1) The document discusses fracture of the tibia shaft, including classification, clinical features, imaging findings, treatment options, and postoperative management. 2) Treatment depends on factors like soft tissue state, bone injury severity, stability, and contamination. Options include conservative treatment, intramedullary nailing, and plating. 3) Intramedullary nailing is the treatment of choice for most tibia shaft fractures. Plating is best for metaphyseal fractures not suitable for nailing. External fixation is an alternative to avoid exposure.

1. Fracture shaft of Tibia
Dr. Ashiqur Rahman
Resident Orthopedics
Dhaka Medical College & Hospital

2. Introduction:
-Because of the subcutaneous position, the tibia is more
commonly fractured, & more often sustain an open # (23.5%).
-The commonest mechanism are falls, sporting & transport
accidents, with higher-energy mechanisms seen more commonly
in younger pt.

6. Tscherne’s classification of skin lesions in closed fractures
IC1 : No skin lesion
IC2 : No skin laceration but contusion
IC3 : Circumscribed degloving
IC4 : Extensive, closed degloving
IC5 : Necrosis from contusion

7. Clinical Features:
1. signs of soft-tissue damage:
- bruising,
- severe swelling,
- crushing
- or tenting of the skin
2. open wound,
3. circulatory changes,
4. weak or absent pulses,
5. diminution or loss of sensation and
6. inability to move the toes
7. Always be on the alert for signs of an impending compartment
syndrome.

8. X ray finding:
- The entire length of the tibia and fibula, as well as the knee and
ankle joints, must be seen.
-The type of fracture,
- Its level and
- The degree of angulation
- Displacement are recorded.
- Rotational deformity can be gauged by comparing the width of
tibio-fibular interspace above & below the fracture.
- Spiral # without comminution are low energy trauma.
- Transverse, short oblique & comminuted #, especially if
displaced & associated fibular # are high energy trauma.

9. Choice of treatment – depends on the following factors:
1. The state of the soft tissues-
a. Closed fractures are best described using Tscherne’s method;
b. For open injuries, Gustilo’s grading is more useful
2. The severity of the bone injury
3. Stability of the fracture
4. Degree of contamination

10. Management:
Objectives of management of tibia fibula fractures are:
(1) To limit soft-tissue damage and preserve (or restore, in the
case of open fractures skin cover).
(2) To prevent – or at least recognize – a compartment
syndrome.
(3) To obtain and hold fracture alignment.
(4) To start early weight bearing (loading promotes healing).
(5) To start joint movements as soon as possible.
Fracture pattern: First step to get a clear idea about fracture pattern
& soft tissue condition.

11. Low energy fractures:
Criteria for conservative management:
- Non- displaced or minimally comminuted fractures
- Low energy injury
- Gustilo I after attention of the wound.
- Fibular displacement can be ignored until it involve the ankle joint
- Traffton’s recommendation of conservative treatment:
(Camp2741)
(i) Varus and vulgus angulation < 5 degrees
(ii) Antero-posterior malalignment <10 degrees
(iii) Rotatory malalignment <10 degrees
(iv) Shortening <15mm

12. Technique for conservative Rx
- A full-length cast from upper thigh to metatarsal necks is
applied with the knee slightly flexed and the ankle at a right
angle.
- The limb is elevated and the patient is kept under observation
for 48–72 hours.
- If there is excessive swelling, the cast is split
- After 2 weeks the position is checked by x-ray.
- A change from an above- to a below-the-knee cast is possible
around 4–6 weeks, when the fracture becomes ‘sticky’.

13. - The cast is retained (or renewed if it becomes loose) until the
fracture unites, which is around 8 weeks in children but seldom
under 12 weeks in adults.
- Exercise From the start, the patient is taught to exercise the
muscles of the foot, ankle and knee.
- When the plaster is removed, a crepe bandage or elasticated
support is applied and the patient is told that he may either
elevate and exercise the limb or walk correctly on it, but he must
not let it dangle idly.

14. Intra-medullary fixation
-Rx of choice for the most of the type-I, type-II, & type-IIIA Open
& closed tibial shaft #.
-Segmental & bilateral tibial shaft #.
-The ability to lock nails proximally & distally provides control of
length, alignment & rotation in unstable fractures & permits
stabilization of fractures located below the tibial tubercle or 3 to
4cm proximal to ankle joint.

15. Closed intramedullary nailing:
- The fracture is reduced under x-ray control and image
intensification.
- Identify nail entry point
- This typically is located along the medial slope of the lateral
tibial eminence on the AP view & just anterior to the articular
margin on lateral imaging. (Camb-2749)
- The location of the entry point in relation to the tibial tubercle
varies with patient anatomy.

16. - Make a longitudinal incision over the midline of the tubercle,
extending proximally.
- Retract the patellar tendon laterally, or split the tendon,
depending on surgeon preference and patient anatomy.
- Insert the 2.5 mm Threaded Guide Wire through the incision to
the entry point. Under an AP image intensification view, center
the guide wire in line with the medullary canal
- The medullary canal and the canal is reamed.

17. - A nail of appropriate size and shape is then introduced from the
proximal end across the fracture site.
- Transverse locking screws are inserted at the proximal and
distal ends.
- Postoperatively, partial weight bearing is started as soon as
possible.
- Progressing to full weight bearing when this is comfortable.
- For diaphyseal #, union can be expected in over 95% of cases.
- However, the method is less suitable for # near bone ends.

19. Plate fixation:
- Plating is best for metaphyseal fractures that are unsuitable for
nailing
- The disadvantages of plate fixation included:
(i) the need to expose the fracture site
(ii) Stripping the soft tissues around the fracture. This may
increase the risk of introducing infection and delaying
union.

21. Close plating:
-The plate is slid across the fracture through proximal and distal
‘access incisions’ on the anterolateral aspect of the tibia and
then fixed to the bone only at these levels.
-This method of ‘submuscular’ plating preserves the soft tissues
around the fracture site better than conventional open plating,

23. External fixation:
- This is an alternative to closed nailing;
- It avoids exposure of the fracture site and allows further
adjustments to be made if this should be needed.
Plan of management:
- In open fracture: Surgical toileting with immobilization by
external fixator and plaster.
- Standard fixation: G- IIIA Unreamed IL Nail
- I and II: reamed interlocking nail.
- III B needs flap coverage, Metaphyseal fracture with joint
involvement and pilon fracture: Illizarov.

25. •Complications:
Early complication:
1. VASCULAR INJURY
2. Compartment syndrome
3. Infection
Late Complication:
1. Malunion
2. Delayed union
3. Non union
4. Joint stiffness
5. Osteoporosis

26. What is angle of Harzog?
• 11 degrees bend in AP direction
at junction of upper 1/3dr and
lower 2/3rd of tibial nail.

27. Postoperative management:
- Swelling is common after tibial fractures
- The limb should be elevated and frequent checks made for
signs of compartment syndrome
- After intramedullary nailing of a transverse or short oblique
fracture, weightbearing can be started within a few days and
increased to full weight when this is comfortable.

28. - If the fracture is comminuted or segmental, meaning that
almost the entire load will be taken by the nail initially, only
partial weight bearing is permitted until some callus is seen on x-
ray.
- With plate fixation, additional support with a cast may be
needed if partial weightbearing is to start soon after surgery;
otherwise weight bearing is delayed for 6 weeks.