1) Tibial shaft fractures occur in the diaphyseal region of the tibia and can result from high or low energy trauma. 2) Treatment goals are to restore proper alignment, stability, and allow bone healing within 10-12 weeks while rehabilitation lasts 12-24 weeks. 3) Treatment methods include casting, intramedullary nailing, or plating and depend on the fracture pattern and stability. Complications addressed include compartment syndrome, fat embolism, and nonunion.

1. Tibial Shaft Fractures
Rehabilitation
Dr. Dibyendunarayan Bid

2. Definition
• A tibial shaft fracture is a diaphyseal fracture
of the tibia that does not usually involve the
articular or metaphyseal regions (Figures 28-1 and
28-2).

3. Mechanism of Injury
• High-energy trauma from direct impact may result in
transverse or comminuted fractures, which are often
open.
• Low-energy indirect trauma from a twisting
injury on a planted foot or a fall from a low height may
cause a spiral or oblique fracture pattern.

5. Treatment Goals
• Orthopaedic Objectives
• Alignment
Restore length, angulation, and rotation and compare
to the uninjured limb. Rotation may be best evaluated
by comparison of the position of the second web space
with the tibial tubercle.
• Stability
Stability is best achieved by performing a reduction
that restores bone congruity.

8. • Expected Time of Bone Healing
Ten to 12 weeks.
• Expected Duration of Rehabilitation
Twelve to 24 weeks.

9. Methods of Treatment
• Cast
– Biomechanics: Stress-sharing device.
– Mode of Bone Healing: Secondary.

10. • Indications:
– Long leg cast treatment is satisfactory for tibial
shaft fractures with minimal comminution that are
stable and acceptably aligned once immobilized.
– Relative criteria for stability include displacement
less than 50% of the tibial width and shortening
less than 1 cm.
– Alignment should restore rotation and angulation
in all planes to within 5 degrees to 10 degrees of
the uninjured tibia (Figures 28-3 and 28-4).

12. • Intramedullary Rod
• Biomechanics: The intramedullary rod is a stress
sharing device if the nail is dynamically
interlocked; it is a partial stress-shielding device if
the nail is statically interlocked.
• Mode of Bone Healing: Secondary.

13. • Indications:
• This treatment is the gold standard for unstable and
segmental tibial #s or those that cannot be adequately
aligned and immobilized by nonoperative means.
• The intramedullary rod allows for early mobilization of
the patient as well as early knee range of motion.
• Placing interlocking screws proximal and distal to the #
site is necessary in #s with unstable butterfly fragments
or severe comminution.
• This creates static fixation and prevents shortening and
loss of rotatory alignment.

14. • Transverse #s and those with minimal comminution
may be left unlocked at one end.
• This creates dynamic fixation and allows
interfragmentary compression with weight bearing,
which in turn stimulates healing (Figures 28-5, 28-6, 28-
7, 28-8, 28-9, 28-10, 28-11, 28-12).

20. Special Considerations of the Fracture
• The rate of bone healing in tibial #s depends on the #
pattern and the extent of soft tissue injuries.
• The major blood supply to the tibial shaft is a branch of the
posterior tibial artery, which enters posterolaterally.
• Closed injuries with stable # patterns are able to bear
weight and heal the most rapidly.
• Spiral #s do less damage to the periosteum, which
distributes the blood supply, than do higher energy bending
#s that tear the periosteum transversely.

21. • Therefore, the spiral fracture heals much more
readily.
• Open fractures have significantly more soft tissue
damage and often require much more time for healing.
• In cases of nonunion or delayed union, this fracture
and those with severe comminution may require bone
grafting to stimulate bone healing.

22. Associated Injury
• Compartment Syndrome
• Compartment syndrome can result when soft tissue swelling and
bleeding into a closed compartment lead to pressures that exceed
venous and later arterial circulation.
• These occur most commonly in the anterior compartments where
the tibia, fibula, and interosseous membrane form an unyielding
space.
• Normal resting intracompartmental pressure is 0 to 8 millimeters of
mercury.
• Compartmental pressure of 30 mm of pressure or greater requires
immediate decompression.

23. • Compartment syndrome is diagnosed by symptoms. (The patient is
often casted, which makes a physical examination difficult.)
• A patient who has or in whom compartment syndrome is
developing can be expected to have pain out of proportion to the
injury and symptoms of increasing numbness and paresthesia, even
after the cast or bandage has been removed.
• Exquisite pain with passive toe extension of the MTP joint is an
important sign.
• If compartment syndrome is suspected, compartment pressure
should be measured immediately.
• If the diagnosis is made, the patient should undergo a fasciotomy.

24. • Embolism
Because of the risk of fat or pulmonary emboli, a
baseline arterial blood gas measurement should be
considered in every patient and definitely done in
those with multiple injuries.

25. • Fat emboli syndrome may occur in the acute
phase within the first 72 hours after fracture.
– It causes sudden respiratory distress and hypoxia.
– Petechiae in the conjunctiva and axilla as well as
tachypnea and tachycardia are the signs of this
condition.

26. • Pulmonary embolism may occur after 72 hours of
bed rest or venous pooling.
– Its symptoms are similar to those of fat emboli, except
there is no petechiae.
– Early mobilization by operative fracture fixation helps
reduce the risk of this condition.

27. • Soft Tissue Injury
• Soft tissue injury associated with tibial shaft fractures is common
because the anteromedial tibia is subcutaneous.
• The skin must be examined thoroughly for signs of contusion or
compounding of the fracture.
• These wounds must be examined for surrounding erythema or
fluctuance.
• They require meticulous cleaning and frequent dressing changes to
prevent infection.
• If the fracture has been treated operatively, the operative
wound should be evaluated.
• Edema distal to the fracture site and in the toes must also be
evaluated and treated with elevation of the extremity .

28. Weight Bearing
• The potential for weight bearing varies with the # pattern as well as
the method of fixation.
• Patients with #s with a stable pattern that are treated either by
casting or with dynamically or statically locked intramedullary nails
are often able to begin weight bearing early, as soon as pain
permits.
• Unstable #s treated with external fixators, statically locked nails, or
open reduction and internal fixation usually require extended
periods of non-weight bearing or toe-touch weight bearing,
depending on the comminution.
• This limited weight bearing should continue for the first 6 to 8
weeks until a callus is seen radiographically.

29. Gait

30. TREATMENT

39. LONG-TERM CONSIDERATIONS
AND PROBLEMS
• Nonunion or delayed union occurs most commonly in highly
comminuted or open tibia fractures.
• The high-energy injury that causes these fractures leads to
disruption of the blood supply to the tibia, and an atrophic
nonunion may occur.
• Hypertrophic nonunions occur when there is too much motion at
the fracture site.
• Nonunions may be initially treated with progressive weight bearing.
• This often stimulates bone healing.

40. • If a tibia nonunion occurs in a leg with a healed fibula fracture, then
a fibula ostectomy may be necessary to allow the tibia to transfer
weight from the proximal to the distal segment across the
nonunion.
• This may also promote healing.
• A nonunion may also be treated with bone grafting and plating,
intramedullary rodding, or exchange rodding to a larger reamed nail
if it occurs in a tibia fracture that has initially been treated with an
intramedullary nail.

41. Reference