Tibia and Fibula Fracture Treatment & Management

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.

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 vaccination should be updated, and appropriate antibiotics should be given in a timely manner. Some recommend antibiotics within 3 hours of the accident.^[5] 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

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.^[6]

Open fractures in pediatric patients have a significantly increased risk of developing compartment syndrome.^[6]

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. See the images below.

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.

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.