Tibial Shaft Fractures Clinical Presentation

Updated: Oct 17, 2018
  • Author: Brian K Konowalchuk, MD; Chief Editor: Thomas M DeBerardino, MD  more...
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Presentation

History

Patients with tibial shaft fractures report pain that may vary in degree but 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 report 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. [7]

Whatever the presentation, a complete history and 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 the following:

  • Exactly what the patient was doing at the time of the injury
  • The amount of time that has passed since the injury occurred
  • Nature and severity of pain
  • Any associated paresthesias or numbness
  • Any previous conditions that predispose to this injury or complicate surgery
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Physical Examination

During the physical examination, the physician should not focus solely 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.

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Classification

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. [8, 9, 10, 11, 12, 13] The classic classification for open fractures is that developed by Gustilo et al, as follows [14] :

  • 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 - The wound is wound associated with extensive soft-tissue damage, usually larger than 10 cm, with periosteal coverage (periosteum, the outermost layer of bone, 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 (eg, 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 (OTA) and the Arbeitsgemeinschaft für Osteosynthesefragen also adopted a system of classification applicable to tibial shaft fracture. This system, based on radiographic evaluation and building on the work of Müller et al, [15] was first published in 1996 and was subsequently revised in 2007 [16] and 2018. [17]  In the current classification, tibial shaft fractures would first be labeled by the number of the bone involved (42 in the case of the  tibial diaphysis) and then be divided into the following three main types:

  • Type A - Simple fractures
  • Type B - Wedge fractures
  • Type C - Multifragmentary fractures

Each of these main type is divided into groups.

For type A (simple) fractures, the groups are determined by the angle of the fracture and consist of spiral fractures (A1), oblique (≥30º) fractures (A2), and transverse (< 30º) fractures (A3). The location of the fracture (proximal third, middle third, or distal third) is specified. 

Type B (wedge) fractures are divided into intact wedge fractures (B2) and fragmentary wedge fractures (B3). The location of the fracture (proximal third, middle third, or distal third) is specified.

Type C (multifragmentary) fractures are divided into intact segmental fractures (C2) and fragmentary segmental fractures (C3). Type C3 fractures are also subdivided on the basis of location (proximal diaphyseal–metaphyseal, pure diaphyseal, or distal diaphyseal–metaphyseal).

More detailed descriptions of these fractures may be achieved by using one or more "universal modifiers," which may be appended to the fracture code. Further information on the current AO/OTA classification is available on the AOTrauma Web site.

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