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Nonarticular Proximal Tibia Fractures: Treatment Options and Decision Making

Dr. Bono is Chief Resident, Department of Orthopaedics, New Jersey Medical School, Newark. Dr. Levine is Attending Surgeon, Union Memorial Hospital, Baltimore, Md. Dr. Rao is Clinical Professor of Orthopaedics, New Jersey Medical School. Dr. Behrens is Professor and Chairman, Department of Orthopaedics, New Jersey Medical School.

Reprint requests: Dr. Bono, Department of Orthopaedics, New Jersey Medical School, MSB, Room G-574, Newark, NJ 07107.

Nonarticular proximal-third fractures account for 5% to 11% of tibial shaft injuries and occur as a result of a variety of mechanisms. Treatment is more challenging than for more distal fractures, and the rates of compartment syndrome and arterial injury are higher, especially for displaced fractures. Closed management often leads to varus malunion, especially when the fibula is intact. Closed treatment should therefore be reserved for nondisplaced or minimally displaced fractures with little soft-tissue injury. Plating of the proximal tibia has become a less popular alternative because of the high incidence of infection and fixation failure. However, judicious use of lateral plates as an adjunct to medial external fixation in comminuted fractures can be effective. External fixation remains the most versatile method. It is indicated for fractures with short proximal fragments and in cases of extensive soft-tissue injury that would preclude use of other surgical techniques. Temporary joint-spanning external fixation has a role in the initial management of certain fracture patterns, particularly when accompanied by severe soft-tissue injury. Although intramedullary nailing can lead to valgus malunion in a sizable percentage of patients with this injury, it can be useful for stabilizing fractures with proximal fragments longer than 5 to 6 cm. Placing the entry portal more proximal and lateral, locking in extension, and using specific techniques, such as blocking screws, can improve alignment after nailing. Use of an algorithm that takes into account the severity of soft-tissue injury, the length of the fracture fragment, and the degree of fracture stability allows effective decision making among current treatment techniques.