This document discusses tibia fractures, including: 1. Tibia fractures are more common than other long bone fractures and often result in open fractures. 2. Tibia fractures are caused by twisting, angulatory, or indirect/direct forces and are classified based on the soft tissue injury and fracture stability. 3. Treatment depends on the soft tissue condition, fracture severity, stability, and degree of contamination. Most are treated non-operatively but unstable or open fractures may require surgery.

1. Presenter; Joyce F. Mwatonoka
MD5
November 2016

4.  Because of its subcutaneous position, the
tibia is more commonly fractured, and more
often sustains an open fracture, than any
other long bone

5.  Twisting force-spiral fracure
 Angulatory force-transverse/short oblique
 Indirect injury is usually low energy; with a
spiral or long oblique fracture one of the
bone fragments may pierce the skin from
within
 Direct injury crushes or splits the skin over
the fracture; this is usually a high-energy
injury and the most common cause is a
motorcycle accident

6.  The behaviour of these injuries – and
therefore the choice of treatment –depends
on the following factors;
1. The state of the soft tissues; direct
proportion to risk of complications and #
healing. Closed fractures are best described
using Tscherne’s (Oestern and Tscherne,
1984) method; for open injuries, Gustilo’s
grading. Risk of infection 1% in Gustilo 1 -
30% in Gustilo 3c.

7. 2. The severity of the bone injury;
High-energy fractures are more damaging and
take longer to heal than low-energy fractures;
this is regardless of whether the fracture is
open or closed. Lowenergy breaks are
typically closed or Gustilo I or II, and spiral.
High-energy fractures are usually caused by
direct trauma and tend to be open (Gustilo III
A–C), transverse or comminuted

8. 3. Stability of the fracture
Consider whether it will displace if weight
bearing is allowed. Long oblique fractures
tend to shorten; those with a butterfly
fragment tend to angulate towards the
butterfly. Severely comminuted fractures are
the least stable of all, and the most likely to
need mechanical fixation

9. 4. Degree of contamination
In open fractures this is an important
additional variable

10. IC1 No skin lesion
IC2 No skin laceration but contusion
IC3 Circumscribed degloving
IC4 Extensive, closed degloving
IC5 Necrosis from contusion

11.  The limb should be carefully examined for
signs of soft-tissue damage: bruising, severe
swelling, crushing or tenting of the skin, an
open wound, circulatory changes, weak or
absent pulses, diminution or loss of
sensation and inability to move the toes. Any
deformity should be noted before splinting
the limb.
 Always be on the alert for signs of an
impending compartment syndrome

12.  X-ray 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 and
displacement are recorded
 Spiral fractures without comminution are low
energy injuries
 Transverse, short oblique and comminuted
fractures, especially if displaced or associated
with a fibula # at a similar level, are high
energy injuries

13. (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 weightbearing (loading
promotes healing);
(5) To start joint movements as soon as
possible.

14.  Most can be treated by non-operative
methods
 Undisplaced or minimally displaced #; a full-
length cast from upper thigh to metatarsal
necks is applied with the knee slightly flexed
and the ankle at a right angle
 Displacement of the fibular fracture, unless it
involves the ankle joint, is unimportant and
can be ignored.

15.  If the fracture is displaced, it is reduced
under GA with x-ray control
 Apposition need not be complete but
alignment must be near-perfect (no more
than 7 degrees of angulation) and rotation
absolutely perfect. A full-length cast is
applied as for undisplaced fractures (note,
however, that if placing the ankle at 0
degrees causes the fracture to displace, a few
degrees of equinus are acceptable)

16.  The position is checked by x-ray; minor
degrees of angulation can still be corrected
by making a transverse cut in the plaster and
wedging it into a better position
 Then observation for 48-72 hrs
 If there is excessive swelling, the cast is split
 Then discharged and allowed to bear minimal
weight with the aid of crutches

17.  The immediate application of plaster may be
unwise if skin viability is doubtful, in which
case a few days on skeletal traction is useful
as a preliminary measure
 A change from an above- to a below-the-
knee cast is possible around 4–6 weeks, when
the fracture becomes ‘sticky’. 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

18.  If follow-up x-rays show unsatisfactory
fracture alignment
 Unstable #s
 Open #s

19. Closed intra medullary nailing
 method of choice for internal fixation
 a guide-wire, a nail, transverse locking
screws
 For diaphyseal fractures, union can be
expected in over 95% of cases.
 However, the method is less suitable for
fractures near the bone ends

20. Plate fixation
 Best for metaphyseal fractures that are
unsuitable for nailing
 Also sometimes used for unstable tibial shaft
fractures in children
 Full weightbearing will need to be deferred
until some callus formation is evident on
xray, usually at 6–8 weeks.

21. External fixation
 An alternative to closed nailing
 Partial weightbearing is permitted from the
start and the external fixator can be replaced
by a functional brace once there are signs of
union

22.  First check for surrounding soft tissue and
bone viability
 Transverse fractures are usually stable after
reduction; they can be treated ‘closed’
 Comminuted and segmental fractures, those
associated with bone loss, and indeed any
high-energy fracture that is inherently
unstable, require early surgical stabilization

23.  For closed #s, external fixation and closed
nailing are equally suitable
 For open #s, the use of internal fixation has
to be accompanied by debridement and
prompt cover of the exposed bone and
implant; alternatively, external fixation can be
used

24.  Each of your feet has 26 bones, 33 joints, and
more than 100 tendons, muscles, and
ligaments

26.  Most common of all sports related injuries,
accounting for over 25% of cases
 In more than 75% of cases it is the lateral
ligament complex that is injured, in particular
the anterior talofibular and calcaneofibular
ligaments
 Medial ligament injuries are usually
associated with a fracture or joint injury.

27.  They are 3 ligaments that resist inversion of the
ankle joint
 They run from the lateral malleolus of
the fibula to the talus and calcaneus
 Anterior talofibular ligament (ATFL)
◦ anterior component
◦ arises from distal fibula; inserts on the lateral talus
 Calcaneofibular ligament
◦ middle component
◦ arises from distal fibula; inserts on the lateral calcaneus
 Posterior talofibular ligament (PTFL)
◦ posterior component
◦ arises from distal fibular; inserts on the posterior talus

29.  Attaches the medial malleolus to multiple
tarsal bones
 The ligament is composed of two layers;
 The superficial layer has variable attachments
and crosses two joints while. Has 4 ligaments
 The deep layer has talar attachments and
crosses one joint. It is intra-articular and has
2 ligaments

30.  It occurs due to eversion and/or pronation
injury, or can be associated with lateral ankle
fractures
 About 15% are ass/c ankle #

31. (1) Pain around the malleolus;
(2) Inability to take weight on the ankle
immediately after the injury;
(3) Inability to take four steps in the Emergency
Department;
(4) Bone tenderness at the posterior edge or tip
of the medial or lateral malleolus or the base
of the fifth metatarsal bone
 Anteroposterior, lateral and ‘mortise’ (30-
degree oblique) views are done

32. P – protection; crutches, splint or brace
R – rest;
I – ice; for 20min every 2hours and after any
activity
C - compression
E – elevation
R – rehabilitation; supported return to function
 Continued for 1–3 weeks depending on the
severity of the injury and the response to
treatment
 Use of NSAIDs oral/topical for pain management

33.  If no impovement after 2weeks, further review
and investigation are called for
 Persistent problems at 12 weeks after injury,
despite physiotherapy, may signal the need for
operative treatment (ORIF)
 Postoperatively the ankle is immobilized in
eversion for 2 weeks; a below-knee cast is then
applied for another 4 weeks, during which time
the patient can bear weight
 Thereafter, a removable brace is worn (for 3
months) and exercises are encouraged. The brace
can be used from time to time for sports
activities

34.  Fractures and fracture dislocations of the
ankle are common
 Most are low-energy fractures of one or both
malleoli, usually caused by a twisting
mechanism
 Less common are the more severe fractures
involving the tibial plafond, the pilon
fractures, which are high-energy injuries
often caused by a fall from a height

35.  The patient stumbles and falls
 Usually the foot is anchored to the ground
while the body lunges forward
 The ankle is twisted and the talus tilts
and/or rotates forcibly in the mortise,
causing a low-energy fracture of one or both
malleoli, with or without associated injuries
of the ligaments

37.  The precise fracture pattern is determined by:
1) The position of the foot;
2) The direction of force at the moment of
injury
 Classification
a) Lauge-Hansen (1950)
b) Danis and Weber (Müller et al., 1991), which
focuses on the fibular fracture

42.  A transverse fracture of the fibula below the
tibiofibular syndesmosis
 Perhaps associated with an oblique or vertical
fracture of the medial malleolus; this is
almost certainly an adduction (or adduction
and internal rotation) injury

43.  An oblique fracture of the fibula in the
sagittal plane (better seen in the lateral xray)
at the level of the syndesmosis;
 Often there is also an avulsion injury on the
medial side (a torn deltoid ligament or # of
the medial malleolus)
 This is probably an external rotation injury
and it may be associated with a tear of the
anterior tibiofibular ligament

44.  Above the level of the syndesmosis, the
tibiofibular ligament and part of the
interosseous membrane must have been torn
 This is due to severe abduction or a
combination of abduction and external
rotation
 Associated injuries are an avulsion # of the
medial malleolus (or rupture of the medial
collateral ligament), a posterior malleolar
fracture and diastasis of the tibiofibular joint

45.  The patient usually presents with a history of
a twisting injury, usually with the ankle going
into inversion, followed by immediate pain,
swelling and difficulty weightbearing
 Bruising often comes out soon after injury
 The site of tenderness is important; if both
the medial and lateral sides are tender, a
double injury (bony or ligamentous) must be
suspected

46.  At least 3 views are needed: AP, lateral and a
30-degree oblique ‘mortise’ view
 The level of the fibula # is often best seen in
the lateral view
 Diastasis may not be appreciated without the
mortise view
 Further x-rays may be needed to exclude a
proximal fibular fracture

47.  Swelling is usually rapid and severe
 Ankle fractures are often unstable
 Look for clues to the invisible ligament injury
a) Widening of the tibiofibular space
b) Asymmetry of the talotibial space
c) Widening of the medial joint space, or
d) Tilting of the talus

48. (1) The fibula must be restored to its full length
(2) The talus must sit squarely in the mortise,
with the talar and tibial articular surfaces
parallel;
(3) The medial joint space must be restored to
its normal width, i.e. the same width as the
tibio-talar space (about 4mm);
(4) Oblique x-rays must show that there is no
tibiofibular diastasis

49.  An isolated, undisplaced Danis–Weber type A
fracture is stable and will need minimal
splintage, a firm bandage or stirrup brace is
applied
 Undisplaced type B fractures; a below-knee
cast is applied with the ankle in the
anatomical position (+/- an overboot). Pretty
unstable, x-ray after 2 weeks to confirm that
the # remains undisplaced. The cast can
usually be discarded after 6–8 weeks, then
physio

50.  Reduction ASAP
 Indications for ORIF;
1) All fracture-dislocations
2) All type C #s
3) Trimalleolar #s
4) Talar shift or tilt
5) Failure to achieve or maintain closed
reduction

51.  NB; A trimalleolar fracture is a # of the ankle
that involves the lateral malleolus, the medial
malleolus, and the distal posterior aspect of
the tibia, which can be termed the posterior
malleolus

53.  Internal fixation; plate and screws or tension-
band wiring can be used. After ORIF
movements should be regained before
applying a below-knee plaster cast
 Postoperatively a ‘walking cast’ or removable
splintage boot is applied for 6 weeks
 Prognosis depend upon anatomic reduction
 High incidence of post-traumatic arthritis

54. EARLY
 Vascular injury
 Wound breakdown and infection
LATE
 Incomplete reduction
 Non-union
 Joint stiffness (when the plaster is removed,
he or she must, until circulatory control is
regained, wear a crepe bandage and elevate
the leg whenever it is not being used actively)

55.  Algodystrophy
 Osteoarthritis (Malunion and/or incomplete
reduction may lead to secondary
osteoarthritis in later years)

56.  Is a fracture of the distal part of the tibia,
involving its articular surface at the ankle
joint
 Occurs when a large force drives the talus
upwards against the tibial plafond, like a
pestle (pilon) being struck into a mortar
 Damage to the articular cartilage and the
subchondral bone may be broken into several
pieces; in severe cases, the comminution
extends some way up the shaft of the tibia

59.  Control of soft tissue swelling is a priority;
this is best achieved either by elevation and
applying an external fixator across the ankle
joint
 It may take 2– 3 weeks before the soft tissues
improve
 Once the skin has recovered, an open
reduction and fixation with plates and screws
(usually with bone grafting) may be possible

60.  The bones in the foot may be broken in many ways
including direct blows, crush injuries, falls and
overuse or stress
 Initial treatment may include RICE (rest, ice,
compression, elevation). Rest may include the use
of crutches to limit weight bearing
 X-rays often help make the dx but bone scan or CT
may be needed to help visualize the injury
 Rx of foot #s depend upon which bone is broken
but many #s are treated with a compression
dressing, a stiff- soled shoe, and weight bearing as
tolerated
 Some foot fractures require surgery to repair the
damage
 Complications of foot fractures include non-union
at the fracture site, arthritis if a joint is involved,
and infection if the skin is broken