Tibia and Fibula Fracture in the ED 

Updated: Nov 30, 2017
Author: Jeffrey G Norvell, MD, MBA, RDMS; Chief Editor: Trevor John Mills, MD, MPH 

Overview

Practice Essentials

Lower leg fractures include fractures of the tibia and fibula. Of these two bones, the tibia is the only weightbearing bone. Fractures of the tibia generally are associated with fibula fracture, because the force is transmitted along the interosseous membrane to the fibula. Causes include direct forces such as those caused by falls and motor vehicle accidents and indirect or rotational forces[1, 2, 3, 4, 5]

The skin and subcutaneous tissue are very thin over the anterior and medial tibia, and as a result, a significant number of fractures to the lower leg are open fractures. Even in closed fractures, the thin, soft tissue can become compromised. In contrast, the fibula is well covered by soft tissue over most of its course with the exception of the lateral malleolus.

The tibia and fibula articulate at the proximal tibia-fibular syndesmosis. Fractures of the tibia can involve the tibial plateau, tibial tubercle, tibial eminence, proximal tibia, tibial shaft, and tibial plafond. The common peroneal nerve crosses the fibular neck. This nerve is susceptible to injury from a fibular neck fracture, the pressure of a splint, or during surgical repair. This can result in foot drop and sensation abnormalities.

Delayed union, nonunion, and arthritis may occur. Among the long bones, the tibia is the most common site of fracture nonunion. Limb loss may occur as a result of severe soft-tissue trauma, neurovascular compromise, popliteal artery injury, compartment syndrome, or infection such as gangrene or osteomyelitis. Popliteal artery injury is a particularly serious injury that threatens the limb and is easily overlooked.

When examining a patient for a lower leg fracture, one should first examine the patient for edema, ecchymosis, and point tenderness. Gross deformities should be noted and splinted. Perform radiographs of the knee, tibia/fibula, and ankle as indicated. A careful neurovascular assessment should be performed, and an emergent fracture reduction should be performed if neurovascular deficits are present. A careful examination should be performed for open wounds. Open fractures require antibiotics and an emergent orthopedic consultation.

Tetanus vaccination should be updated, and appropriate antibiotics should be given in a timely manner. Some recommend antibiotics within 3 hours of the accident.[1]

In a study of compartment syndrome associated with tibial fracture, the odds of compartment syndrome increased by 1.67 per 10% increase in the ratio of fracture length to tibial length when considering all fractures. Compartment syndrome was most likely to occur with plateau fractures, at 12% (shaft fractures, 3%; pilon fractures, 2%).[6]

See the fracture image below.

Shown is an intra-articular fracture of the medial Shown is an intra-articular fracture of the medial condyle of the tibial plateau.

The AO/OTA Fracture and Dislocation Classification can be used in diagnosing specific forms of long bone fractures.[7, 8, 9]

For more information, see Medscape's Trauma Resource Center. For excellent patient education resources, visit eMedicineHealth's First Aid and Injuries Center. Also, see eMedicineHealth's patient education article Broken Leg.

Epidemiology

Fractures of the tibia are the most common long bone fractures. The annual incidence of open fractures of long bones is estimated to be 11.5 per 100,000 persons, with 40% occurring in the lower limb.[10] The most common fracture of the lower limb occurs at the tibial diaphysis.[11] Isolated midshaft or proximal fibula fractures are uncommon.

Toddler fracture (distal spiral fracture of the tibia) is most common in children aged 9 months to 3 years. The majority of uncomplicated toddler fractures of the tibia do not need an orthopaedic surgeon's intervention or follow-up. In a study of the National Pediatric Trauma Registry for children and adolescents with compartment syndrome over a 51-month period, 133  cases were identified. Boys outnumbered girls 4 to 1, the median age was 12 years, and peak incidence was in patients aged 10 to 14 years.[12, 13, 14]

Tibial plateau fractures are common in the elderly population after a low-energy mechanism. Fractures in elderly patients may be complicated by osteoporosis, osteoarthritis, and medical comorbidities.[15]

 

 

 

Presentation

History

Mechanisms of injury for tibia-fibula fractures can be divided into 2 categories: (1) low-energy injuries such as ground levels 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 complain of pain, swelling, and inability to ambulate with tibia fracture. 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 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.

Tibial eminence fractures occur with trauma to the distal femur while the knee is flexed such as 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.

Tibial shaft fractures usually present with a history of major trauma. An exception to this is a toddler's fracture, which is a spiral fracture that occurs with minor trauma in children who are learning to walk.

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.

Maisonneuve fractures are rare and 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 a result of repetitive submaximal stresses that may occur while participating in athletics. The history may reveal some change in training routine.

Patients with osteoporosis may have a seemingly innocent mechanism of injury and still sustain fracture.[16]

Physical

When examining a patient for a lower leg fracture one should first examine the patient 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 should be performed if neurovascular deficits are present.

A careful examination should be performed for open wounds. Open fractures require antibiotics and an emergent orthopedic consultation.

Tibial plateau fractures often present with a knee effusion. Tenderness will be 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 Schatzk 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 Schatzk 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 will have 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 a knee effusion and pain and may represent an avulsion of the tibial attachment of the anterior cruciate ligament.

Tibial shaft fractures are the most common long bone fracture and usually involve the fibula as well. Tibial fractures present with localized pain, swelling, and deformity.

Maisonneuve fractures involve a fracture of the proximal fibula in association with a fractured 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 will have tenderness along the distal tibial and may have severely decreased range of motion in the ankle.

Complications

The following complications may be noted:

  • Neurovascular compromise

  • Compartment syndrome

  • Peroneal nerve injury

  • Infection

  • Gangrene

  • Osteomyelitis

  • Delayed union, nonunion, or malunion

  • Amputation or skin loss

  • Posttraumatic arthritis

  • Fat embolism

 

DDx

 

Workup

Imaging Studies

Radiography

Perform radiographs of the knee, tibia/fibula, and ankle as indicated (see the image below). Pedestrians struck by motor vehicles with lower extremity fractures have a high incidence of concomitant spine, chest, or intra-abdominal injuries.[17] These patients may need additional radiographic tests to rule out these injuries when clinically indicated.

Radiograph demonstrating a displaced tibial shaft Radiograph demonstrating a displaced tibial shaft fracture with associated fibula fracture.

Computed tomography

Computed tomography is indicated for severely injured patients if unable to get diagnostically sufficient radiographs of the knee.[18, 19]

In patients with tibial plateau fractures and tibial plafond fractures, computed tomography can help further evaluate the extent of the fracture.  In a study of CT evaluation of characteristics of tibial plateau fractures, diagnostic accuracy of fracture characteristics ranged from 70 to 89% for (1) a posteromedial component, (2) a lateral component, (3) a tibial tubercle component, and (4) a tibial spine (central) component.[20]

See the CT images of tibial plateau fractures below.

Tibial plateau fractures. CT image through the tib 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.
Tibial plateau fractures. Coronal reformatted CT. 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.

In tibial plateau fractures, radiographs may underestimate the degree of articular depression when compared with computed tomography. This is important because articular depression of greater than 3 mm may be considered for surgery.

For stress fractures

Radiographic findings are usually seen after 2-8 weeks of symptoms, and radiographs may not be very sensitive during the early stages of symptoms.

Radionucleotide scanning and MRI are more sensitive in diagnosing stress fractures and stress injuries than radiographs.

 

Treatment

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.[16]  Inpatient admission may be advised to observe development of compartment syndrome. Continuous compartment pressure monitoring in asymptomatic patients with tibia fractures is not recommended.[21]

Open fractures must be diagnosed and treated appropriately. Tetanus vaccination should be updated, and appropriate antibiotics should be given in a timely manner. Some recommend antibiotics within 3 hours of the accident.[1] 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. Open fractures require debridement and irrigation in the operating room.

According to one study, delay of the first operative procedure beyond the day of admission appears to be associated with a significantly increased probability of amputation in patients with open tibia fracture. In this study, data were analyzed from the Nationwide Inpatient Sample, 2003 to 2009.[22]

Compartment syndrome

Compartment syndrome can develop in fractures of the lower leg.[23, 24, 25, 26, 27]

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.[12, 28, 23, 24, 25]

Risk factors for compartment syndrome of the lower leg include tibial diaphysis fracture, soft-tissue injury, and crush injury.[12]

Open fractures in pediatric patients have a significantly increased risk of developing compartment syndrome.[12]

In one study, the authors ascertained whether all children under the age of 12 years with fractures of the tibia warranted admission because of the risk of acute compartment syndrome. The mean age of the patients was 5.8 years. According to the authors, patients who have minimally displaced tibial fractures, whose pain is adequately controlled, and who can safely be moved with parental supervision may be discharged from the emergency department. None of the children younger than 12 years developed acute compartment syndrome; however, the authors noted that certain features, such as a history of high-energy injury, displaced fractures, or coexisting fibular fractures, should raise concern that compartment syndrome may occur and, thus, admission and observation may be considered.[28]

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.

In a study of 158 patients with 162 tibial plateau fractures, the overall rate of compartment syndrome was 11%. Tibial widening and femoral displacement were found to be significant associated factors.[26]

See the images of tibial plateau fractures below.

Type II tibial plateau fracture in a young active 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 depr 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.

In one study of patients with tibial tubercle fractures, mean age at surgery was 14.6 years, and the most common fracture reported was type III (50.6%). Compartment syndrome was present in 3.57% of cases.[29]

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.

Patients should see a primary care physician or be referred to an orthopedic surgeon within 1 week for further evaluation and treatment of isolated fibula fractures.

 

Medication

Medication Summary

Drugs used to treat fractures include nonsteroidal anti-inflammatory agents and analgesics. In addition, administer proper antibiotics and tetanus prophylaxis for open fractures.

Nonsteroidal anti-inflammatory agents (NSAIDs)

Class Summary

These drugs have analgesic and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may involve inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.

Ibuprofen (Addaprin, Advil, Motrin, NeoProfen)

Usually DOC for treatment of mild to moderately severe pain, if no contraindications. Inhibits inflammatory reactions and pain, probably by decreasing activity of enzyme cyclooxygenase, which decreases prostaglandin synthesis.

Naproxen (Anaprox, Aleve, Naprelan, Naprosyn)

Used for relief of mild to moderately severe pain. Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, decreasing prostaglandin synthesis.

Ketoprofen (Active-Ketoprofen)

Inhibits synthesis of prostaglandins in body tissues by inhibiting at least 2 cyclooxygenase isoenzymes, cyclooxygenase-1 (COX-1) and -2 (COX-2)

May inhibit chemotaxis, may alter lymphocyte activity, decrease proinflammatory cytokine activity, and may inhibit neutrophil aggregation. These effects may contribute to its anti-inflammatory activity

Indomethacin (Indocin, Tivorbex)

Inhibits synthesis of prostaglandins in body tissues by inhibiting at least 2 cyclo-oxygenase (COX) isoenzymes, COX-1 and COX-2

May inhibit chemotaxis, alter lymphocyte activity, decrease proinflammatory cytokine activity, and inhibit neutrophil aggregation; these effects may contribute to anti-inflammatory activity

Fenoprofen (Nalfon)

Inhibits synthesis of prostaglandins in body tissues by inhibiting at least 2 cyclooxygenase isoenzymes, cyclooxygenase-1 (COX-1) and -2 (COX-2)

May inhibit chemotaxis, may alter lymphocyte activity, decrease proinflammatory cytokine activity, and may inhibit neutrophil aggregation. These effects may contribute to its anti-inflammatory activity

Analgesics

Class Summary

Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained fractures.

Acetaminophen (Tylenol, Ofirmev, Aspirin Free Anacin, Mapap)

DOC for treatment of pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or taking oral anticoagulants.

Acetaminophen and codeine (Tylenol with Codeine #3, Capital/Codeine)

Drug combination indicated for treatment of mild to moderately severe pain.

Hydrocodone bitartrate and acetaminophen (Vicodin ES, Norco, Lortab, Vendrocet)

Drug combination indicated for relief of moderately severe to severe pain.

Oxycodone and acetaminophen (Percocet, Primlev, Roxicet, Endocet)

Drug combination indicated for relief of moderately severe to severe pain. DOC for aspirin-hypersensitive patients.

Morphine sulfate (Duramorph, Astramorph, Kadian, MS Contin)

DOC for narcotic analgesia because of its reliable and predictable effects, safety, and ease of reversibility with naloxone. Administered IV, may be dosed in a number of ways and commonly is titrated until desired effect obtained.

Immunoglobulins

Class Summary

Patients who may not have been immunized against Clostridium tetani products should receive tetanus immune globulin.

Tetanus immune globulin (Hypertet S/D)

Used for passive immunization of any person with a wound that may be contaminated with tetanus spores.

Vaccines, Inactivated, Bacterial

Class Summary

This agent is used for tetanus immunization. Booster injection in previously immunized individuals is recommended to prevent this potentially lethal syndrome.

Tetanus toxoid adsorbed or fluid

Used to induce active immunity against tetanus in selected patients. Tetanus and diphtheria toxoids are immunizing AOC for most adults and children >7 y. Necessary to administer booster doses to maintain tetanus immunity throughout life.

Pregnant patients should receive only tetanus toxoid, not a diphtheria antigen-containing product.

In children and adults, may administer into the deltoid or midlateral thigh muscles. In infants, preferred site of administration is midthigh laterally.

 

Questions & Answers

Overview

What is tibia and fibula fracture?

What are complications of tibia and fibula fracture?

What is included in the initial care of tibia and fibula fracture in the emergency department (ED)?

How are tibia and fibula fracture classified?

What is the prevalence of tibia and fibula fracture?

Presentation

Which clinical history is characteristic of tibia and fibula fracture?

What are the types of tibia and fibula fracture?

What is included in the physical exam for tibia and fibula fracture?

Which physical findings are characteristic of tibia and fibula fracture?

What are the complications of tibia and fibula fracture?

DDX

What are the differential diagnoses for Tibia and Fibula Fracture in the ED?

Workup

What is the role of radiography in the diagnosis of tibia and fibula fracture in the emergency department (ED)?

What is the role of CT in the diagnosis of tibia and fibula fracture in the emergency department (ED)?

Which radiographic findings suggest stress fracture of the tibia and fibula?

Treatment

What is the included in prehospital care for tibia and fibula fracture?

What is included in initial emergency department (ED) care for patients with tibia and fibula fracture?

What is compartment syndrome resulting from tibia and fibula fracture and how is it managed?

What is included in emergency department (ED) care for tibial plateau fracture?

What is included in emergency department (ED) care for tibial eminence fracture?

What is included in emergency department (ED) care for tibial tubercle fracture?

What is included in emergency department (ED) care for proximal tibia fractures?

What is included in emergency department (ED) care for isolated midshaft or proximal fibula fracture?

What is included in emergency department (ED) care for tibia and fibula stress fractures?

Which medical personnel provide consultation to patients with tibia and fibula fracture?

Medications

Which medications are used in the treatment of tibia and fibula fracture in the emergency department (ED)?

Which medications in the drug class Vaccines, Inactivated, Bacterial are used in the treatment of Tibia and Fibula Fracture in the ED?

Which medications in the drug class Immunoglobulins are used in the treatment of Tibia and Fibula Fracture in the ED?

Which medications in the drug class Analgesics are used in the treatment of Tibia and Fibula Fracture in the ED?

Which medications in the drug class Nonsteroidal anti-inflammatory agents (NSAIDs) are used in the treatment of Tibia and Fibula Fracture in the ED?