History
Mechanisms of injury for tibia-fibula fracture can be divided into 2 categories: (1) low-energy injuries such as ground-level falls and athletic injuries, and (2) high-energy injuries such as motor vehicle injuries, pedestrians struck by motor vehicles, and gunshot wounds
Patients may report a history of direct (motor vehicle crash or axial loading) or indirect (twisting) trauma and may describe pain, swelling, and inability to ambulate with fracture of the tibia. 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 in a 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. [19]
Tibial eminence fractures occur with trauma to the distal femur while the knee is flexed, such as when 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. [20] Pediatric patients are most commonly affected because of the weakness of the subchondral bone, which causes the bone to fail before the anterior cruciate ligament (ACL). It is considered an ACL equivalent injury in children. [20]
Tibial shaft fractures usually present with a history of major trauma. An exception to this is toddler's fracture, which is a spiral fracture that occurs with minor trauma in children who are learning to walk. [21, 7]
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. The posterolateral approach to the distal tibia is commonly used for stabilization of ankle fractures, as it allows good visualization and direct reduction of the posterior distal tibia and malleolar fragments. It is important for surgeons to be aware of the surgical anatomy of the peroneal artery (PA) to avoid inadvertent injury during the posterolateral approach to the distal tibia. The PA may bifurcate as close as 36 mm from the tibial plafond with possible variation bilaterally. The operating surgeon must pay special attention while dissecting in this region because of wide anatomic variation in vasculature. However, once the PA is mobilized, any fixation modality can be safely performed. [22]
Maisonneuve fractures are rare and are 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 the result of repetitive submaximal stresses that may occur during participation in athletics. The history may reveal some change in the training routine.
Patients with osteoporosis may have a seemingly innocent mechanism of injury and may still sustain fracture. [23]
Physical
When examining a patient for a lower leg fracture, one should first look 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 is needed if neurovascular deficits are present.
A careful examination for open wounds should be performed. Open fractures require antibiotics and an emergent orthopedic consultation.
Tibial plateau fractures often present with a knee effusion. Tenderness is present along the medial or lateral tibial plateau. Approximately 20% of tibial plateau fractures are associated with ligamentous injuries.
(See the images below.)
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 reveals 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 knee effusion and pain and may represent an avulsion of the tibial attachment of the anterior cruciate ligament.
Tibial shaft fracture, the most common long bone fracture, usually involves the fibula as well. Tibial fractures present with localized pain, swelling, and deformity.
Maisonneuve fracture involves fracture of the proximal fibula in association with fracture of the 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 reveal tenderness along the distal tibia; patients may have severely decreased range of motion in the ankle.
Complications
The following complications may be noted:
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Neurovascular compromise
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Compartment syndrome
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Peroneal nerve injury
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Infection
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Gangrene
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Osteomyelitis
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Delayed union, nonunion, or malunion
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Amputation or skin loss
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Posttraumatic arthritis
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Fat embolism
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Venous thromboembolism
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Shown is an intra-articular fracture of the medial condyle of the tibial plateau.
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Standard anteroposterior radiograph of a tibial shaft fracture with intramedullary nail fixation. Note the commonly associated fibular fracture that is also apparent.
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Radiograph demonstrating a displaced tibial shaft fracture with associated fibula fracture.
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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.
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Type III tibial plateau fracture with central depression in an elderly person treated surgically using percutaneous elevation, bone grafting, and cancellous screw fixation.
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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.
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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.
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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.
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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.
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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.
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Classification of tibial tuberosity fractures.
