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Orthotic Design and Application for Functional Treatment of Tibial Shaft Fractures

Joseph B. Zagorski, MD
Gregory A. Zych, DO
Loren L. Latta, PE, PhD
Alan R. Finnieston, CPO

Introduction

The general principles for functional treatment of fractures also apply to treating fractures of the tibial diaphysis: 1) begin muscle function as soon as possible after acute symptoms have subsided, 2) encourage motion of all adjacent joints to the fracture and 3) control the bone fragments through soft tissue compression and molding of the soft tissue parts.

Diaphyseal fractures of the tibia lend themselves well to fracture orthoses because tibia fractures treated with immobilization and some internal fixation methods may not heal properly. Now that it is understood that motion at the fracture site is not detrimental to fracture healing and that joint motion is good for muscular activity and blood supply,

Discussion

The tibia and the fibula are connected by the interosseous membrane. Despite the major loading conditions of early weightbearing, most fractures within the diaphyseal region of the tibia can be stabilized easily by using an orthosis (31). The orthosis need not restrict motion of the knee and ankle joints since the cylindrical portion can contain the bulk of the muscular tissue regardless of the extensions, materials, connectors, etc. of the particular device (see Figure 1 on page 129)(32). The soft tissues become tendinous across the knee and ankle, providing a natural anatomic container for both ends. Thus, a cylinder encompassing the leg from the tibial tubercle to the initial flare of the malleoli bears the loads and is all that is required to prevent angulatory deformities (9,22,30,33).

Length and rotation stability must be achieved before bracing. This is usually accomplished by four to six weeks of cast immobilization with progressive weightbearing as tolerated in long and/or short casts (see Figure 2 and Figure 3 ).

Studies of the extensions of the tibial sleeve proximally and distally have shown these extensions are not only very compliant, but also have negligible effect on rotation and bending stability (see Figure 4 )(32). The footpiece for the tibial orthosis also provides only negligible stabilizing effect in bending or rotation, but it is clinically important in maintaining suspension of the sleeve (see Figure 5 ). Flattening the posterior calf musculature with soft tissue compression provides the major source of control and load bearing in the leg (see Figure 6 )(22). Thus, any size adjustments in the orthosis must be made in such a manner that this soft tissue molding is maintained. Stabilizing the fit of the orthosis is critical to retain angular position of the bone fragments during the early phases of fracture repair (see Figure 7 ).

Internal fixation and functional bracing are generally thought to be very different in their philosophies (though not in their goals). But since it is now understood that healing with peripheral callus can be compatible with fracture site motion, early function and good clinical results, many compliant fixation methods have been developed to heal with peripheral callus (1,2,4-6,9, 13,22,31,33-35). Fixation methods that try to obtain healing through peripheral callus and early functional activity can be compatible with functional bracing (9,33-35). Orthoses can be used in conjunction with compliant forms of fixation either sequentially or simultaneously (9,34-36).

Tibial fractures that do not have adequate length and rotation stability for closed, functional treatment alone can often have internal fixation of a minimal nature, supplemented by an orthosis (9,34,35). Segmental tibial fractures are a good example of tibial fractures that typically will have unacceptable initial shortening (because of two or more fractures). Angulation can be adequately controlled by an orthosis. Two small, flexible intramedullary nails can provide the needed length stability but will not adequately control rotation or angulation. A more extensive surgical procedure can provide the needed stability, but so can an orthosis at far less risk (see Figure 8 ). Thus, a minimal surgical insult supplemented by an orthosis can provide early function, low-risk treatment and rapid return to independent function for a difficult injury (see Figure 9 ).

External fixation can also provide stability during the acute phases of soft tissue healing until adequate stability is reached for orthotic treatment (9,36). Soft tissue healing will provide length stability and some rotational stability. The orthosis can provide the required angular stability (the last stability to be achieved clinically) and some rotational support while the bone heals. But the external fixation must be removed early so functional bracing can begin within the six-week "golden period" if one expects to achieve the usual benefits of early function on the biology of repair see (Figure 10 ). This means that many Grade III injuries may not be able to be braced early enough to maintain alignment and still achieve early function (36).

Conclusion

With an understanding of the role soft tissues play in providing stability to the limb when controlled by a fracture orthosis, it is possible to understand the proper timing of orthotic application and the proper indications for closed functional treatment of a wide variety of diaphyseal fractures of the tibia. Orthoses are not applied acutely, but are applied secondarily after acute symptoms have subsided and patients have demonstrated tolerance for functional activity.

The goal of orthotic management of fractures is early function, which greatly affects materials applied and the mechanical philosophy for the design of devices used for early function in the closed management of fractures. Through many years of experience, both clinically and in the laboratory, the authors have developed a rationale for orthotic design, which involves an understanding of soft tissue compression and the elastic support to the bone fragments from surrounding soft tissues. A wide variety of means of accomplishing these goals of closed functional treatment are available to orthopaedic surgeons and orthotists.

JOSEPH B. ZAGORSKI, MD, FACS, is a clinical professor for the department of orthopaedics and rehabilitation at University of Miami School of Medicine, 7867 N. Kendall Drive, Suite 100, Miami, FL 33156; (305) 598-7777.

GREGORY A. ZYCH, DO, is a professor and chief of trauma service for the department of orthopaedics and rehabilitation, University of Miami School of Medicine, Miami, FL 33101; (305) 5857076.

LOREN L. LATTA, PE, PhD, is a professor and director of research for the department of orthopaedics and rehabilitation, University of Miami School of Medicine, Miami, FL 3310]; (305) 5473512.

ALAN R. FINNIESTON, CPO, is president, Finnieston Clinic, Maramed Precision Corp. & AFI Endolite, 300 Bird Road, Coral Gables, FL 33146; (305) 444-6104. bracing has become popular for diaphyseal fractures of the tibia (1-9). In fact, weightbearing and early function have proven to be effective in obtaining consistent healing in these very difficult cases (9-30).

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