History and Physical Examination

Upon admission, a detailed patient history must be obtained to determine the nature of the injury and to determine whether any other injuries are present.

Clinical examination starts with excluding life-threatening injuries and stabilizing all vital parameters. A comprehensive screening to rule out pelvic, abdominal, chest, and head injuries is necessary. Thereafter, attention should be given to the limb to immediately assess for limb-threatening vascular and neurologic injuries.

The patient should be assessed for compartment syndromes, closed soft-tissue injury, and open wounds (see the image below). The extent of injury is roughly classified, with the assessment being completed only intraoperatively. A bulky dressing and an above-knee splint are applied, and radiographs are ordered.

$Diaphyseal tibial fracture. Compound grade 3C inju$ Diaphyseal tibial fracture. Compound grade 3C injury with extensive soft-tissue injury.

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The diagnosis of a traumatic tibial shaft fracture is usually straightforward and is made on the basis of classic symptoms and signs. However, stress fractures can be missed by reason of the subacute or chronic nature of the presentation.^[35]The possibility of serious infections (eg, necrotizing fasciitis^[36]and gas gangrene^[37]) must be considered in open fractures with delayed presentation, as well as perioperatively in the presence of extensive injury.

Workup

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Media Gallery

Diaphyseal tibial fracture. Unstable tibial fracture treated with interlocking nail.
Diaphyseal tibial fracture. Mechanism of compounding.
Diaphyseal tibial fracture. nonunion with deformity after conservative management of grade 3 open fracture.
Diaphyseal tibial fracture. Unstable tibia with comminution treated with interlocked nails.
Diaphyseal tibial fracture. Isolated tibial fracture without fibular fracture.
Diaphyseal tibial fracture. Clinical and radiographic findings of compound grade 2 injury.
Diaphyseal tibial fracture. Compound grade 3C injury with extensive soft-tissue injury.
Diaphyseal tibial fracture. Management of grade 3 injury in external fixator followed by delayed nailing using a Küntscher-Herzog nail.
Diaphyseal tibial fracture. Malunion in unacceptable position as a result of suboptimal management of unstable fracture.
Patellar tendon-bearing brace fabricated from Orfit Industries.
Diaphyseal tibial fracture. Anteriorly applied T frame for grade 3 open injury.
Diaphyseal tibial fracture. Tibial plating with wound breakdown.
Locked compression plate and combination hole.
Diaphyseal tibial fracture. Gustilo grade 3A midshaft open tibial fracture in 25-year-old man. External fixator was applied.
Blood vessels of leg and nutrient arteries to tibia and fibula.
Compartments of leg: anterior, lateral, superficial posterior, and deep posterior.
Types of frame constructs used for external fixation of tibial fractures: (a) unilateral uniplanar, (b) bilateral uniplanar, (c) unilateral biplanar, and (d) bilateral biplanar.
Lateral tibial locking compression plate.
Close-up of locking compression plate shows combination hole system in plate.
Diaphyseal tibial fracture. Preoperative (a) and postoperative (b) anteroposterior and lateral radiographs of leg show use of long medial malleolar locking compression plate for long spiral distal tibial shaft fracture.
Diaphyseal tibial fracture. Postoperative anteroposterior and lateral radiographs of leg show use of double-locking compression plating for segmental tibial shaft fracture with high proximal extension of fracture line.
Diaphyseal tibial fracture. Preoperative anteroposterior and lateral radiographs of leg show use of long tibial locking compression plate as internal fixator through minimally invasive percutaneous plate osteosynthesis (MIPPO) technique. Courtesy of Dr Raghavan Sivaram, Apollo Hospital, India.
Diaphyseal tibial fracture. Postoperative anteroposterior and lateral radiographs of leg show use of long tibial locking compression plate as internal fixator through minimally invasive percutaneous plate osteosynthesis (MIPPO) technique. Courtesy of Dr Raghavan Sivaram, Apollo Hospital, India.
Diaphyseal tibial fracture. Preoperative anteroposterior and lateral radiographs of leg before use of intramedullary interlocking nail for comminuted tibial shaft fracture. Courtesy of Dr Smruti Ranjan Panda, Mercy Hospital, India.
Diaphyseal tibial fracture. Immediate postoperative anteroposterior and lateral radiographs of leg show use of intramedullary interlocking nail for comminuted tibial shaft fracture (note splinter in proximal locking site and valgus fixation). Courtesy of Dr Smruti Ranjan Panda, Mercy Hospital, India.
Diaphyseal tibial fracture. Six-month postoperative anteroposterior and lateral radiographs of leg after use of intramedullary interlocking nail for comminuted tibial shaft fracture. Courtesy of Dr Smruti Ranjan Panda, Mercy Hospital, India.

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Author

Murali Poduval, MBBS, MS, DNB Orthopaedic Surgeon, Senior Consultant, and Subject Matter Expert, Tata Consultancy Services, Mumbai, India

Murali Poduval, MBBS, MS, DNB is a member of the following medical societies: Association of Medical Consultants of Mumbai, Bombay Orthopedic Society, Indian Orthopedic Association, Indian Society of Hip and Knee Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Saseendar Shanmugasundaram, MBBS, MS(Orth), DNB(Orth), MNAMS, Dip SICOT(Belg), FISOC Consultant Arthroscopy, Arthroplasty, and Trauma Surgeon, CARE Sports Injury, India; Specialist Orthopaedic Surgeon, Apollo Hospital, Sultanate of Oman

Saseendar Shanmugasundaram, MBBS, MS(Orth), DNB(Orth), MNAMS, Dip SICOT(Belg), FISOC is a member of the following medical societies: Asia-Pacific Knee, Arthroscopy and Sports Medicine Society, Indian Arthroplasty Association, Indian Arthroscopy Society, Indian Cartilage Society, Indian Orthopedic Association, International Society for Knowledge for Surgeons on Arthroscopy and Arthroplasty, International Society of Orthopaedic Surgery and Traumatology, Latin American Society of Arthroscopy, Knee and Sports (SLARD), Magellan Society - Orthopaedic Research and Education Foundation, Pondicherry Orthopaedic Association, Shoulder and Elbow Society of India, Tamilnadu Arthroscopy Society, Tamilnadu Orthopaedic Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Thomas M DeBerardino, MD, FAAOS, FAOA Professor of Orthopaedic Surgery, University of Texas Health Science Center at San Antonio, Joe R and Teresa Lozano Long School of Medicine; Professor of Orthopaedic Surgery and Faculty of Sports Medicine Fellowship, Baylor College of Medicine; Sports Medicine Orthopaedic Surgeon, Department of Orthopaedics, UT Health San Antonio; Consulting Surgeon, Sports Medicine, Arthroscopy and Reconstruction of the Knee, Hip and Shoulder

Thomas M DeBerardino, MD, FAAOS, FAOA is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, Clinical Orthopaedic Society, Herodicus Society, International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Arthrex, Inc.; MTF; Aesculap; Conmed; JRF<br/>Received research grant from: Arthrex, Inc.; MTF.

Additional Contributors

Satishchandra Kale, MD, MBBS, MBA, MCh(Orth), FRCS(Edin), FRCS(Tr&Orth) Diploma in Sports and Exercise Medicine(UK)

Satishchandra Kale, MD, MBBS, MBA, MCh(Orth), FRCS(Edin), FRCS(Tr&Orth) is a member of the following medical societies: Bombay Orthopedic Society, British Orthopaedic Association, Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

Phillip J Marone, MD, MSPH Clinical Professor, Department of Orthopedic Surgery and Department of Rehabilitation Medicine, Jefferson Medical College of Thomas Jefferson University

Phillip J Marone, MD, MSPH is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Medical Association, American Orthopaedic Society for Sports Medicine, Philadelphia County Medical Society

Disclosure: Nothing to disclose.

Diaphyseal Tibial Fractures Clinical Presentation

History and Physical Examination

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