Tension band plating of an anterior tibial stress fracture nonunion in an elite athlete initially treated with intramedullary nailing

Case Studies 5 min 705

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Created On: 14/01/2020

Tension band plating of an anterior tibial stress fracture nonunion in an elite athlete initially treated with intramedullary nailing

An Elite African football player aged 23-year-old was presented with a midshaft anterior cortex tibial stress fracture 2.5 years ago. He was treated with cast immobilisation with no weight bearing for three months, but the fracture did not heal. He has again continued no weight bearing for an additional three months. The fracture did not improve, and then he underwent an operation in which the medullary canal of the tibia was rearmed, and intramedullary (IM) nail was inserted. Unfortunately, the fracture site did not consolidate after 18 months, and again he was presented for counselling. The imaging results revealed a non-union of fracture and failure of intramedullary nailing. Tension band plating with bone grafting resulted in fracture union without removing the pre-existing IM nail.

Which of the following conservative treatment modality is more useful for an anterior tibial stress fracture?

Intramedullary nailing
Tension band plating
Use of an orthosis

See All

Key take away

Stress fractures are common in military recruits, athletes, and patients with nutritional or endocrine abnormalities with an expected incidence rate of 0.04 injuries/1000 hours in elite football players.

Medical history

He had a free medical history. He did not smoke tobacco.

Examination & lab investigations

Clinical diagnosis: The analysis of the peripheral nervous system of his lower extremities did not reveal any pathologic findings. The laboratory examinations for possible metabolic or endocrine disorders were negative.

Confirmatory diagnosis: X-ray imaging studies revealed a non-union of the fracture.

Management

A reoperation was advised after an indication of the non-union of the fracture. The tension band plate fixation with bone grafting and without removing the IM nail was performed. It is a technique used for the treatment of anterior tibial stress fractures that failed non-operative treatment. After three months he reported complete pain relief and started core stabilisation exercises.

At six months, he was symptom-free and returned to play football six months postoperatively.

Discussion

Anterior tibial stress fractures in athletes present a challenge for clinicians. Non-surgical therapies such as rest, braces, ultrasound therapy, or electromagnetic field therapy result in psychological effects and prolonged lengthy healing time. It also leads to delayed union, non-union and progression to complete fractures. In general, the non-surgical treatment is the primary treatment for stress fractures, but it may not be the optimal treatment for anterior tibial stress fractures. These fractures are non-responsive to conservative treatment due to high tensile load, lack of adequate muscle and soft tissue coverage, poor local vascularity compromising bone healing. Therefore, early surgical intervention should be reviewed for anterior tibial stress fractures.
It is believed that IM nailing is an ideal treatment option for posteromedial tibial stress fractures, but tension band plate is convenient for anterior tibial stress fractures. Moreover, insertion of the tibial nail violates the knee joint, interrupts the extensor mechanism, and can cause the pain in the anterior knee with kneeling and bending.

Tension band plating has some biomechanical advantages over IM nailing. It prevents tensile forces from the posterior muscle group and provides compression at the tension side of the tibial cortex. The distance between the plate and the central axis of the bone is another integral factor that improves fracture opening displacement, tensile strengths, and motion. The tension band plating technique allows the surgeon to remove the non-viable tissue, perform local removal of necrotic bone in cases of non-union of tibial stress fractures, and drilling and grafting at the fracture site.

Learning

Tension band plating is a worthwhile and valuable option to treat anterior stress fractures treated previously with IM nailing.

References

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