first of all, the basic concept is that weight bearing (full) is only advised when enough callus with RUST score (>8) is present. in between we can infiltrate autologous bone marrow if healing is delayed

Dear Mitja

Do you have an initial fracture RX and a pos op RX with plate and screws?

In the first operation was the principle of absolute or relative stability?

Initial fracture in Austria. He was operated with the idea to achieve absolute stability in the next 3 months.

10 days post OP

6 weeks post OP

15 weeks post OP with valgus deformitiy and after 3 weeks of full weightbearing

Dear Mitja

It was a 43-B3 fracture ( AO classification) and in my opinion there was an indication for relative stability. My first option IM nail with AO tibial expert nail and the second should be a bridge plate with LCP distal tibia . The absolute stability was not achieved and the indication was not adequate. The HIM allows immediate loading with crutches or walker

Dear Nelson, thank you for your answer. What should the treating physician advise to the patient now, about two weeks after IM nail was inserted? How long to wait before weightbearing? Expected time to recovery? Any medications (such as teriparatide...)? I was consulted due to peroneal nerve palsy, which was most likely due to intraoperative traction injury. The patient is a young athlete...thanks for your input!

Dear Mitja

The patient is young and there is no necessity of drugs. The weight bearing can start now , as soon as possible. and the time to bone healing is estimated between four and 6 months after the IM nail. My option is to wait the recovery of peroneal nerve palsy . I believe there is a possibility of neuropraxis and the physical terapy should begin immediately

Dear Nelson,

Do you mean full weight bearing without crutches already after 2 weeks post OP? Our orthopedic surgeons are much more conservative and he was advised NO weightbearing for at least 6 weeks and strict use of crutches. I absolutely agree that we should wait for the peroneal nerve to recover and no surgical exploration is needed.

Looking forward to your further input...

Hi. With i feel that toe touching walking with help of crutches will facilitate the bone healing by improving vascularity and by providing micromovements. Off course wait and watch for nerve injury with continous physiotherapy.

Weightbearing as tolerated, might as well the full weight. Superficial peroneal nerve palsy Is a often seen complication, the neuropraxia resolves usual within weeks.

I would understand the superficial peroneal nerve palsy, but this patient has both signs of deep peroneal nerve (extensor hallucis weakness) and signs of tibial nerve dysfunction.

I would still be worried abou full weightbearing in the statically locked IM tibial nail with both distal and proximal locking screws in situ.

There is no doubt in my mind that I would have selected a circular external fixator at the index operation for this compound fracture. Or for the second operation for that matter. It allows full weigth bearing as soon as soft tissue allow.

As you stated earlier after plating in Austria the pt. had mild peroneal nerve palsy. Which is encountert due to the screws in the lower holes (holes number 11- 14 in the plate). Now you are saying he has sup./ deep and some tibial nerve palsy as well? Deep peroneal nerve supplies EHL, EDC, Tib. ant. and Peroneus tertius muscle. Superf. peroneal nerve supplies PL and PB. Posterior tibial nerve innervates Post. Tibialis, FHL, FDL.

Concerning the statically locked IM nail- it should be completely stabile. That encourage weightbearing as tolerated, as I suggested.

The neurological picture is somewhat complex. When the patient was explaining his difficulties, he described clear superficial peroneal sensory deficit, but when performing exam, deep peroneal sensory area was clearly involved and EHL and EDC were weaker, but there was no foot drop. In addition, EMG showed tibial nerve damage, which could not be shown clinically.

EMG is probably wrong positive. Nailing can cause sup./ deep peroneal neuropraxia. Since there is no functional deficit of the deep portion, in mild Gases the nerve will recover within weeks.

Dear Dr Mitja

No doubt he can weight bear, do dynamise the nail if it is not already so. Its not very clear from the single Xray I can see, a lateral view.Monitor serial X-rays. You may need to resect a piece of the fibula and do an exchange nail if need be and you do no see any signs of union. That should do the trick.

Here's the AP view after the last surgery, it it helps ...

Dear Mitja

The IM nail is locked up and down, weightwearing is not very important. The best option and what we do in these cases is to initiate weightwearing as pain tolerance and continue supporting or wait. If consolidation is not seen within 2-3 months should be assessed to make a fibular osteotomy that is what is preventing the consolidation of the tibial fracture.

Thanks for hearing this case

Dear Mitja

Thank you for this case - I work in a reconstructive clinic and manage this type of complications on a weekly basis. We have recently seen a couple of long bone diaphyseal non-unions secondary to locked plate fixation - most often due to comminuted fractures that are treated with very stiff locked plate constructs. Would you be able to give a little more information regarding the initial treatment of this fracture. If this was initially treated with a locked plate - that is probably the reason for the delayed / non-union (plate with 15 screws)

With regards to the subsequent treatment, I would probably have gone with removal of the plate a screws followed by a fine wire circular external fixator and probably a autogenous bone graft. This will be followed by immediate full weight bearing and functional rehabilitation. Whatever fixation method you choose, it should provide enough stability to allow early functional rehabilitation - this patient has already been non or partial weight bearing for the preceding 5 months and any further limitation / delay in rehabilitation will just add to his overall morbidity.

Dear Nando, please, see all the storyline from the beginning, there is a full story with all the pictures from the initial to the last one.

Click on "show previous comments" - all the images are there.

The patient was treated in Austria (near Innsbruck !!!) at the end of janaury with Synthes LCP plate, into which 14 screws were inserted, plus an additional malleolar screw. After 3 months, he began with full weightbearing, and after 4 months, valgus deformity was seen. He was reoperated 16 days ago, plate and screws were removed and a single site of delayed union was seen. The medullary canal was reamed and Synthes Expert IM nail was inserted. Local spongioplasty was also performed. After the second surgery, the leg swelling has almost disappeared, but there is some patella and patellar ligament pain. In about 2 weeks, he will have the first follow-up exam.

Thanks for your interest!

Dear Mitja:

Fibular osteotomy, progressive weightbearing and I wil wait for some time for the recovering of peroneal nerve.

Plating remains a standard treatment for many surgeons and - on my humble opinion - can't be blamed, even if it wouldn't have been my best choice in this specific case.

The AP looks good now and I wouldn't worry about the lateral X-Rays right now.

As far as I understood the full story, the best option now should be to wait for a full nerve recovery and a progressive bone healing under full weight bearing (no matter static or dynamic). Peroneal nerve problems are well documented and have been often reported after reaming and nailing

In case of trouble or supplementary delayed union (or 6 months non-union due to early consolidation of the fibula site) I would propose a nail exchange (dynamic) with intra-medullary graft associated to a fibular osteotomy.

I wouldn't take care right now to the difficulties occurred in knee after nailing.

Wish you the best with this case!

Dear Mitja,

I would recommend proximal dynamization of the nail and high energy shockwave therapy in one session. After the procedure I would avoid weight bearing for three to four weeks to give capillaries a chance to develope and cross the non-union gap and then start with full weight bearing.

Best regards

Wolfgang

Plating in spiral tibial fractures is used by many surgeons. I do not think it is a mistake. Unfortunately, some fractures develop delayed union and weight-loading should have been postponed in this particular case /we do not have the X-ray at 3 months when full weight bearing was allowed !/. Probably it was started too early. As far as the second surgery is concerned I think it is properly done except for the omitted osteotomy of the fibula. At the picture after the second operation we see that the fibula fracture is consolidated. This is a serious stress shielding factor which makes dynamization and early weight bearing problematic. Let us think that I am wrong but a new delayed union may be expected. I would perform fibula osteotomy with tubular resection 1-2 cm as soon as possible and start full weight bearing.

While all you orthopods are on the line, what are your opinions regarding tibial fractures, plaster casts and nerve or central blocks postoperatively for pain relief.

There are anaesthetists who consider blockade to be contraindicated in this situation because of the risk of missing a compartment syndrome

I just want to say that no two fractures are exactly the same hence treatment outcomes using the type internal fixation may. I will opt for IM nailing with autogenous bone grafting. Early weight bearing to allow compression of fracture site. Dynamization may be needed at some point. Also consider early use of TENS to stimulate callous formation. Just wonder how he got nerve palsy at the index surgery?

Dear Peter, I would like to inform that I am orthopaedic and trauma surgeon and not a orthopod. The case discussed on has nothing to do with your questions. Anyway, it is not recommendable to apply blocks for pain relief in freshly reduced tibial fractures with plaster casts on lower extremities. In my opinion this would oppose the classic conservative treatment of tibial fractures. Volkmann's contracture as a sequella of acute compartment syndrome is a severe complication.

I think the nail should be of greater diameter so it can be placed exactly centrally in the medullary canal, I did not see the AP view ) ,if it is small and not central in the canal it should be replaced by a larger one.

Otherwise it can be kept with proximal dynamization of the nail, fibula osteotomy,foot drop brace, full weight bearing and physiotherapy because loading the fracture and muscle activity encourage fracture healing

Hallo Dr. Cox,

since compartment syndrome incidence is high in tibial fractures, in fact the highest in the whole body, the early diagnosis is of primary importance. Diagnostic measures are immens pain out of proportion, hard calf muscles, pain after flexing/ extending the toe´s (passive stretching), par-/ hypesthesia, absent peripheral pulses, paralysis- how can you rule out compartment, when the leg is blocked with LA?. Compartment pressure measuring is as well not an option in a plaster cast.

In my view, postop nerve blocks in that scenario (tibial fracture) is contraindicated

This is the lateral view 4 weeks post IM tibial nail. Comments?

Thank you Panayot and Jean for your answers (sorry if you found the word "orthopod" offensive Panayot!)

It is interesting that you both have the same opinion that periferal blocks are contraindicated where compartment syndrome may be expected. I'm sure that many of your colleagues also feel this to be the case.

In fact there are very few cases where local blockade has masked a compartment problem whereas there are several cases where heavy sedation or opiate analgesia has done so.

The really important factor is that the concentration of LA used must be low enough to give relief but at the same time allow the experience of breakthrough pain.

The other important factor of course is vigilance on the part of the nursing staff, and this is helped by the use of a strict protocol.

Diagnosis of a compartment syndrome may be difficult and it may be advisable to employ profylactic fasciotomy or compartment pressure monitoring where the risk is great such as young men with a complex fracture as in this case.

A prohylactic fasciotomy- I don´t think that is an option. At least, I wouldn´t have one. The open question ist, who knows the effective LA Dose for every patient? That seems to have too much imponderables, I suppose.

JE

Hi Mitja,

as I said from beginning, weightbearing as tolerated, mainly full. I would proximal dynamize th nail and see what happens.

kind regards

Hi Jean!

0,2% ropivacain for a CPNB or even an epidural (combined with fentanyl) will provide analgesia without affecting breakthrough pain or motor function. In fact one can almost say that pain despite such blockade is highly suspicious of a compartment syndrome and perhaps alerts the clinician at an earlier stage.

Peter

I had a spiral fracture in my tibia about 9 years ago at the age of 24. My fibula was intact and I was treated non surgically with only external co-optation. I had an external cast for 6 months and I walked with assist for another 1 month. Finally my tibia healed with no complication. Maybe you can manage it with non weight bearing co optation and after callus formation an assisted walk with external co optation.

Dear Sarah, each case is different in history, mechanism of trauma, pathomorphology, previous treatment modality. So I do not think your case is identical with the case discussed on. Of course there is conservative treatment for some fractures. Decision making depends on many variables. However, 6 months immobilization with cast seems to be very difficult for the patient, and has many drawbacks (muscular hypotrophy, joint stiffness, etc.). The modern orthopaedic surgery tends to ensure exact reduction, stable fixation, early ambulation, joint motions, weight bearing. That is why today the majority of patients are treated surgically.

Dear Panayot, offcours as a surgeon, I would consider surgical treatment but my doctors decided to do so because I assured them I will keep my leg safe during the long period.

In my own opinion, I believe the post IM nailing radiographs are satisfactory. The application of spongious bone graft at the fracture site is also commendable. The fracture has a good chance of healing. Additionally patient could be placed on weekly oral alendronate for 12 weeks after IM nailing plus calcium and vitamin D supplementation also for 12 weeks.

Patient should be able to transition from partial weight bearing to full weight bearing from 10 to 12 weeks post IM nailing.