eMedicine Specialties > Orthopedic Surgery > Knee

Tibial Shaft Fractures

Author: Brian K Konowalchuk, MD, Staff Physician, Department of Orthopedic Surgery, University of Minnesota College of Medicine
Coauthor(s): Nicholas J Wills, MD, Fellow, Twin Cities Spine Center; Brian Tollefson, MD, Flight Surgeon, United States Air Force; Marc Swiontkowski, MD, Chair, Professor, Department of Orthopedic Surgery, University of Minnesota at Minneapolis
Contributor Information and Disclosures

Updated: May 15, 2009

Introduction

An understanding of the diagnosis and treatment of tibial shaft fractures is of importance to primary care physicians and orthopedic surgeons alike. Often, the primary care provider first comes into contact with tibial shaft fractures and must make the diagnosis and early treatment decisions. High-speed lifestyles with motor vehicles, snowmobiles, and motorcycles, as well as the growing popularity of extreme sports, contribute to the increasing occurrence of tibial shaft fractures in today's society. In fact, the tibia is currently the most commonly fractured long bone in the body.

History of the Procedure

Plating tibial shaft fractures was the treatment of choice 2-3 decades ago. Intramedullary nailing and external fixation have replaced fracture plating because they are associated with decreased technical difficulty, lower infection rates, and less damage to local soft tissues (see Treatment, Intraoperative details, below).

Problem

The tibia is the most commonly fractured long bone in the body. Tibial shaft fractures are often the result of high-speed trauma but can also be insidious in onset, such as stress fractures in active individuals. During the initial evaluation, the patient with a tibial shaft fracture should be evaluated carefully for open wounds at the fracture site, neurovascular sufficiency, and elevated compartment pressures. Abnormalities in any of these areas constitute a surgical emergency.

Frequency

The tibia is currently the most commonly fractured long bone in the body. Alho et al have reported an annual incidence of 2 tibial shaft fractures per 1000 individuals.¹ The average age of patients with tibial shaft fractures is approximately 37 years, and teenage males are reported to have the highest incidence.²

Etiology

In the etiology of tibial fractures, high-speed trauma is paramount. In areas where people drive cars at high speeds and engage in activities with high potential for leg trauma (eg, skiing, soccer), the number of tibial fractures seen in the emergency department is high. While a direct blow to the tibia is the most common cause, countless other etiologies for tibial shaft fractures are encountered. Two of the most prevalent are falls or jumps from significant height and gunshot wounds to the lower leg.

Presentation

Patients with tibial shaft fractures report pain of varying degrees, but pain is usually severe. An inability to bear weight on the affected leg and a visible malformation of the leg are often present. Partial fractures may be less characteristic in presentation. The evaluating physician should always keep tibial fracture as part of the differential diagnosis after trauma, especially in a patient with an altered mental status who cannot provide a reliable history.

If the patient's symptoms stem from a stress fracture, the patient may reveal a recent change in lifestyle or an increase in physical activity. The pain is worse with weightbearing exercise and improves with rest. A classic presentation is an athlete who did not participate in conditioning work during summer vacation and presents to the physician's office 2 weeks after beginning vigorous training in a fall sport.³

Whatever the presentation, taking a complete history and performing a thorough physical examination are important. The history should include the patient's description of the events that brought him or her to the office. Important details to obtain from the patient include exactly what the patient was doing at the time of the injury, the amount of time that has passed since the injury occurred, a description of pain, any associated paresthesias or numbness, and a history of previous conditions that predispose to this injury or complicate surgery.

During the physical examination, the physician should not focus just on the leg, because concomitant injury is common with tibial fractures. After the other aspects of the examination have been addressed, the physician should specifically attempt to assess the neurovascular status of the patient's injured leg. The results of these examinations are important because their outcomes determine the emergent level of the situation and dictate which surgical specialists must be consulted. The overlying skin should also be examined, with particular care taken in assessing any open wounds or color changes that may indicate a more serious injury.

Classification and nomenclature

Classifications for fractures are useful for consistent communication between physicians. They have been used to predict probability of fracture union and, hence, as a guide for fracture treatment.^4,5,6,7,8,9 The classic classification for open fractures was described by Gustilo et al, as follows¹⁰ :

• Type I: The wound is clean and is shorter than 1 cm.
• Type II: The wound is longer than 1 cm and does not have extensive soft tissue damage.
• Type IIIa: This fracture type is a wound associated with extensive soft tissue damage usually larger than 10 cm with periosteal coverage. (Periosteum is the outermost layer of bone. It has a rich vascular supply and is important in bone growth and repair.) This fracture type also includes less traumatic fractures with increased chances of complications, such as gunshot wounds, farmyard injuries, and fractures requiring vascular repair.
• Type IIIb: This type is defined as bone with periosteal stripping that must be covered; these fractures nearly always require flap coverage.
• Type IIIc: This type of injury requires vascular repair.

The Orthopaedic Trauma Association has also adopted a system of classification for tibial shaft fracture. Their system, based on radiographic evaluation, divides fractures into 3 main categories (ie, A, B, and C).^11,12 Each category is divided into 3 groups, and each group is then further divided into 3 subgroups.

• Type A: This type encompasses unifocal fractures. The subgroups (A1, A2, and A3) are determined by the angle of the fracture. Spiral fractures make up group A1, oblique fractures are A2, and transverse fractures are classified as A3.
• Type B: These are wedge fractures. This category is then further divided into intact spiral wedge fractures, intact bending wedge fractures, and comminuted wedge fractures. These are classified as groups B1, B2, and B3, respectively. The 3 subgroups for both type A and type B fractures are determined by the extent of fibular injury and location of fracture with respect to the tibia.
• Type C: Complex fractures are classified as type C. C1 fractures are spiral wedge fractures. The number of fragments present determines C1 subgroups. C1 subgroups are assigned according to the number of fracture fragments present, with 2 or 3 fragments being classified as C1.1 or C1.2, respectively. Fractures with more than 3 fragments are classified as C1.3 in this system. Segmental fractures are type C2 fractures. C2 fractures, like C1 fractures, are subclassified by the number of fracture fragments present. Highly comminuted fractures are labeled as C2.3. The subdivisions in this group are classified according to the number of fracture fragments and the extent of comminution.

Indications

Most closed tibial fractures can be treated nonoperatively with good result, but infection risk and fracture stability must be considered. Littenberg et al reviewed 2372 case reports of closed tibial fractures and compared clinical outcomes of cast treatment, open reduction and internal fixation, and intramedullary rod therapy. They showed cast treatment to be associated with fewer superficial infections than open reduction and internal fixation. Open reduction and internal fixation, however, demonstrated a higher union rate at 20 weeks.¹³

In some instances, the fracture cannot be treated properly with nonoperative methods. Operative fixation is required when fractures are unstable. Instability is defined as greater than 1.5 cm of shortening, more than 5° of varus or valgus angulation, 10° of anterior or posterior angulation, and/or less than 50% translation while the leg is in a cast. Factors that contribute to instability are the degree of comminution, the presence of ipsilateral fibular fractures, and the location of the fracture along the tibia. The original presenting radiograph is useful because, often with cast or brace treatment, the original amount of shortening is what the fracture ultimately heals with; therefore, shortening greater than 1 cm is a relative indication for operative stabilization.

Relevant Anatomy

The leg is divided into 4 distinct fascial compartments. The compartmental anatomy can become extremely important during a traumatic situation in which internal bleeding in the leg can lead to a compartment syndrome.

The anterior compartment contains the dorsiflexors of the foot, including the tibialis anterior, extensor digitorum longus, extensor hallucis, and peroneus tertius. Also housed in the anterior compartment is the deep peroneal nerve. The major blood supply to the anterior compartment is from the anterior tibial artery and its associated vessels.

The lateral compartment contains the peroneus longus and brevis muscles, which primarily serve in eversion of the foot. The superficial peroneal nerve is contained in this compartment and innervates these 2 muscles.

The posterior aspect of the leg is divided into 2 compartments, superficial and deep. The deep compartment contains the plantarflexor muscles, including the tibialis posterior, flexor hallucis longus, and flexor digitorum longus. The peroneal and the posterior tibial arteries also course through this compartment with their corresponding veins. The superficial posterior compartment is the largest of the 4 compartments but contains only muscle. These plantarflexing muscles include the soleus, the gastrocnemius, and the plantaris.

Contraindications

Several contraindications to surgery are recognized for the treatment of tibial shaft fractures. All patients require a thorough preoperative evaluation and must be cleared for general anesthesia prior to any operation, including treatment of tibial shaft fractures. In cases of acute trauma, patients should be stabilized by the trauma team prior to fixation of a tibial shaft fracture. Incision and drainage of infected fracture sites often is indicated; however, hardware should never be placed into an infected wound. In cases in which infected hardware is removed, treat the infection with intravenous antibiotics and replace the hardware in a second surgery after the infection has been treated thoroughly.

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