Fractures of tibia and fibula
Tibial shaft fracture
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Most common long bone fractures
Isolated tibial fracture – 23 %
Both tibia and fibular fractures – 77 %
77 % of tibial fractures are closed
23 % are open fractures
Features of tibial fractures
• Most common of all long bone fractures
• Subcutaneous and hence incidence of
open fracture is high
• Distal one third has a deficient blood
supply and a fracture in this area is known
for delayed union and nonunion
• Bounded above and below by hinge joints
• Respond well to conservative treatment
• Only 5 % need operative treatment
Mechanism of injury
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RTA – 37 %
Sports – 25 %
Assaults – 5 %
Falls – rest
Direct voilence due to RTA (common ) ,
fall , assault , etc. Open fractures are
common
• Indirect voilence due to falls , twisting
force due to sports injuries .
Classification ( Ellis )
Grades of severity
1
minor
2
moderate
3
major
Features
• Undisplaced
• Not angulated
• Minor comminution
• Minor open fracture
• Total displacement
• Small degree of comminution
• Minor open wound
• Complete displacement
• Major comminution
• Major open fracture
Tscherne Classification
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Grade
0
Soft Tissue Injury
(Superficial)
Absent or negligible
Soft Tissue Injury
(Deep)
Compartments
Absent or negligible
Soft and/or normal
Contusion from within
Soft and/or normal
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1
2
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Superficial abrasion
Deep contaminated abrasion
Significant contusion
.
3
.
Crushed skin, subcutaneous Crushed devitalized
avulsions
Muscle
Impending compartment
syndrome
.
Compartment syndrome
Clinical features
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Pain
Deformity
Investigation :
Acute cases : AP and Lateral view
Delayed cases : AP ,Lateral and oblique
view showing knee joint and ankle joints
Treatment
Conservative management : – Closed reduction under general anaesthesia
and a long leg cast application
Indication :
– Closed fractures
– Undisplaced fracture
– Low energy trauma
– Young adults
– # with minor or moderate displacements
Method of reduction
• Two methods of closed reduction :
1 . The patient is supine and limb held parallel to the table
, the # is reduced by traction and countertraction method
and a long leg cast is applied
Disadvantage : – Posterior angulation develops at the fracture site due to
the gravitational forces
2 . Commonly followed method :– Position : sitting or supine ( under anaesthesia)
– Patient is brought to the edge of the table and both the
legs are kept dangling .
– Holds the leg of the patient and manipulates the fracture
and a long leg cast is applied
Criteria of acceptable reduction
– Ankle and knee joint surface should be parallel
– Acceptable varus or valgus angulation is 5 degree in AP
view
– Anterior or posterior angulation of 10 degree in the lateral
view
– Shortening of 5 – 7 mm is acceptable
Advantages :
– Traction and countertraction do not require an assistant
– Patient`s own weight of the leg provides traction through the
gravity
– Easy to compare with the normal leg regarding the accuracy
of closed reduction by looking at the control of rotation and
angle
Sarmiento`s total contact below knee cast
– After reduction of the fracture and application of a long leg
cast for 2 to 3 weeks , a total below knee cast which is
moulded around the tibial condyles and patella in the
fashion of patellar tendon bearing prosthesis is applied
(PTB casts or brace )
Advantages
– Allows early knee movements
– Ease of ambulation for
patients with bilateral fracture
– Decreases the incidence of
delay union and nonunion
Cont..
Functional braces ( allows both ankle and
knee joints )
Pins above and below the fracture:
• Indication :
• For moderate and severe fracture
• Unstable fracture
• Open fracture
Surgical treatment
– Open reduction and internal fixation
– Indication :
– Tibial fracture with vascular or neural injuries
– Segmental fractures
– Inadequate reduction
– Associated plafond fracture
Complications
– Delayed union (bone grafting )
– Nonunion (rigid internal fixation with compression
plating and bone grafting )
– Malunion ( osteotomy )
– Shortening
– Infection
– Compartmental syndromes
– Joint stiffness
– Refracture
– Fat embolism