eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Fracture, Tibia and Fibula

Jeffrey G Norvell, MD, Clinical Assistant Professor of Emergency Medicine, University of Kansas School of Medicine
Mark Steele, MD, Associate Dean for Truman Medical Center Programs, Professor, Department of Emergency Medicine, University of Missouri-Kansas City; Thomas M Cooper, MD, Resident Physician, Department of Family Medicine, Research Medical Center, Kansas City

Updated: Oct 1, 2009

Introduction

Background

Lower leg fractures include fractures of the tibia and fibula. Of these two bones, the tibia is the only weightbearing bone. Fractures of the tibia generally are associated with fibula fracture, because the force is transmitted along the interosseous membrane to the fibula.

The skin and subcutaneous tissue are very thin over the anterior and medial tibia and as a result of this, a significant number of fractures to the lower leg are open. Even in closed fractures, the thin, soft tissue can become compromised. In contrast, the fibula is well covered by soft tissue over most of its course with the exception of the lateral malleolus.

The tibia and fibula articulate at the proximal tibia-fibular syndesmosis.

Fractures of the tibia can involve the tibial plateau, tibial tubercle, tibial eminence, proximal tibia, tibial shaft, and tibial plafond.

Shown is an intra-articular fracture of the medial condyle of the tibial plateau.

Frequency

United States

Fractures of the tibia are the most common long bone fractures. The annual incidence of open fractures of long bones is estimated to be 11.5 per 100,000 persons, with 40% occurring in the lower limb.¹ The most common fracture of the lower limb occurs at the tibial diaphysis.² Isolated midshaft or proximal fibula fractures are uncommon.

Mortality/Morbidity

• Limb loss may occur as a result of severe soft-tissue trauma, neurovascular compromise, popliteal artery injury, compartment syndrome, or infection such as gangrene or osteomyelitis. Popliteal artery injury is a particularly serious injury that threatens the limb and is easily overlooked.
• The common peroneal nerve crosses the fibular neck. This nerve is susceptible to injury from a fibular neck fracture, the pressure of a splint, or during surgical repair. This can result in foot drop and sensation abnormalities.
• Delayed union, nonunion, and arthritis may occur. Among the long bones, the tibia is the most common site of fracture nonunion.

Age

Toddler fracture (distal spiral fracture of the tibia) is most common in children aged 9 months to 3 years.

Clinical

History

• Mechanisms of injury for tibia-fibula fractures can be divided into 2 categories:
  • Low-energy injuries such as ground levels falls and athletic injuries
  • High-energy injuries such as motor vehicle injuries, pedestrians struck by motor vehicles, and gunshot wounds
• Patient may report a history of direct (motor vehicle crash or axial loading) or indirect (twisting) trauma.
• Patient may complain of pain, swelling, and inability to ambulate with tibia fracture.
• Ambulation is possible with isolated fibula fracture.
• Tibial plateau fractures occur from axial loading with valgus or varus forces, such as in a fall from a height or collision with the bumper of a car. The lateral tibial plateau is fractured more frequently than the medial plateau.
• Tibial tubercle fractures usually occur during jumping activities such as basketball, diving, football, and gymnastics. This type of fracture is more common in adolescents than in adults.
• Tibial eminence fractures occur with trauma to the distal femur while the knee is flexed such as falling off of a bicycle. Another mechanism for this fracture is hyperextension. Tibial eminence avulsion fractures occur most often in children aged 8-14 years but can occur in a skeletally mature patient.
• Tibial shaft fractures usually present with a history of major trauma. An exception to this is a toddler's fracture, which is a spiral fracture that occurs with minor trauma in children who are learning to walk.
• Tibial plafond fractures refer to fractures involving the weightbearing surface of the distal tibia. This type of injury usually results from high-energy axial loading but may result from lower-energy rotation forces.
• Maisonneuve fractures are rare and considered unstable ankle injuries. This type of injury usually involves a pronation-external rotation force.
• Stress fractures of the tibia and fibula may occur as a result of repetitive submaximal stresses that may occur while participating in athletics. The history may reveal some change in training routine.

Physical

• When examining a patient for a lower leg fracture one should first examine the patient for edema, ecchymosis, and point tenderness. Gross deformities should be noted and splinted. A careful neurovascular assessment should be performed, and an emergent fracture reduction should be performed if neurovascular deficits are present.
• A careful examination should be performed for open wounds. Open fractures require antibiotics and an emergent orthopedic consultation.
• Tibial plateau fractures often present with a knee effusion. Tenderness will be present along the medial or lateral tibial plateau. Approximately 20% of tibial plateau fractures are associated with ligamentous injuries.

Tibial plateau fractures. Line drawings of Schatzker types I, II, and III tibial plateau fractures. Type I consists of a wedge fracture of the lateral tibial plateau, produced by low-force injuries. Type II combines the wedge fracture of the lateral plateau with depression of the lateral plateau. Type III fractures are classified as those with depression of the lateral plateau but no associated wedge fracture.

Tibial plateau fractures. Line drawings of Schatzker types IV, V, and VI tibial plateau fractures. Type IV is similar to type I fracture, except that it involves the medial tibial plateau as opposed to the lateral plateau. Greater force is required to produce this type of injury. Type V fractures are termed bicondylar and demonstrate wedge fractures of both the medial and lateral tibial plateaus. Finally, type VI fractures consist of a type V fracture along with a fracture of the underlying diaphysis and/or metaphysis.

• Tibial tubercle fracture will have tenderness over the anterior tibia approximately 3 cm distal to the articular surface. In more severe tibial tubercle fractures, full extension of the knee is not possible. The patella may be high riding.
• Tibial eminence fracture may present with a knee effusion and pain and may represent an avulsion of the tibial attachment of the anterior cruciate ligament.
• Tibial shaft fractures are the most common long bone fracture and usually involve the fibula as well. Tibial fractures present with localized pain, swelling, and deformity.
• Maisonneuve fractures involve a fracture of the proximal fibula in association with a fractured medial malleolus (or injured deltoid ligament) and diastasis of the distal tibiofibular syndesmosis. Patients present with proximal fibular pain in addition to medial ankle pain. This is an unstable ankle injury.
• Tibial plafond fractures will have tenderness along the distal tibial and may have severely decreased range of motion in the ankle.

Causes

• Direct forces such as those caused by falls and MVCs
• Indirect or rotational forces

Differential Diagnoses

Other Problems to Be Considered

Shin splints
Stress fracture

Workup

Imaging Studies

• Perform radiographs of the knee, tibia/fibula, and ankle as indicated.

Radiograph demonstrating a displaced tibial shaft fracture with associated fibula fracture.

• Computed tomography
  • Computed tomography is indicated for severely injured patients if unable to get diagnostically sufficient radiographs of the knee. 
  • In patients with tibial plateau fractures and tibial plafond fractures, computed tomography can help further evaluate the extent of the fracture.

Tibial plateau fractures. CT image through the tibial plateau shows a fracture of the posterior aspect of the lateral tibial plateau, which is the source of the lipohemarthrosis.

Tibial plateau fractures. Coronal reformatted CT. This image demonstrates a bicondylar fracture of the tibial plateau along with a fracture of the tibial diaphysis, a Schatzker VI fracture. Note the articular incongruity.

• In tibial plateau fractures, radiographs may underestimate the degree of articular depression when compared with computed tomography. This is important because articular depression of greater than 3 mm may be considered for surgery.
• For stress fractures
  • Radiographic findings are usually seen after 2-8 weeks of symptoms, and radiographs may not be very sensitive during the early stages of symptoms.
  • Radionucleotide scanning and MRI are more sensitive in diagnosing stress fractures and stress injuries than radiographs.

Treatment

Prehospital Care

• Address airway, breathing, and circulation.
• Check and document neurovascular status.
• Apply sterile dressing to open wounds.
• Apply gentle traction to reduce gross deformities; splint the extremity.
• Administer parenteral analgesics for an isolated extremity injury in a hemodynamically stable patient.

Emergency Department Care

• Parenteral analgesia should be administered when appropriate. Although management of pain has improved, pain due to long bone fractures is notably undertreated in the emergency department.³
• Open fractures must be diagnosed and treated appropriately (also see Tibia Fractures, Open). Tetanus should be updated and appropriate antibiotics given. This should involve antistaphylococcal coverage and consideration of an aminoglycoside for more severe wounds. Orthopedics should be consulted for emergent debridement and wound care. Fractures with tissue at risk for opening should be protected to prevent further morbidity.
• Compartment syndrome can develop in fractures of the lower leg.
  • Signs of compartment syndrome include crescendo symptoms, pain with passive movement of involved muscles, paresthesias, and pallor, and a very late finding is pulselessness. Increased compartment pressure is present during compartment syndrome; therefore, external palpation frequently aids in the diagnosis. However, a soft extremity on palpation does not rule out compartment syndrome.
  • Serial examinations should be performed on patients with high-risk injuries or patients with equivocal symptoms.
  • If compartment syndrome is suspected, obtain an emergent orthopedic consult and measure compartment pressures. Compartment syndrome must be treated promptly with an emergency surgical fasciotomy. If untreated, the increased compartment pressures can cause ischemia and necrosis of the structures within that facial compartment and permanent disability.
  • Risk factors for compartment syndrome of the lower leg include tibial diaphysis fracture, soft-tissue injury, and crush injury.⁴
  • Open fractures in pediatric patients have a significantly increased risk of developing compartment syndrome.⁴
• Tibial plateau fracture
  • Immobilize nondisplaced fractures and have the patient remain nonweightbearing.
  • Obtain an orthopedic consultation for displaced (depressed) fractures, which require open reduction and internal fixation. Articular depression of greater than 3 mm may be considered for surgery.

Type II tibial plateau fracture in a young active adult with good bone stock treated with percutaneous elevation and cannulated cancellous screw fixation without bone grafting.

Type III tibial plateau fracture with central depression in an elderly person treated surgically using percutaneous elevation, bone grafting, and cancellous screw fixation.

• Tibial eminence fracture
  • For nondisplaced fractures (and stable knee joint), immobilize the knee.
  • Obtain an orthopedic consultation for an unstable knee, or displaced fracture for possible surgical fixation.
• Tibial tubercle fracture
  • For nondisplaced fractures, immobilize the knee.
  • Obtain an orthopedic consultation for a displaced fracture to consider open reduction and internal fixation.
• Proximal tibia fractures
  • Intra-articular fractures require reduction and internal fixation.
  • Other methods to surgically repair proximal tibia fractures include external fixation, plating, and intramedullary nailing.
  • Closed treatment involves reduction and the placement of a long leg cast. Intact extensor mechanisms can make it difficult to maintain good fracture alignment.
• Tibial shaft fractures that are closed may be treated with cast immobilization if alignment is good or with intramedullary nailing.
• Isolated midshaft or proximal fibula fracture
  • Immobilization in a long leg cast generally is not required. Recommend a few days without weightbearing activity until swelling resolves, followed by weightbearing activity as tolerated.
  • Short leg walking cast usually is not required; however, some orthopedists may prefer a short leg walking cast or cam walker with weight bearing.
• Tibia and fibula stress fractures
  • The keystone of treating stress fractures is the temporary cessation of the offending activity.
  • Crutches may be used initially to allow the patient to be non – weight-bearing.

Consultations

• Tibia and fibula fractures
  • Obtain emergent orthopedic consultation for open fractures.
  • Consultation is also generally indicated for closed fractures.
• Emergent consultation is needed in suspected compartment syndrome.
• Advise patient to obtain orthopedic follow-up care of isolated fibula fractures.

Medication

Drugs used to treat fractures include nonsteroidal anti-inflammatory agents and analgesics. In addition, administer proper antibiotics and tetanus prophylaxis for open fractures.

Nonsteroidal anti-inflammatory agents (NSAIDs)

These drugs have analgesic and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may involve inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.

Ibuprofen (Ibuprin, Advil, Motrin)

Usually DOC for treatment of mild to moderately severe pain, if no contraindications. Inhibits inflammatory reactions and pain, probably by decreasing activity of enzyme cyclooxygenase, which decreases prostaglandin synthesis.

Dosing

Adult

200-400 mg PO q4-6h prn; not to exceed 3.2 g/d

Pediatric

<6 months: Not established
6 months to 12 years: 20-40 mg/kg/d PO divided tid/qid
>12 years: Administer as in adults

Interactions

Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants—monitor PT closely and instruct patients to watch for signs of bleeding; may increase risk of methotrexate toxicity; may increase phenytoin levels

Contraindications

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy

Naproxen (Anaprox, Naprelan, Naprosyn)

Used for relief of mild to moderately severe pain. Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, decreasing prostaglandin synthesis.

Dosing

Adult

500 mg PO followed by 250 mg q6-8h; not to exceed 1.25 g/d

Pediatric

<2 years: Not established
>2 years: 5-7 mg/kg/dose PO q8-12h

Interactions

Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants—monitor PT closely and instruct patients to watch for signs of bleeding; may increase risk of methotrexate toxicity; may increase phenytoin levels

Contraindications

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug

Analgesics

Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained fractures.

Acetaminophen (Tylenol, Panadol, aspirin-free Anacin)

DOC for treatment of pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or taking oral anticoagulants.

Dosing

Adult

325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d

Pediatric

<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses in 24 h

Interactions

Rifampin can reduce analgesic effects; barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity

Contraindications

Documented hypersensitivity; known G-6-P deficiency

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Hepatotoxicity possible in chronic alcoholics following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products and combined use with these products may result in cumulative acetaminophen doses exceeding recommended maximum dose

Acetaminophen and codeine (Tylenol #3)

Drug combination indicated for treatment of mild to moderately severe pain.

Dosing

Adult

30-60 mg/dose based on codeine content PO q4-6h or 1-2 tab q4h; not to exceed 12 tab/d

Pediatric

0.5-1 mg/kg/dose based on codeine content PO q4-6h; 10-15 mg/kg/dose based on acetaminophen content; not to exceed 2.6 g/d of acetaminophen

Interactions

CNS depressants or tricyclic antidepressants increase toxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in patients dependent on opiates since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction

Hydrocodone bitartrate and acetaminophen (Vicodin ES)

Drug combination indicated for relief of moderately severe to severe pain.

Dosing

Adult

1-2 tab/cap PO q4-6h prn

Pediatric

<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d of acetaminophen
>12 years: 750 mg acetaminophen q4h; single dose not to exceed 10 mg of hydrocodone bitartrate; not to exceed 5 doses/d

Interactions

Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants increase toxicity

Contraindications

Documented hypersensitivity; high-altitude cerebral edema; elevated intracranial pressure

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Tablets contain metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction

Oxycodone and acetaminophen (Percocet)

Drug combination indicated for relief of moderately severe to severe pain. DOC for aspirin-hypersensitive patients.

Dosing

Adult

1-2 tab/cap PO q4-6h prn

Pediatric

0.05-0.15 mg/kg/dose oxycodone PO q4-6h prn; not to exceed 5 mg/dose oxycodone

Interactions

Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants increase toxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Duration of action may increase in elderly persons; be aware of total daily dose of acetaminophen patient is receiving; do not exceed 4000 mg/24 h of acetaminophen; higher doses may cause liver toxicity

Morphine sulfate (Duramorph, Astramorph, MS Contin)

DOC for narcotic analgesia because of its reliable and predictable effects, safety, and ease of reversibility with naloxone. Administered IV, may be dosed in a number of ways and commonly is titrated until desired effect obtained.

Dosing

Adult

Starting dose: 0.1 mg/kg IV/IM/SC
Maintenance dose: 5-20 mg/70 kg IV/IM/SC q4h
Relatively hypovolemic patients: Start with 2 mg IV/IM/SC, and reassess hemodynamic effects of dose

Pediatric

Neonates: 0.05-0.2 mg/kg IV/IM/SC q2-4h prn
Children: 0.1-0.2 mg/kg IV/IM/SC q2-4h prn

Interactions

Phenothiazines may antagonize analgesic effects; tricyclic antidepressants, MAOIs, and other CNS depressants may potentiate adverse effects

Contraindications

Documented hypersensitivity; hypotension; potentially compromised airway in which establishing rapid airway control would be difficult

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Avoid in hypotension, respiratory depression, nausea, emesis, constipation, and urinary retention; caution in atrial flutter and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate

Immunoglobulins

Patients who may not have been immunized against Clostridium tetani products should receive tetanus immune globulin.

Tetanus immune globulin (Hyper-Tet)

Used for passive immunization of any person with a wound that may be contaminated with tetanus spores.

Dosing

Adult

Prophylaxis: 250-500 U IM in opposite extremity to tetanus toxoid
Clinical tetanus: 3,000-10,000 U IM

Pediatric

Prophylaxis: 250 U IM in opposite extremity to tetanus toxoid
Clinical tetanus: Administer as in adults

Interactions

None reported

Contraindications

Since antibodies in globulin preparation may interfere with immune response to vaccination, do not administer within 3 mo of live virus immune globulin administration; may be necessary to revaccinate persons who received immune globulin shortly after live virus vaccination

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Persons with isolated IgA deficiency have potential for developing antibodies to IgA and could have anaphylactic reactions to subsequent administration of blood products that contain IgA; do not perform skin testing since intradermal injection of concentrated gamma globulin may cause localized area of inflammation and can be misinterpreted, causing medication to be withheld from patient not allergic to this material; true allergic responses to human gamma globulin given in prescribed IM manner are extremely rare; do not admix with other medications since usually incompatible

Toxoids

This agent is used for tetanus immunization. Booster injection in previously immunized individuals is recommended to prevent this potentially lethal syndrome.

Tetanus toxoid

Used to induce active immunity against tetanus in selected patients. Tetanus and diphtheria toxoids are immunizing AOC for most adults and children >7 y. Necessary to administer booster doses to maintain tetanus immunity throughout life.
Pregnant patients should receive only tetanus toxoid, not a diphtheria antigen-containing product.
In children and adults, may administer into the deltoid or midlateral thigh muscles. In infants, preferred site of administration is midthigh laterally.

Dosing

Adult

Primary immunization: 0.5 mL IM; give 2 injections 4-8 wk apart and a third dose 6-12 mo after second injection
Booster dose: 0.5 mL q10y

Pediatric

Administer as in adults

Interactions

Patients receiving immunosuppressants, including corticosteroids or radiation therapy, may remain susceptible despite immunization due to poor immune response; cimetidine may enhance or augment delayed-hypersensitivity responses to skin-test antigens; avoid concurrent use of chloramphenicol since it may impair amnestic response to tetanus toxoid; concurrent use of tetanus immune globulin may delay development of active immunity by several days (interaction is nevertheless clinically insignificant and does not preclude its concurrent use)

Contraindications

Documented hypersensitivity; history of any type of neurological symptoms or signs following administration of this product
FDA recommends that elective tetanus immunization be deferred during any outbreak of poliomyelitis because tetanus toxoid injections are important cause of provocative poliomyelitis

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Do not use to treat actual tetanus infections, or for immediate prophylaxis of unimmunized individuals (use instead tetanus antitoxin, preferably human tetanus immune globulin); diminished antibody response to active immunization may be seen in patients receiving immunosuppressive therapy; better to defer primary diphtheria immunization until immunosuppressive therapy discontinued; routine immunization of symptomatic and asymptomatic HIV-infected persons recommended

Follow-up

Further Inpatient Care

• Tibia and fibula fractures
  • Open fractures require debridement and irrigation in operating room.
  • Inpatient admission may be advised to observe development of compartment syndrome.
  • Continuous compartment pressure monitoring in asymptomatic patients with tibia fractures is not recommended.⁵

Further Outpatient Care

• Patient should see primary care physician or be referred to an orthopedic surgeon within 1 week for further evaluation and treatment of isolated fibula fractures.

Transfer

• Transfer is reasonable if approved by patient (for insurance or other reasons) or if a hospital bed or an orthopedic surgeon is unavailable at the transferring institution.

Complications

• Neurovascular compromise
• Compartment syndrome
• Peroneal nerve injury
• Infection
• Gangrene
• Osteomyelitis
• Delayed union, nonunion, or malunion
• Amputation or skin loss
• Posttraumatic arthritis
• Fat embolism

Prognosis

• Tibia and fibula fractures
  • Prognosis is generally good yet is dependent on degree of soft-tissue injury and bony comminution.
  • Prognosis is good for isolated fibula fractures.

Patient Education

• For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education article Broken Leg.

Miscellaneous

Medicolegal Pitfalls

• Failure to recognize and treat associated life-threatening injuries
• Failure to consider ankle injury with proximal fibula fracture (Maisonneuve fracture)
• Failure to recognize open injuries and obtain timely orthopedic consultation
• Failure to recognize compartment syndrome

Special Concerns

• Toddler fracture
  • Typically, this type of fracture is nondisplaced spiral fracture of distal tibia unrelated to child abuse.
  • Midshaft tibial fractures, unrelated to a history of major trauma, should alert emergency physician to possibility of child abuse.

Multimedia

Media file 1: Standard anteroposterior radiograph of a tibial shaft fracture with intramedullary nail fixation. Note the commonly associated fibular fracture that is also apparent.

Media file 2: Radiograph demonstrating a displaced tibial shaft fracture with associated fibula fracture.

Media file 3: Type II tibial plateau fracture in a young active adult with good bone stock treated with percutaneous elevation and cannulated cancellous screw fixation without bone grafting.

Media file 4: Type III tibial plateau fracture with central depression in an elderly person treated surgically using percutaneous elevation, bone grafting, and cancellous screw fixation.

Media file 5: Shown is an intra-articular fracture of the medial condyle of the tibial plateau.

Media file 6: Tibial plateau fractures. Line drawings of Schatzker types I, II, and III tibial plateau fractures. Type I consists of a wedge fracture of the lateral tibial plateau, produced by low-force injuries. Type II combines the wedge fracture of the lateral plateau with depression of the lateral plateau. Type III fractures are classified as those with depression of the lateral plateau but no associated wedge fracture.

Media file 7: Tibial plateau fractures. Line drawings of Schatzker types IV, V, and VI tibial plateau fractures. Type IV is similar to type I fracture, except that it involves the medial tibial plateau as opposed to the lateral plateau. Greater force is required to produce this type of injury. Type V fractures are termed bicondylar and demonstrate wedge fractures of both the medial and lateral tibial plateaus. Finally, type VI fractures consist of a type V fracture along with a fracture of the underlying diaphysis and/or metaphysis.

Media file 8: Tibial plateau fractures. CT image through the tibial plateau shows a fracture of the posterior aspect of the lateral tibial plateau, which is the source of the lipohemarthrosis.

Media file 9: Tibial plateau fractures. Axial CT image through the tibial shows a fracture through the lateral tibial plateau with slight diastasis between the fragments. This is a Schatzker II injury.

Media file 10: Tibial plateau fractures. Coronal reformatted CT. This image demonstrates a bicondylar fracture of the tibial plateau along with a fracture of the tibial diaphysis, a Schatzker VI fracture. Note the articular incongruity.

Media file 11: Classification of tibial tuberosity fractures.

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Keywords

lower leg fracture, broken leg, long bone fracture, popliteal artery injury, compartment syndrome, gangrene, osteomyelitis, injury to the peroneal nerve, foot drop, delayed union, fracture nonunion, arthritis, toddler fracture, distal spiral fracture of tibia

Contributor Information and Disclosures

Author

Jeffrey G Norvell, MD, Clinical Assistant Professor of Emergency Medicine, University of Kansas School of Medicine
Jeffrey G Norvell, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Mark Steele, MD, Associate Dean for Truman Medical Center Programs, Professor, Department of Emergency Medicine, University of Missouri-Kansas City
Mark Steele, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Thomas M Cooper, MD, Resident Physician, Department of Family Medicine, Research Medical Center, Kansas City
Thomas M Cooper, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Association, and American Medical Student Association/Foundation
Disclosure: Nothing to disclose.

Medical Editor

Michelle Ervin, MD, Chair, Department of Emergency Medicine, Howard University Hospital
Michelle Ervin, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, National Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

David B Levy, DO, FACEP, FAAEM, Chairman, Department of Emergency Medicine, St Elizabeth Health Center; Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine
David B Levy, DO, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Informatics Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

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