This document provides information on fractures of the tibia. It begins with definitions of fractures and their various classifications. The causes of tibial fractures include direct forces, indirect forces, twisting, bending, and pathological fractures. Fracture patterns include transverse, oblique, spiral, impacted, comminuted, and compression fractures. Treatment options for tibial fractures depend on the fracture type and include casting, intramedullary nailing, plating, and external fixation. Complications can include nonunion, malunion, infection, and hardware failure. Open fractures require urgent debridement and antibiotics to prevent infection.

1. Dr.Sarthy.V
Dept Of Orthopaedics
SSSMCRI

2. 
Break in the structural
continuity of bone

3. 
Injury

Repetitive Stress

Pathological

4. 







Direct force.
Indirect force
Twisting.
Bending.
Compression.
Tension.
Fatigue / Stress Fractures
Pathological Fracture.

5. ◦
◦
◦
◦
◦
◦
Transverse.
Oblique.
Spiral.
Impacted.
Comminuted.
Compression.
Complete
◦ Green Stick.
◦ Plastic Deformation.
InComplete

7. 
Why we need them?

8. 
OPEN FRACTURE

9. 
Translation.

Angulation.

Rotation.

Shortening.

Lengthening.

11. Fracture Healing
• Stage of Hematoma
• Stage of Inflammation
• Stage of repair
• Stage of remodeling

12. Stage of Hematoma
Stage of repair
Stage of Inflammation
Stage of remodeling

13. Healing By Callus
Direct Union

14. 
Alleviate pain.

To ensure union in good position.

Permit early movement of the limb & return
of function.

15. 



Fracture.
Types.
Causes.
Healing.
LEG?

18. 
Ant Comp - Deep
Peroneal N.

Lateral - Sup Peroneal N.

Deep Post. - Tibial N.

Sup Post. - Sural N.

19. Anterior Compartment
• Dorsiflexes ankle
• Tib
ant, EDL, EHL, and
peroneus tertius
muscles
• Anterior tibial a./v.
• deep peroneal n.
1st webspace sensation

20. Lateral Compartment
• Everts the foot
• Peroneus brevis and
longus muscles
• Superficial peroneal n.
dorsal foot sensation

21. Superficial Posterior
Compartment
• Plantarflexes ankle
• Gastrocnemius, soleus
, popliteus, and
plantaris muscles
• Sural nerve
Lateral heel sensation
• Greater and lesser
saphenous veins

22. Deep Posterior Compartment
• Plantarflexion and
inversion of foot
• FDL, FHL, Tib post
muscles
• Post tibial
vessels, peroneal a.
• tibial nerve
Plantar foot sensation

23. High Enregy
Low Energy.

24. Classification
• Numerous classification systems
• Important variables
Pattern of fracture
location of fracture
comminution
associated fibula fracture
degree of soft tissue injury

25. OTA Classification
• Follows Johner &
Wruh system
• Relationship between
fracture pattern and
mechanism
• Comminution is
prognostic for time
to union
Johner and Wruhs, Clin Orthop 1983

26. Henley‟s Classification
• Applies Winquist &
Hansen grading of
femur to fractures of
the tibia

27. Tscherne Classification of
Soft Tissue Injury
•
•
•
•
Grade 0- negligible soft tissue injury
Grade 1- superficial abrasion or contusion
Grade 2- deep contusion from direct trauma
Grade 3- Extensive contusion and crush injury
with possible severe muscle injury, compartment
syndrome

29. History & Physical
• Pain, inability to bear weight, and deformity
• Local swelling and edema variable
• Careful inspection of soft tissue
envelope, including compartment swelling
• Thorough neurovascular assessment including
motor/sensory exam and distal pulses

30. Physical Exam
• Soft tissue injury with high-energy crush
mechanism may take several days to fully
declare itself
• Repeated exam to follow compartment
swelling

31. Radiographic Evaluation


AP and Lateral
views of entire
tibia from knee to
ankle
Oblique views can
be helpful in
follow-up to
assess healing

32. Associated Injuries
• Up to 30% of patients
with tibial fractures have
multiple injuries
• Ipsilateral fibula fracture
common
• Ligamentous injury of
knee with high energy
tibia fractures
Browner and Jupiter, Skeletal Trauma, 3rd Ed

33. Associated Injuries
• Ipsilateral femur fx,
“floating knee”
• Neuro/vascular injury less
common than in proximal
tibia fx or knee dislocation
• Foot and ankle injury

34. 

Common with
high energy tibia
fractures
Treatment is 4
compartment
fasciotomies

35. 

5-15%
HISTORY
◦Hi-Energy
◦ Crush

4 leg
compartments

36. 
Limit soft tissue damage.

Preserve or restore soft tissue cover.

Prevent or recognize & treat Compartment
Syndrome.

To obtain & hold fracture alignment.

Early weight bearing.

To start joint movements as early as possible.

37. 
Depends on the type of fracture.
◦ Open / Closed
◦ High Energy / Low Energy

39. 




Broad Spectrum of
Injures w/ many
treatments
Nonsurgical
management
Intramedullary nails
Plates
External Fixation

40. 
Minimal soft tissue damage

Stable fracture pattern
 < 5 varus/valgus
 < 10 pro/recurvatum
 < 1 cm shortening

Ability to bear weight in cast or fx brace

Frequent follow-up
Schmidt, et.al., ICL 52, 2003

41. 
Closed Functional Treatment
◦
1,000 Tibial Fractures
60% Lost to F/u

All < 1.5cm shortening
Only 5% more than 8 varus

Average 3.7wks in long leg cast, then

◦ Functional fracture brace
Sarmiento, JBJS 1984

42. 
Long-term angular deformities may be well
tolerated without associated knee or ankle
arthrosis

Kristensen
F/U: 20-29 yr
All patients >10 degree deformity

Merchant & Dietz
F/U: 29 yrs.
◦ Outcome not associated with ang., site, immob.
(37/108 patients)

43. Surgical Options
• Intramedullary nail
• ORIF with plate
• External Fixation

44. Advantages of IM Nail
• Less malunion and
shortening
• Earlier weight bearing
• Early ankle and knee
motion
• Possibly cheaper than
casting if time off
work included
Tovainen, Ann Chir Gynaecol, 2000

45. Disadvantages of IM Nail



Anterior knee pain
(up to 56.2%)
Risk of infection
Increased
hardware failure
with unreamed
nails
*Court-Brown et al. JOT 96

46. Plating of Tibial Fractures
• Narrow 4.5mm
DCP plate can be
used for shaft
fractures
• Newer periarticular
plates available for
metaphyseal
fractures

47. Advantages of Plating
Anatomic reduction
usually obtained
In low energy fractures
97% very good/good
results have been
reported
Ruedi et al. Injury vol 7

48. Disadvantages of Plating
• Increased risk of
infection and soft
tissue
problems, especially in
high energy fractures
• Higher rate hardware
failure than IM nail
Johner and Wruhs, Clin Orthop 1983

49. External Fixation
• Generally reserved
for open tibia
fractures or
periarticular
fractures

50. Technique of External Fixation
• Unilateral frame with half pins
• 5mm half pins („near-near and
far-far‟)
• Pre-drilling of pins recommended
• Fracture held reduced while
clamps and connecting bar
applied

51. Advantages of External Fixator
• Can be applied quickly
in polytrauma patient
• Allows easy
monitoring of soft
tissues and
compartments

52. Outcomes of External Fixation




95% union rate for
group of closed and
open tibia fractures
20% malunion rate
Loss of reduction
associated with
removing frame prior to
union
Risk of pin track
infection
Anderson et al. Clin Orthop 1974
Edge and Denham JBJS[Br] 1981

53. 
Common fracture w/ several treatment
options.

Closed stable fxs. can be treated in a cast.

Unstable fxs. often best treated by
intramedullary nail

55. Objectives
Prevent Infection
 Soft tissue
coverage
 Union
 Function


Often requires
staged treatment
over several
months

56. 
Controversial issue
◦ Classically <6hrs
◦ Currently urgent, not emergent


Early antibiotics may be more critical
More wound contamination requires more
urgency and more frequency
-Bosse, JAAOS, 2002
-Skaggs, JBJS 2005

57. 



Meticulous debridement
Explore/Extend wound
Deliver bone ends for full exposure
Excise all foreign material, necrotic
muscle, unattached bone fragments, exposed
fat and fascia
◦ Infection 21% vs 9% w/ improved debridement

Fasciotomy as indicated
-Edwards, CORR 1988
-Patzakis, JAAOS 2003

58. 
D & I “Debridement & Irrigation”
No consensus on volume required

Pulse lavage

◦ May remove debris vs. harmful to osteoblasts

Antibiotics vs. Soap
-Anglen, JBJS 2005

59. Bead Pouches



Tobra 1.2g per packet
of PMMA
Seal wound to create
antibiotic-laden seroma
Reduced risk of
infection
◦ 12% vs 4%

Reduced
aminoglycoside toxicity
-Ostermann, JBJS-B 1995

60. 

Reduces risk of
infection
External Fixation
◦ uniplane vs. multiplane
◦ provisional vs. definitive
tx


Intramedullary nail
Plate fixation

61. Advantages of External
Fixator

Can be applied
quickly in
polytrauma patient

Allows easy
monitoring of soft
tissues and
compartments

62. Technique of External
Fixation

63. Outcomes of External
Fixation




95% union rate for
group of closed and
open tibia fractures
20% malunion rate
Loss of reduction
associated with
removing frame
prior to union
Risk of pin track
infection
Anderson et al. Clin Orthop 1974
Edge and Denham JBJS[Br] 1981

64. Advantages of IM Nail
Less malunion and
shortening
 Earlier weight
bearing
 Early ankle and
knee motion
 Reduced time to
union

-Shannon, J. Trauma 2002

65. Infection
 Union
 Knee Pain

1-5%
>90%
56%
w/ kneeling 90%
w/ running 56%
at rest
33%
Court-Brown, JOT 1996

66. Plating of Tibial Fractures

Narrow 4.5mm DCP
plate can be used for
shaft fractures

Periarticular plates
available

Plate through open
wound

67. Subcutaneous Tibial Plating

Newer alternative
is use of limited
incisions and
subcutaneous
plating- requires
indirect reduction
of fracture

68. Disadvantages of Plating

Increased risk of
infection

13% deep infection
-Bach, CORR 1989

69. 


Primary closure controversial
◦ Surgical judgement gained with experience
◦ If in doubt, repeat debridement 24-72hrs
Type I and some Type II wounds can be
closed primarily or after repeat I+D
Type II and Type IIIa can be closed after
repeat debridement if clean
-Bosse, JAAOS 2002

70. 
Type IIIB fractures
require local rotation
flap, split-thickness
skin graft, or free flap
◦ “reconstructive ladder”
◦ within 7 days
◦ <72 hrs may be better

Reduced need for
complex flaps with
negative pressure
wound therapy
-Parrett, Plast & Recon Surg, 2006
-Gopal, JBJS-B, 2000

71. 


Proximal third tibia
fractures gastrocnemius
rotation flap
Middle third tibia
fractures - soleus
rotation flap
Distal third fractures
- free flap or reverse
sural rotation flap

72. 


Typically no acute bone grafting due to risk
of infection
Bone graft substitutes
BMP-2, OP-1
◦ BESST trial w/ BMP-2 in open fxs
◦ Safe, fewer infections, faster fracture healing
◦ Unknown cost effectiveness
-Govender, et.al. JBJS 2002

73. 

Low energy missiles
rarely require
debridement and can
often be treated like
closed injuries
Fractures due to high
energy missiles (eg
assault rifle or close
range shot gun) treated
as standard open
injuries

74. 




Nonunion
Malunion
Infection- deep and superficial
Fatigue fractures
Hardware failure

75. 
Definition varies from
3 months to one year
Rule out infection

Treatment options:

◦ onlay bone grafts
◦ Bone graft substitutes
◦ free vascularized bone
grafts
◦ reamed exchange
nailing
◦ compression plating
◦ Ilizarov ring fixator

76. 
Varus malunion more of a
problem than valgus

May not be symptomatic

For symptomatic patients
with significant deformity
treatment is osteotomy
-Kristensen et al. Acta Orthop Scand 1

77. 
Ex-fix pin tracts

Should respond to elevation and appropriate
antibiotics (typically gram + cocci coverage)

High index of suspicion for deep infection
with repeat debridement required

78. 

Pain, erythema,wound
drainage, or sinus
formation
Multiple staged
treatment
◦
◦
◦
◦
◦
◦
◦
Radical Debridement
Hardware removal
Cultures
Antibiotic beads/nail
Soft tissue coverage
IV antibiotics
Delayed bone
reconstruction
-Patzakis, JAAOS 2005

79. 



Sometimes seen during rehab after
prolonged non-weight bearing
Can present with localized tenderness in
metatarsal, calcaneus, or distal fibula
Bone scan or MRI may be required to make
diagnosis as plain radiographs often normal
Treatment is temporary reduction in weight
bearing

80. 


Usually due to delayed
union or nonunion
Rule out infection
Treatment depends on
type of failure:
plate or nail breakage
often requires revision
locking screw in nail may
not require operative
intervention

81. Saving a functional
limb versus saving
the patient

82. 

An attempt to help
guide between
primary
amputation vs.
limb salvage
Score of 7 or
higher was
predictive of
amputation
-Johansen et al. J Trauma 1991

83. 
Host factors
◦ Type A – healthy
◦ Type B – minimal
comorbidities
◦ Type C – Multiple
comorbidites, tobacc
o use, poor social
support

The four “D’s”
◦
◦
◦
◦
Disabled
Destitute
Drunk
Divorced

84. 





Fracture.
Leg.
Types Of Fracture.
Clinical Features.
Red Flags.
Management
◦ Conservative.
◦ Surgical.
When? How? Pros & Cons….