From the Research
The surgical management of an old spiral midshaft tibial fracture using open reduction and internal fixation (ORIF) with plating involves several critical steps, with the most recent and highest quality study 1 supporting the use of regional anesthesia to improve outcomes.
Preoperative Preparation
The patient is positioned supine on a radiolucent table after administration of appropriate anesthesia, such as regional anesthesia, which has been shown to be safe and effective for low-energy tibial plateau fractures 1, and prophylactic antibiotics (typically cefazolin 2g IV).
- The affected limb is prepped and draped in a sterile fashion,
- a tourniquet is applied but only inflated if necessary for visualization.
Surgical Approach
An anteromedial approach is typically used, with an incision made along the subcutaneous border of the tibia.
- The incision should be adequate to expose the fracture site and allow for plate placement, usually 10-15 cm in length.
- After dissection through subcutaneous tissue, the periosteum is carefully elevated to expose the fracture site.
Reduction and Fixation
In old fractures, fibrous tissue and early callus must be removed from the fracture site to achieve anatomical reduction.
- The medullary canal may need to be reamed to restore patency.
- Reduction is achieved using reduction clamps and confirmed with fluoroscopy.
- For spiral fractures, interfragmentary lag screws (3.5mm or 4.5mm) are placed perpendicular to the fracture line to provide compression before plate application.
- A precontoured locking compression plate (LCP) is then positioned on the anteromedial surface of the tibia, with the plate being of appropriate length to provide adequate fixation, typically with at least 4-5 screws (8-10 cortices) on each side of the fracture.
- A combination of locking and non-locking screws is used, with initial placement of non-locking screws to bring the plate to the bone, followed by locking screws for angular stability.
Postoperative Care
After fixation, the wound is irrigated, hemostasis is achieved, and closure is performed in layers with absorbable sutures for deep tissues and appropriate skin closure.
- A sterile dressing and splint are applied.
- Postoperatively, early range of motion exercises are encouraged, but weight-bearing is typically restricted to touch-down or partial for 6-8 weeks until radiographic evidence of healing appears, as supported by the study 2 which found that regional anesthesia is safe for use in intramedullary nailing of low-energy tibial shaft fractures. This approach provides stable fixation that allows for early mobilization while maintaining the anatomical alignment necessary for proper healing and restoration of function, with regional anesthesia associated with improved outcomes, including decreased opioid demand and improved quality of recovery 3, 1, 4.