Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

Featured on Channel NewsAsia

Tibial Shaft Fracture

Basics

Description
  • A fracture of the diaphysis (usually midportion) of the tibia
  • Classification:
    • Fractures are classified by the amount of comminution and the position of the fracture.
    • The AO system can be used to describe the fracture further.
    • Open fractures are classified by the system of Gustilo and Anderson.
Epidemiology
  • Can occur in any age group
  • In 1 study, 76% of fractures were closed.
Prevalence
Fractures occur most commonly in people <40 years old.
Risk Factors
  • Motor vehicle accident
  • High-impact sports
  • Bumper injuries
Etiology
  • Low-energy falls
  • Twisting mechanisms
  • High-energy crush injuries
  • High-impact injuries
Associated Conditions
  • Fibular fracture
  • Knee ligament injuries
  • Femur fractures
  • Neurovascular injury
  • Compartment syndrome
Diagnosis
Signs and Symptoms
  • Instability of the leg at the fracture site
  • Swelling
  • Ecchymosis
  • Pain
  • Tenderness
Physical Exam
  • Evaluate the knee and ankle.
  • Perform a skeletal screening examination.
  • Scrutinize the leg closely for signs of skin penetration or open fracture.
  • Carefully evaluate swelling for compartment syndrome.
  • Examine the patient’s neurologic and vascular status.
Tests
Imaging
Obtain AP and lateral radiographs of the tibia, which include the ankle joint distally and the knee joint proximally.
Diagnostic Procedures/Surgery
If concern exists for compartment syndrome, compartment pressures should be measured.
Differential Diagnosis
  • Compartment syndrome
  • Fibular fracture
  • Open versus closed fracture
Treatment
General Measures
  • Closed fractures:
    • Fractures that are <50% displaced, are <1 cm shortened, and have <10% of angulation in any plane:
      • May be treated in an above-the-knee cast
      • The cast is converted to a functional brace after 6-8 weeks.
    • Fractures with greater displacement, angulation, or comminution are treated with reduction and fixation using an intramedullary nail.
  • Open fractures:
    • Treated with urgent and often repetitive irrigation and bridement
    • Intravenous antibiotics are given for 24-48 hours.
    • Definitive treatment is based on the nature of the fracture and involves external fixation or open reduction with an intramedullary nail, depending on fracture severity.
  • Tibial shaft fractures often are associated with compartment syndrome and neurovascular injury.
    • Closely monitor compartment tension.
    • Evaluate the neurovascular status of the limb immediately on presentation and frequently thereafter.
Activity
Tibial shaft fractures often require 2-6 months of protected weightbearing on the affected extremity.

P.459
Special Therapy
Physical Therapy
Gait training for nonweightbearing is indicated.
Medication
Analgesics
Surgery
  • Internal fixation:
    • Placement of an intramedullary nail starting at the knee and extending to the ankle or placement of a plate and screws
    • Nails may be inserted through the patellar tendon or with a lateral or medial parapatellar insertion.
      • The method of insertion does not seem to relate to later anterior knee pain.
    • Nails may be reamed or unreamed.
      • Reaming of the canal allows for a larger diameter nail to be placed.
      • Reamed nails have lower rates of hardware failure and nonunion.
      • The term unreamed is really a misnomer, because some amount of reaming must be done to place even the smallest nail.
    • Plate fixation often is necessary for fractures that involve the proximal or distal 1/3 of the tibia.
    • Pediatric fractures may be treated with multiple elastic nails that can be inserted without damage to the growth plate.
    • Open fractures have lower nonunion and infection rates when treated with recombinant BMP-2 in addition to intramedullary nailing.
  • External fixation:
    • Placement of PINS in the proximal and distal portions of the fracture and reduction of the fracture and maintenance of the reduction with the external frame
    • Indications:
      • Soft-tissue injury preventing intramedullary nail insertion
      • Damage control orthopaedics in the multiply injured patent
      • Pediatric tibia fractures
Follow-up
Prognosis
  • Low-energy injuries with displacement of <50% have a good prognosi.
  • The incidence of complications increases and the prognosis worsens with high-energy, comminuted fractures.
  • Distal fractures and those with a remaining fracture gap after fixation have been shown to have a high rate of nonunion.
  • Open fractures have the worst prognosis and the highest incidence of complications.
  • Severe tibia fractures with major soft-tissue injuries have a poor prognosis.
  • Patients who smoke have a higher rate of nonunion than do nonsmokers .
Complications
  • Compartment syndrome
  • Neurovascular injury
  • Malunion
  • Delayed union
  • Nonunion
  • Osteomyelitis
  • Hardware pain
  • Anterior knee pain
Patient Monitoring
Closely monitor the patient’s neurovascular status and look for compartment swelling.
Miscellaneous
Codes
ICD9-CM
  • 823.2 Closed tibial shaft fracture
  • 823.3 Open tibial shaft fracture
Patient Teaching
  • Patients should be:
    • Informed that tibial fractures are occasionally difficult to treat and may have a prolonged healing time
    • Encouraged to stop smoking
FAQ
Q: Does a closed tibial shaft fracture require surgery?
A: Surgery may allow for earlier weightbearing and return to function. Fractures that are well reduced have an excellent prognosis with nonoperative treatment (functional brace).
Q: How should severe open tibial fractures be treated?
A: Severe open tibial fractures are treated with stabilization of fracture fragments followed by soft-tissue coverage. Amputation is sometimes necessary secondary to infection or soft-tissue injury.

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