Tibial Shaft Fractures

Tibial shaft fractures are often the result of the high-energy injury. Sometimes they can also be insidious in onset, such as stress fractures.

Motor vehicles, snowmobiles, and motorcycles, as well as the growing popularity of extreme sports, contribute to the increasing occurrence of tibial shaft fractures. The tibia is currently the most commonly fractured long bone in the body.

The average age of patients with tibial shaft fractures is approximately 37 years.

The highest incidence is found in teenage males.

Anatomy of Tibia

The tibia is a unique anatomical structure. Its anteromedial surface is entirely subcutaneous prone to injury. The location, morphology, and degree of displacement of the fracture has a marked influence on the outcome of the fracture.

At the proximal end, the has  the medial and lateral condyles, the widened parts forming a flat surface known as the tibial plateau with an intervening region called the intercondylar eminence

Inferior to the condyles, the tibial tuberosity is situated. This is where the patella ligament attaches

The shaft of the tibia has three borders and three surfaces; anterior, posterior and lateral.

The distal end of the tibia also widens and on the medial side ends in a projection called medial malleolus which forms part of the ankle joint. On the posterior surface of the tibia, there is a groove where the tibialis posterior muscle attaches.

Laterally, on the distal end, there is a notch, where the fibula is bound to the tibia. It is known as the fibular notch.

The leg is divided into four distinct fascial compartments.

The anterior compartment contains the dorsiflexors of the foot, including the tibialis anterior, the extensor digitorum longus, the extensor hallucis, and the peroneus tertius. It contains deep peroneal nerve. The anterior tibial artery is the major source of blood supply.

The lateral compartment contains the everters of the foot [ the peroneus longus and the peroneus brevis]. It contains superficial peroneal nerve.

The leg has two posterior compartments – superficial and deep.

The deep compartment contains the tibialis posterior, the flexor hallucis longus, and the flexor digitorum longus. It also contains the posterior tibial artery. Peroneal artery also courses through.

The superficial posterior compartment is the largest and contains the soleus, the gastrocnemius, and the plantaris muscles

Read more about Tibial anatomy

Mechanism of Tibial Shaft Fractures

The morphology of the fracture will suggest the nature of injury behind. A tibial shaft fracture could be transverse, short oblique, or spiral depending on the trauma causing it. The fracture could be displaced or undisplaced.

Transverse and short oblique fractures, unless associated with a pathological lesion in the bone, are indicative of a more severe force than are spiral fractures. Marked comminution and gross displacement often accompany.

A high-energy injury caused by shearing forces is usually transverse,

Comminuted,  and  markedly  displaced spiral fractures  with minimal  displacement  and  minimal comminution   represent   examples   of  low-energy injury

Fractures of the proximal third of tibia are discussed separately.

Tibial shaft fractures can be low energy or high energy.

Low energy fractures are the result of the torsional injury. It is kind of indirect trauma and causes a spiral fracture. The fibula is fractured at a different level. It is associated with minimal soft tissue injury

high energy fracture pattern are caused by direct forces resulting in a wedge or short oblique fracture and sometimes significant comminution. The fibula is fractured at the same level.

It is associated with severe soft tissue injury.

Associated Conditions

The presence or absence of other injuries in the same limb will greatly affect the natural history of a tibial fracture.  For example, fractures of the pelvis and acetabulum may require long-term bed rest, making early weight bearing impossible.

Following injuries are known to be associated with tibial shaft fractures

• Soft tissue injury (open wounds)
• Compartment syndrome
• Bone loss
• Ipsilateral skeletal injury
  • Extension to the tibial plateau or plafond
  • Femoral fracture
  • Posterior malleolar fracture
    • most commonly associated with a spiral distal third tibia fracture

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Classification of Tibial Shaft Fractures [Orthopaedic Trauma Association]

Type A – Unifocal fractures

• A1 – Spiral fractures
• A2 – Oblique fractures
• A3 – Transverse fractures

Type B – Wedge fractures

• B1-  Spiral wedge fractures
• B2 – Intact bending wedge fractures
• B3 – Comminuted wedge fractures

Type C – Complex fractures

• C1 – Spiral
• C2 – Segmental
• C3 – Irregular

Classification of Closed Fracture Soft Tissue Injury [Oestern and Tscherne]

Grade 0

Injuries from indirect forces with negligible soft-tissue damage

Grade I

Superficial contusion/abrasion, simple fractures

Grade II

Deep abrasions, muscle/skin contusion, direct trauma, impending compartment syndrome

Grade III

Excessive skin contusion, crushed skin or destruction of muscle, subcutaneous degloving, acute compartment syndrome, and rupture of a major blood vessel or nerve.

Clinical Presentation of Tibia Fractures

The significant injury would result in swelling and deformity. Often the pain is severe. There would be a visible malformation of the leg are in case of displaced fractures present.

Undisplaced or partial fractures may be less characteristic in the presentation. Tibial shaft fractures without fibula fractures present with lesser deformities than those with fibula fractured.

A patient stress fracture presents with pain on weight bearing, often with an antecedent change in lifestyle or an increase in physical activity. The pain is classically worse with weight-bearing exercise and improves with rest.

The injured should be examined completely to look for concomitant injuries. The leg should be examined for the extent of the injury. Ipsilateral knee and ankle joint should be assessed for injury. Deformity, angulation, and malrotation should be noted. Contusions, blisters and open wounds must be accounted.

Compartment syndrome evaluation may be done if required.

The particular care is taken to assess any open wounds or color changes that may indicate a more serious injury.

The distal neuro-vascular examination should be done and compared to the opposite side.

Laboratory Studies

For conservative treatment, no lab study is required

For surgery, a complete blood count, chemistry panel, and a type and crossmatch should be done, along with any other tests in the hospital protocol.

Calcium and phosphorus levels in metabolic or endocrine causes may be done for the decreased bone density related to the fracture if the fracture occurs without significant trauma.

Imaging Studies

Radiographs

Full length anteroposterior and lateral views of the affected tibia are done. AP, lateral and oblique views of ipsilateral knee and ankle are also done to rule out/confirm the involvement of the joint.

CT

CT is useful to evaluate intra-articular fracture extension. It defines the fracture pattern better. It could be also used to find stress fracture suspected clinically but not visible on x-ray.

Bone Scan

A bone scan can provide evidence of a stress fracture.

Arteriography

Used in case of vascular compromise.

Treatment of Tibial Shaft Fracture

Most closed tibial fractures can be treated nonoperatively.

Operative fixation is required when fractures are unstable.

Instability is defined as any of the following values when the leg is in the cast

• Shortening> 1.5 cm of shortening
• Valgus/varus angulation>5 degrees
• Anterior or posterior angulation> 20 degrees

Open fractures and fractures with vascular injuries are surgical emergencies.

Non-operative Treatment

The fracture should be aligned and an above-knee padded plaster is applied. The patient should be observed and closely monitored for compartment syndrome.

Once the initial phase of the injury is over, the patient is encouraged to stand upright and begin weight-bearing as much as it can be tolerated. Full weight bearing is usually achieved by 7-14^th day.

Depending on the type of fracture present, the above-knee cast may be converted to a below-knee patellar-bearing plaster or to a functional cast brace between the fourth and eighth week.

Fractures close to the knee joint or with intact fibula should be left in left in an above-knee plaster only.

The patient must be carefully monitored throughout the treatment phase.

• closed low energy fractures with acceptable alignment
  • < 5 degrees varus-valgus angulation
  • < 10 degrees anterior/posterior angulation
  • > 50% cortical apposition
  • < 1 cm shortening
  • < 10 degrees rotational malalignment
  • if displaced perform closed reduction under general anesthesia
• Non-ambulatory persons or those unfit for surgery
• Carry risk of varus malunion in fractures with an intact fibula

Surgical Treatment

Operative fixation is required when fractures are unstable. Surgical options include plating, external fixation, intramedullary nailing, and, in some cases, amputation.

Indications for Surgery in Tibial fractures

• Associated intra-articular and shaft fracture
• Open fracture
• Major bone loss
• Neurovascular injury
• Compartment syndrome
• Ipsilateral femoral and tibial fractures (floating knee)
• Unstable fractures or  inability to maintain reduction
• Relative shortening
• Segmental fractures
• Tibial fractures with an intact fibula
• Transition zone fractures [metaphysis-diaphysis transition]
• Polytrauma
• Management of complications

If the patient is seen shortly after injury and there is a strong  indication for surgical treatment,  surgery can proceed  quickly,

If, however, the patient arrives late, or surgery is delayed beyond 8–24 h after injury, the extremity may become very swollen and the skin contusions, with areas of fracture blisters and, it is best to delay surgery until the skin has recovered enough.

Surgical Options

External fixation

• Open fractures
• can be useful for proximal or distal metaphyseal fractures
• First stage procedure for staged IM nailing or plating
• pin tract infections common

Intramedullary Nailing

• Intramedullary nailing after closed or open reduction is the treatment of choice and preferred technique
• Reamed nails are preferred if there is no contraindication to reaming
• Approaches
  • medial parapatellar

• • • The most common starting point
    • can lead to valgus malalignment when used to treat proximal fractures
  • lateral parapatellar
    • helps maintain reduction when nailing proximal 1/3 fractures
    • requires mobile patella
  • patellar tendon splitting
    • • • gives direct access to the start point
  • suprapatellar (transquadriceps tendon)
    • requires special instruments
    • can damage patellofemoral joint

• contraindicated in children with open physis (use a flexible nail, plate, or external fixation instead)

Percutaneous Locking Plate

• Proximal/distal tibia fractures not suitable for IM nailing
• Greater surgical and radiation exposure
• Longer surgical duration

Amputation

Amputation is uncommon but is sometimes indicated for severe tibial fractures with significant soft tissue trauma and warm ischemia > 6 hrs. A non-salvageable concomitant foot injury is also an indication.

Follow Up

The motion of the extremity may be started to be started early if the fixation is good. For immobilization, the leg should be elevated with the ankle splinted at 95° dorsiflexion. The splint may be removed after 48-72 hours and then applied intermittently especially in the night to prevent plantar flexion deformity or at least 2–3 weeks following injury.

The mobilization exercises may be delayed if there is concern about the stability of the fracture, or (b) if soft tissue healing would be jeopardized

Complications

Complications of Tibial Shaft Fractures

• Malunion
• Nonunion
• Malrotation
• Compartment syndrome
• Nerve injury

References

• Connelly CL, Bucknall V, Jenkins PJ, Court-Brown CM, McQueen MM, Biant LC. Outcome at 12 to 22 years of 1502 tibial shaft fractures. Bone Joint J. 2014 Oct. 96-B(10):1370-7.
• Heyworth BE, Green DW. Lower extremity stress fractures in pediatric and adolescent athletes. Curr Opin Pediatr. 2008 Feb. 20(1):58-61.
• Littenberg B, Weinstein LP, McCarren M, et al. Closed fractures of the tibial shaft. A meta-analysis of three methods of treatment. J Bone Joint Surg Am. 1998 Feb. 80(2):174-83.
• Kindsfater K, Jonassen EA. Osteomyelitis in grade II and III open tibia fractures with late debridement. J Orthop Trauma. 1995 Apr. 9(2):121-7.
• Ma CH, Tu YK, Yeh JH, Yang SC, Wu CH. Using external and internal locking plates in a two-stage protocol for the treatment of segmental tibial fractures. J Trauma. 2011 Sep. 71(3):614-9.
• Lefaivre KA, Guy P, Chan H, Blachut PA. Long-term follow-up of tibial shaft fractures treated with intramedullary nailing. J Orthop Trauma. 2008 Sep. 22(8):525-9. Busse JW, Morton E, Lacchetti C, Guyatt GH, Bhandari M. Current management of tibial shaft fractures: a survey of 450 Canadian orthopedic trauma surgeons. Acta Orthop. 2008 Oct. 79(5):689-94.
• Court-Brown CM, Will E, Christie J, McQueen MM. Reamed or unreamed nailing for closed tibial fractures. A prospective study in Tscherne C1 fractures. J Bone Joint Surg Br. 1996 Jul. 78(4):580-3.
• Coles CP, Gross M. Closed tibial shaft fractures: management and treatment complications. A review of the prospective literature. Can J Surg. 2000 Aug. 43(4):256-62.