figures A and B, and intramedullary nailing of the fracture is planned. A 5-year-old girl falls off of a trampoline and sustains a tibia fracture. Treatment protocols aimed at addressing these issues have included closed treatment . Diagnosis can be confirmed with plain radiographs. Symptoms often occur after running long distances. Treatment is activity restriction with protected weight-bearing in most cases. Treatment is urgent to avoid complication of osteonecrosis, nonunion, and premature physeal closure. She now has a 15-degree valgus deformity. Isolated proximal fibular stress fractures are rare and usually seen only in athletes and military recruits. Both the broken bone and any soft-tissue injuries must be treated together. (OBQ06.201) You can rate this topic again in 12 months. A college football player has progressive leg pain for over 6 months, is no longer able to run and has failed all modalities of non-operative treatment. Proximal third tibia fractures are relatively common fractures of the proximal tibial shaft that are associated with high rates of soft tissue compromise and malunion (valgus and procurvatum). Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. medial (posteromedial) tibial stress syndrome, anterior (anterolateral) tibial stress syndrome, training errors (sudden increase in training intensity and duration), history of previous lower extremity injuries, over-pronation or increase internal tibial rotation, traction periostitis of tibialis anterior on tibia and interosseous membrane, traction periostitis of tibialis posterior and soleus, females have 1.5-3.5 increased risk of progression to stress fractures, vague, diffuse pain along middle-distal tibia that, differentiate from exertional compartment syndrome, for which pain increases with running, earlier onset of pain with more frequent training (later stages), tenderness along posteromedial border of tibia, 4cm proximal to medial malleolus, extending proximally up to 12cm, conventional radiographs are normal in first 2-3weeks, differentiate from stress fracture, which shows "dreaded black line", normal findings on Phase 1 (flow phase) and, differentiate from stress fracture, which has, Differential Diagnosis for Exertional Leg Pain, Vague, diffuse pain along anterolateral tibia, worse at beginning of exercise that, Vague, diffuse pain along middle-distal tibia, worse at beginning of exercise, that, May be Achilles tendon, peroneal tendon, or tibialis posterior, Worse with lumbar tension position (sitting), first line of treatment and successful in vast majority, decreasing running distance, frequency and intensity by 50%, use low-impact and cross-training exercises during rehab period, avoid running on hills, uneven or hard surfaces, change running shoes every 250-500miles as shoes lose shock absorbing capacity at this distance, orthotics may be helpful in patients with pes planus, strengthening of invertors and evertors of the calf, local phonophoresis with corticosteroids may be effective, variable results, not likely to cause complete resolution of symptoms, common after resumption of heavy activity, Spontaneous Osteonecrosis of the Knee (SONK), Osgood Schlatter's Disease (Tibial Tubercle Apophysitis), Anterior Superior Iliac Spine (ASIS) Avulsion, Anterior Inferior Iliac Spine Avulsion (AIIS), Concussions (Mild Traumatic Brain Injury). Thank you. Treatment is usually closed reduction and casting in extension with a varus mold. A 34-year-old male presents with a closed left leg injury after falling off a 20ft ladder. Tibial plateau fractures are periarticular injuries of the proximal tibia frequently associated with soft tissue injury. MB BULLETS Step 1 For 1st and 2nd Year Med Students. Which of the following is the most appropriate initial management? Which of the following operative techniques would have helped to best avoid the procurvatum deformity? (OBQ06.251) classic mechanism is a child going down a slide in the lap of an adult with leg extended, triangular shaped bone with apex anteriorly that broadens distally, posterior tibial a. provides nutrient and periosteal vessels, nutrient vessels supply inner 2/3 of the tibial diaphysis, important radiographic parameters include, majority are incomplete (greenstick, torus), presence of fibula fracture suggests higher energy, usually minimal soft tissue swelling or deformity, evaluate carefully for compartment syndrome, presence of any angulation, usually valgus, presence of proximal fibula fracture, which may indicate a more unstable fracture pattern, long leg cast in extension with varus mold, place cast with varus mold (aim for slight overcorrection), casts are maintained for 4-6 weeks with serial radiographs. Its occurrence with osteoarthritis of the knee is not documented. Application of an anterior unicortical plate. (OBQ06.275) Proximal Tibia Epiphyseal Fractures are rare injuries seen in adolescents that may be associated with vascular injury. 0000004851 00000 n Femoral Shaft Fracture Antegrade Intramedullary Nailing - Trauma - Orthobullets 402ms Topics Trauma General Trauma Amputations Compartment Syndrome Upper Extremity Shoulder Humerus Elbow Forearm Pelvis Trauma Acetabulum Lower Extremity Femur Knee Tibia & Fibula Ankle and Hindfoot Subtrochanteric Fractures Pathway Updated: Oct . INTRODUCTION Fibular fractures, particularly those involving the ankle and the shaft just proximal, are common. A 37-year-old male sustains the closed injury seen in figure A. 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