Tibia and Fibula Fracture Treatment & Management
- Author: Jeffrey G Norvell, MD; Chief Editor: Rick Kulkarni, MD more...
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 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.
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
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.
Court-Brown CM, Rimmer S, Prakash U, McQueen MM. The epidemiology of open long bone fractures. Injury. Sep 1998;29(7):529-34. [Medline].
Howard M, Court-Brown CM. Epidemiology and management of open fractures of the lower limb. Br J Hosp Med. Jun 4-17 1997;57(11):582-7. [Medline].
Horwitz DS, Kubiak EN. Surgical treatment of osteoporotic fractures about the knee. Instr Course Lect. 2010;59:511-23. [Medline].
Hannon M, Hadjizacharia P, Chan L, Plurad D, Demetriades D. Prognostic significance of lower extremity long bone fractures after automobile versus pedestrian injuries. J Trauma. Dec 2009;67(6):1384-8. [Medline].
Louie KW. Management of open fractures of the lower limb. BMJ. Dec 17 2009;339:b5092. [Medline].
Grottkau BE, Epps HR, Di Scala C. Compartment syndrome in children and adolescents. J Pediatr Surg. Apr 2005;40(4):678-82. [Medline].
Harris IA, Kadir A, Donald G. Continuous compartment pressure monitoring for tibia fractures: does it influence outcome?. J Trauma. Jun 2006;60(6):1330-5; discussion 1335. [Medline].
Accousti WK, Willis RB. Tibial eminence fractures. Orthop Clin North Am. Jul 2003;34(3):365-75. [Medline].
Fredericson M, Jennings F, Beaulieu C, Matheson GO. Stress fractures in athletes. Top Magn Reson Imaging. Oct 2006;17(5):309-25. [Medline].
Germann CA, Perron AD, Sweeney TW. Orthopedic pitfalls in the ED: tibial plafond fractures. Am J Emerg Med. May 2005;23(3):357-62. [Medline].
Haller PR, Harris CR. The tibia and fibula. In: Emergent Management of Skeletal Injuries. St Louis: Mosby-Year Book; 1995:499-517.
Khalily C, Behnke S, Seligson D. Treatment of closed tibia shaft fractures: a survey from the 1997 Orthopaedic Trauma Association and Osteosynthesis International--Gerhard Kuntscher Kreis meeting. J Orthop Trauma. Nov 2000;14(8):577-81. [Medline].
Konstantakos EK, Dalstrom DJ, Nelles ME, Laughlin RT, Prayson MJ. Diagnosis and management of extremity compartment syndromes: an orthopaedic perspective. Am Surg. Dec 2007;73(12):1199-209. [Medline].
Krieg JC. Proximal tibial fractures: current treatment, results, and problems. Injury. Aug 2003;34 Suppl 1:A2-10. [Medline].
McKoy BE, Stanitski CL. Acute tibial tubercle avulsion fractures. Orthop Clin North Am. Jul 2003;34(3):397-403. [Medline].
McQueen MM, Gaston P, Court-Brown CM. Acute compartment syndrome. Who is at risk?. J Bone Joint Surg Br. Mar 2000;82(2):200-3. [Medline].
Miller NC, Askew AE. Tibia fractures. An overview of evaluation and treatment. Orthop Nurs. Jul-Aug 2007;26(4):216-23; quiz 224-5. [Medline].
Mustonen AO, Koskinen SK, Kiuru MJ. Acute knee trauma: analysis of multidetector computed tomography findings and comparison with conventional radiography. Acta Radiol. Dec 2005;46(8):866-74. [Medline].
Newton EJ, Love J. Emergency department management of selected orthopedic injuries. Emerg Med Clin North Am. Aug 2007;25(3):763-93, ix-x. [Medline].
Ritsema TS, Kelen GD, Pronovost PJ, Pham JC. The national trend in quality of emergency department pain management for long bone fractures. Acad Emerg Med. Feb 2007;14(2):163-9. [Medline].
Roberts DM, Stallard TC. Emergency department evaluation and treatment of knee and leg injuries. Emerg Med Clin North Am. Feb 2000;18(1):67-84, v-vi. [Medline].
Russell TA. Fractures of the tibia and fibula. In: Fractures in Adults. 4th ed. Philadelphia, Pa: Lippincott-Raven; 1996:2127-2201.
Sproule JA, Khalid M, O'Sullivan M. Outcome after surgery for Maisonneuve fracture of the fibula. Injury. Aug 2004;35(8):791-8. [Medline].
Taketomo CK, Hodding JH, Kraus DM. Naproxen. In: Pediatric Dosage Handbook. Vol 6. 1999-2000:632-633.
Yang JP, Letts RM. Isolated fractures of the tibia with intact fibula in children: a review of 95 patients. J Pediatr Orthop. May-Jun 1997;17(3):347-51. [Medline].

