Tibia fracture-external fixation

Tibia fracture with External fixation

Jeff Danielewicz

ATHT 4960

Jason Bennett

18 April 2002

Table of contents

Subjects Page(s)

Table of contents 1

Introduction to tibia fractures 2

Anatomy of the lower leg, ankle, and knee 3-4

Biomechanics of the injury 5

Mechanism of the injury 5

Phase I: Rehabilitation 5-6

Phase II: Rehabilitation 7-9

Phase III: Rehabilitation 9-10

Phase IV: Rehabilitation 10-11

Summary 11

Introduction: Tibia fracture-external fixation

I. Introduction: Tibia Fractures

1. One of the most frequently fractured long bones

2. The most common place for a tibia fracture to occur is the middle one third of the tibial shaft (see figure 6)

3. Often times when a tibia fracture occurs, the fibula is also fractured

4. Immediate medical attention should be taken with a tibia fracture, including immobilization and proper transportation to hospital

5. Important to note that often times after a tibia fracture surgery anterior lower leg should be monitored for about 24 hours post surgery, due to possible anterior compartment syndrome

6. Tibia fractures are most commonly seen in sports such as: soccer, skiing, and wrestling, and in extreme sports such as snowboarding and skating due to mechanism of injury (see figure 2)

7. There are different types of tibia fractures such as:

· Open fracture which the tibia would be exposed out of the skin

· Closed fracture which the tibia is broken under the skin

· Maisonneuve fracture: According to Anderson, Hall and Martin (2000), this involves external rotation of the ankle with an associated fracture of the proximal third of the fibula.

· Volkmann’s contracture: According to Arnheim and Prentice (1993), this involves internal rotation tension caused by hemorrhage and swelling within closed fascial compartments, inhibiting the blood supply and resulting in necrosis of muscles and in contractures.

8. Different types of treatment for a tibia fracture are the following: casting, internal fixators, pinning, rods, plates, and external fixators

9. Of the different types of treatments for tibia fractures external fixation proves to be one of the best (see figure 1)

10. Treatment of tibia fractures can involve an external fixator. Advantages and disadvantages of the external fixator are the following:

· Causes very little surgical trauma and bleeding

· Helps for earlier weight bearing

· Cuts back on deep infections

· Can perform corrections to the device during treatment

· Helps with bone defects

· Helps in reduction in osteoporosis after surgery

· Disadvantages to external fixation

· Malunion

· Nonunion

· Loosening of pins

· Pin tract infections

II. Anatomy of the lower leg and knee

1. According to Starkey and Ryan (1996), the lower leg is divided into four distinct compartments, known as the anterior compartment, lateral compartment, superficial compartment, and deep posterior compartment. Each contains muscles and neurovascular structures of the lower leg.

2. Bone structures of the lower leg, ankle, and knee include:

· Tibia

· Fibula

· Femur

· Talus

· Calcaneus

· Patella

3. Articulations and ligaments of the lower leg (talocrural joint):

· Anterior talofibular ligament

· Calcaneofibular ligament

· Posterior talofibular ligament

· Deltoid ligament

· Anterior tibiotalar ligament

· Tibiocalcaneal ligament

· Posterior tibiotalar ligament

· Tibionavicular ligament

4. The collateral ligaments of the knee:

· Medial collateral ligament

· Lateral collateral ligament

5. The cruciate ligaments of the knee:

· Anterior cruciate ligament

· Posterior cruciate ligament

6. The interosseous membrane of the lower leg (syndesmosis joint):

7. The distal tibiofibular syndesmosis of the lower leg:

· Anterior tibiofibular ligaments

· Posterior tibiofibular ligaments

· Crural interosseous ligaments

8. The subtalar joint of the lower leg:

· Tibia

· Talus

9. Anterior compartment includes:

· Tibialis anterior

· Extensor hallucis longus

· Extensor digitorum longus

· Peroneus tertius

· Extensor retinaculum

· Deep peroneus nerve

· Anterior tibial artery

· Dorsalis pedis artery

a. Lateral compartment includes:

· Peroneus longus

· Peroneus brevis

· Retinaculus

· Inferior peroneal retinaculus

· Superficial peroneal nerve

· Peroneal artery

b. Superficial posterior compartment includes:

· Gastrocnemuis

· Plantaris

· Soleus

· Tibial nerve

· Posterior tibial artery

c. Deep posterior compartment includes:

· Tibial posterior

· Flexor digitorum longus

· Flexor hallucis longus

10. Quadriceps muscles:

· Vastus lateralis

· Vastus intermedius

· Vastus medialis

· Vastus medialis oblique

· Rectus femoris

11. Hamstring muscles:

· Semitendinosus

· Semimembranosus

· Biceps femoris

12. The pes anserine muscles of the knee:

· Gracilis

· Sartorius

· Semitendinosus

13. The iliotibial band muscles of the knee:

· Tensor fasciae latae and iliotibial band

III. Biomechanics of a fractured tibia

1. The tibia is mainly responsible for bearing weight and muscle attachment

2. Most tibia fractures occur in the lower one third of the shaft

3. The tibia works in conjunction with the femur to create flexion and extension of the knee

4. The tibia works in conjunction with the subtalar joint to create inversion, eversion, plantarflexion, and doriflexion of the ankle

IV. Mechanism of the injury

1. Direct impact to the bone such as a forceful object blown to the knee (bullet or person, see figure 2)

2. Indirect impact to the bone such as when the foot is planted and rotational forces are combined with compressive forces (skateboarding, skiing, snowboarding)

3. A pop or a snap is generally heard

4. Loss of movement is involved with the injured limb

5. Observation would include: crepitus, swelling, deformity

V.

Direct impact: figure 2 http://www. ilovebacon.com.htm

Phase I: Rehabilitation for a tibia fracture with external fixation

1. Definition of phase I

· That period of time immediately following an injury or surgery during which movement in the involved part is either:

· Involuntarily limited because of pain, swelling, muscle spasm, etc.

· Purposely restricted by immobilization in casts, splints, slings, etc.

2. Therapeutic objectives

· To teach proper ambulation techniques (crutch, walking, etc.)

· To assist the healing process through the use of appropriate therapeutic modalities such as: electrical stimulation, cryotherapy, hydrotherapy, massage, etc

· To minimize loss of muscular strength and retard the progression of muscle atrophy

· To retard the development of tendon and/or capsule adversions

· To maintain an acceptable level of overall physical fitness

3. Goals for healing

· Protection (see figure 3)

· Clean wound daily

· Monitor infection of pins

· Active Rest

· Upper body ergometer for cardiovascular endurance

· Ice

· Limit swelling, Decrease pain, decrease secondary hypoxity syndrome

· Compression to decrease swelling and pain

· Ace wrap

· Compressive sleeve

· Elevation to decrease swelling and pain

· Pillows

· Clothes

· Books

4.

Measure with goniometer

· Normal ranges of motion of the knee and ankle

· Planterflexion of ankle (0-50)

· Dorsiflexion ankle (0-50)

· Inversion of ankle (0-50)

· Eversion of ankle (0-50)

· Flexion of knee (0-135)

· Extension of knee (0-135)

5. Exercises to increase range of motion

· Heel slides/3 sets/20 reps

· Wall slides/3 sets/20 reps

· Biomechanical ankle platform system (BAPS)/2 sets/25 reps/clockwise and counterclockwise (See figure 4)

6. Exercises to increase strength

·

BAPS board: Figure 4

http://www. physsportsmed.com/issues/1997/06jun/garl.htm

Straight leg raises/3 sets/20 reps

· Abduction

· Adduction

· Flexion

· Extension

· Isometrics manuals/3 sets/20 reps

· Planterflexion

· Dorisflexion

· Inversion

· Eversion

· Quadriceps sets/3 sets/20 reps

7. Criteria to progress to phase II

· Removal of fixator

· Sufficient reduction of local symptoms (pain, swelling, inflammation, etc.) to permit effective therapeutic exercise

· An acceptable degree of tissue healing to permit therapeutic exercise without aggravation of injury (ex: feeling warm or cold)

VI. Phase II

1. Definition of phase II

· That period of time during which more vigorous therapeutic exercise can and should be initiated

· The use of appropriate therapeutic modalities may be continued during this phase to further enhance the healing process and/or facilitate performance of therapeutic exercise

2. Therapeutic objectives

· To establish weight bearing and restore normal gait patterns

· To restore optimal joint range of motion of knee and ankle

· Increase flexibility

· Increase muscular strength

· Increase muscular endurance

· Increase proprioception

· Maintain overall physical fitness

3. Exercises to increase joint range of motion

· Joint mobilization

· Anterior and posterior glides/3 sets/10 reps

· Posterior tibial glides in extension/3 sets/10 reps

· Talocrucal distraction and glides/3 sets/10 reps

4. Exercises to increase flexibility

· Towel stretches/static hold/dorsiflexion position/10 sets/10 second

· Gastrocnemuis/slant board/static hold/straight leg/10 sets/10 second hold

· Soleus/slant board/ static hold/bent knee/10 sets/10 second hold

· Anterior tibialis/slant board/static hold/straight leg/athlete face down the slant board/10 sets/10 second hold

· Hamstrings/static hold/straight leg/10 sets/10 second hold

· Quadriceps/static hold/athlete on stomach with bent knee/10 sets/10 second hold

· IT band/static hold/straight leg/10 sets/ 10 second hold

· Anterior, lateral, superficial posterior, and deep posterior compartment all stretched on slant board/ static hold/athlete faces up and down board/straight and bent leg/10 sets/10 10 second hold

· Peroneals/static hold/athlete holds foot inversion/10 sets/10 second hold

· Biomechanical ankle platform system (BAPS)/2 sets/25 reps/CW, CCW

5. Exercises to increase muscular strength

· Theraband/plantarflexion and dorsiflexion/green band/3 sets/25 reps

· Towel crunches with weight/3 sets/10 reps

· Manuals with movement/all four directions/2sets/25 reps

· Calf raises/3 sets/25 reps

6. Exercises to increase muscular endurance

· Pool/jogging intervals

· Bike/5 to 10 minutes

7. Exercises to increase proprioception, progress as tolerated

· Stands-weight shifts from side to side/2 sets/1 minute/progress as tolerated

· One leg stands/2 sets/30 seconds/progress as tolerated

· One leg stands with eyes closed/2 sets/30 seconds/progress as tolerated

· Trampoline one leg stands/2 sets/30 seconds/progress as tolerated

· Trampoline one leg stands with eyes closed/2 sets/30 seconds/progress as tolerated

· Trampoline with ball toss/2 sets/30 seconds

8. Exercises to increase physical fitness

· Pool/jogging intervals

· Bike/10 to 20 minutes

· Possible slideboard exercises

9. Criteria to proceed to phase III

· Sufficient reduction of local symptoms and sufficient extent of wound healing to permit resumption of at least part of the athlete’s regular practice or conditioning activities

· Sufficient restoration of joint range of motion, flexibility, muscular strength and endurance, proprioception, and gait patterns to permit safe resumption of at least part of the athlete’s regular practice or conditioning activities

· Satisfactory assurance of adequate protection from reinjury including consideration of:

· Effectiveness of protective taping, special pads, etc

· Safety of playing environment (playing surface)

· Satisfactory modification of conditioning and practice activities

· Satisfactory levels of motivation and confidence on the part of the athlete

VII. Phase III

1. Definition of phase III

· Period of time during which participation in part, or all, of the athlete’s normal practice and conditioning activities are resumed

2. Therapeutic objectives

· Continue optimal restoration of joint range of motion flexibility, muscular strength and endurance necessary for safe resumption of full participation

· Continue optimal development of overall physical fitness

· Reestablish normal patterns of motor activity (gait patterns, coordination, agility, balance, etc). As they relate to specific skills required in the sport involved

· Restore the athlete’s confidence in his/her ability to resume safe participation

3. Exercises to increase joint range of motion and flexibility:

· Biomechanical ankle platform system (BAPS)/3 sets/ 50 reps/ CW and CCW

· Slant board stretches all four compartments of lower leg/15 sets/15 seconds

· Hamstrings, Quadriceps and iliotibial band/static stretch/15 sets/15 second hold

· Peroneals stretches/self stretch as above/15 sets/ 12 second hold

4. Exercises to increase muscular strength and endurance, must modify to fit specific sport:

· Theraband (strength)/ankle/plantarflexion and dorsiflexion/3 sets/50 reps

· Slideboard/multi-exercises

· Ski machine

· Stair stepper

· Wobble boards

5. Exercises to maintain overall fitness level:

· Sports specific exercises

· Core stabilization

· This will very depending on sports

· Example: Basketball player/zig-zag drills with ball

· Example: Soccer player/cone drills with ball (see figure 5)

· Example: Slideboard/upper and lower body

6. Exercises to improve gait pattern:

· Plyometrics/teach in order

· Landing

· Stabilization jumps

· In-place bounding

·

Sports specific: figure 5

Shorts jumps

· Long jumps

· Shock jumps

7. Criteria to proceed to phase IV

· Optimal restoration of all components of physical fitness

· Resumption of complete and unrestricted participation

· Physician’s release

VIII. Phase IV

1. Definition of phase IV

· Period of time after which “complete rehabilitation” is achieved and full activity is resumed

2. Therapeutic objectives

· Maintain muscular strength in the effected part equal to or exceeding that of the opposite normal body part

· Maintain muscular endurance in the effected part at a level consistent with the demands of sports involved

· Maintain flexibility equal to or exceeding that of the non involved side

· This phase will theoretically continue indefinitely

3. Exercises for muscular strength, sport specific

· Proprioceptive neuromuscular ficilitation/D1 or D2 patterns/3 sets/20 reps

4. Exercises for Flexibility

· Hamstring, quadriceps, IT band stretches/static or dynamic stretches/3 sets/12 seconds hold

IX. Summary

1. Tibia fractures are seen as a medical emergency in the sports world, but with the help of an external fixation and a good rehabilitation plan the athlete may return to action in an estimated time of 12 to 50 weeks

2. Every injury is different, so remember this is a general guideline

Tibia fracture: figure 6

http://www. ilovebacon.com.htm

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