High Yield Topics

Tibial Shaft Fracture

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Ovid: 5-Minute Orthopaedic Consult

Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.
Title: 5-Minute Orthopaedic Consult, 2nd Edition
> Table of Contents > Tibial Shaft Fracture

Tibial Shaft Fracture
Simon C. Mears MD, PhD
Michelle Cameron MD
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 (1).
    • Open fractures are classified by the system of Gustilo and Anderson (2).
Epidemiology
  • Can occur in any age group
  • In 1 study, 76% of fractures were closed (3).
Prevalence
Fractures occur most commonly in people <40 years old (4).
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 (5)
      • The cast is converted to a functional brace after 6–8 weeks (6).
    • 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 débridement
    • 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 (7).
    • 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 (8).
      • 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 (9,10).
    • Open fractures have lower nonunion and
      infection rates when treated with recombinant BMP-2 in addition to
      intramedullary nailing (11).
  • 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 prognosis (12).
  • 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 (13).
  • Open fractures have the worst prognosis and the highest incidence of complications (13).
  • Severe tibia fractures with major soft-tissue injuries have a poor prognosis (14).
  • Patients who smoke have a higher rate of nonunion than do nonsmokers (15).
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.
References
1. Müller
ME, Nazarian S, Koch P, et al. The Comprehensive Classification of
Fractures of Long Bones. Berlin: Springer-Verlag, 1990.
2. Gustilo
RB, Anderson JT. Prevention of infection in the treatment of one
thousand and twenty-five open fractures of long bones: Retrospective
and prospective analysis. J Bone Joint Surg 1976;58A:453–458.
3. Court-Brown CM, McBirnie J. The epidemiology of tibial fractures. J Bone Joint Surg 1995;77B:417–421.
4. Grutter R, Cordey J, Buhler M, et al. The epidemiology of diaphyseal fractures of the tibia. Injury 2000;31:C64–C67.
5. Schmidt AH, Finkemeier CG, Tornetta P, III. Treatment of closed tibial fractures. Instr Course Lect 2003;52:607–621.
6. Sarmiento A, Gersten LM, Sobol PA, et al. Tibial shaft fractures treated with functional braces. Experience with 780 fractures. J Bone Joint Surg 1989;71B:602–609.
7. Toivanen
JAK, Vaisto O, Kannus P, et al. Anterior knee pain after intramedullary
nailing of fractures of the tibial shaft. A prospective, randomized
study comparing two different nail-insertion techniques. J Bone Joint Surg 2002;84A:580–585.
8. Larsen
LB, Madsen JE, Hoiness PR, et al. Should insertion of intramedullary
nails for tibial fractures be with or without reaming? A prospective,
randomized study with 3.8 years’ follow-up. J Orthop Trauma 2004;18:144–149.
9. Kubiak
EN, Egol KA, Scher D, et al. Operative treatment of tibial fractures in
children: Are elastic stable intramedullary nails an improvement over
external fixation? J Bone Joint Surg 2005;87A:1761–1768.
10. Vallamshetla
VRP, De Silva U, Bache CE, et al. Flexible intramedullary nails for
unstable fractures of the tibia in children. An eight-year experience. J Bone Joint Surg 2006;88B:536–540.
11. Govender
S, Csimma C, Genant HK, et al. Recombinant human bone morphogenetic
protein-2 for treatment of open tibial fractures: A prospective,
controlled, randomized study of four hundred and fifty patients. J Bone Joint Surg 2002;84A:2123–2134.
12. Milner SA, Davis TRC, Muir KR, et al. Long-term outcome after tibial shaft fracture: Is malunion important? J Bone Joint Surg 2002;84A:971–980.
13. Audige
L, Griffin D, Bhandari M, et al. Path analysis of factors for delayed
healing and nonunion in 416 operatively treated tibial shaft fractures.
Clin Orthop Relat Res 2005;438:221–232.
14. MacKenzie
EJ, Bosse MJ, Pollak AN, et al. Long-term persistence of disability
following severe lower-limb trauma. Results of a seven-year follow-up. J Bone Joint Surg 2005;87A:1801–1809.
15. Harvey EJ, Agel J, Selznick HS, et al. Deleterious effect of smoking on healing of open tibia-shaft fractures. Am J Orthop 2002;31:518–521.
Additional Reading
Forster MC, Bruce ASW, Aster AS. Should the tibia be reamed when nailing? Injury 2005;36:439–444.
Mashru RP, Herman MJ, Pizzutillo PD. Tibial shaft fractures in children and adolescents. J Am Acad Orthop Surg 2005;13:345–352.
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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