Tibia and Fibula Fracture Management in the ED

Fractures of the tibia are the most common long bone fractures. The annual incidence of open fracture of long bones is estimated to be 11.5 per 100,000 persons, with 40% occurring in the lower limb.[12] The most common fracture of the lower limb occurs at the tibial diaphysis.[13] Isolated midshaft and proximal fibula fractures are uncommon.

Toddler fracture (distal spiral fracture of the tibia) is most common among children aged 9 months to 3 years. In most cases, uncomplicated toddler fractures of the tibia do not need an orthopedic 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 of patients was 12 years, and peak fracture incidence was reported in patients aged 10-14 years.[14, 15, 16]

Tibial plateau fractures are common in the elderly population. Fractures in elderly patients may be complicated by osteoporosis, osteoarthritis, and medical comorbidities.[17]

Fracture of the tibia is the most common lower extremity fracture among children. It accounts for 10-15% of all pediatric fractures.[18]

 

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]

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 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.

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

• Venous thromboembolism

Radiography

Radiographs of the knee, tibia/fibula, and ankle should be obtained 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.[24] These patients may need additional radiographic tests to rule out these injuries when clinically indicated.

Computed tomography

Computed tomography (CT) is indicated for severely injured patients if diagnostically sufficient radiographs of the knee cannot be obtained.[25, 26]

For patients with tibial plateau fractures, tibial plafond fractures, and maisonneuve fractures, CT can assist evaluation of fracture extent.[27]  In a study of CT evaluation of characteristics of tibial plateau fractures, the 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.[28]

(See the CT images of tibial plateau fractures below.)

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

Ultrasonography

Point-of-care ultrasound has demonstrated promise for identifying long bone fractures and for confirming proper reduction.[29]  Sensitivity has been found to be as high as 99% in identifying long bone fractures.[30]  Sensitivity for adequate reduction has ranged from 94 to 100%.[29]   

For stress fractures

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

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

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. Although management of pain has improved, pain due to long bone fractures is notably undertreated in the emergency department.[23]  

X-ray is the first and most widely used imaging modality to identify fractures in knee bone trauma. However, point-of-care ultrasonography (POCUS) can be used to successfully diagnose bony lesions of the knee in patients with stable vital signs and without life-threatening injuries. It can also be used to easily diagnose hematoma and hemarthrosis. POCUS can be used as a diagnostic tool in emergency situations when x-ray is not available.[31]

Inpatient admission may be advised for observation of development of compartment syndrome. Continuous compartment pressure monitoring in asymptomatic patients with tibia fractures is not recommended.[32]  

Open fractures must be diagnosed and treated promptly. Tetanus vaccination should be updated, and appropriate antibiotics given in a timely manner. In one study, patients who received antibiotics after 120 minutes from presentation had 2.4 times the hazard of surgical site infection at 90 days.[33] Antibiotic choice should include 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 urgent debridement and irrigation in the operating room. Time to debridement of less than 8 hours has not proved superior to time of 8 to 24 hours following presentation.[34]

Understanding pathogenic characteristics and drug resistance of wound infection in patients with open tibia and fibula fractures is helpful for subsequent treatment. Comprehensive control measures should be taken to decrease the incidence of wound infection.[35]

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. This study analyzed data from the Nationwide Inpatient Sample, 2003 to 2009.[36]

Obtain an emergent orthopedic consultation for open fractures and for suspected compartment syndrome. Consultation is generally indicated for closed fractures. Advise the patient to obtain orthopedic follow-up care for isolated fibula fractures. Patients should see a primary care physician or should be referred to an orthopedic surgeon within 1 week for further evaluation and treatment of isolated fibula fractures.

Investigators in a retrospective cohort study reported that despite the low-energy nature of elderly patients' injuries, the severity of soft tissue insult was equivalent to that in younger patients with high-energy injuries. Data suggest that age and comorbidities should not prohibit lower limb reconstruction.[37]

In a study of 236 tibial tubercle fractures by Haber et al , preexisting Osgood-Schlatter disease was identified in 31% of cases. Type III fractures were the most common (41%), followed by type I (29%). In most cases, type I fractures were  treated nonoperatively (91%), whereas types II through V were most often treated surgically. Compartment syndrome was identified in 4 patients (2%), 3 of which had type IV fractures.[19]

Tibial shaft fractures in adolescents can be treated with several methods, including elastic stable intramedullary nails, interlocking nail, plate and screws, external fixation, and casting.[21]

Compartment syndrome

Compartment syndrome can develop in fractures of the lower leg.[7, 38, 39, 40, 41, 42]

Signs of compartment syndrome include crescendo symptoms, pain with passive movement of involved muscles, paresthesias, and pallor; pulselessness is a very late finding. Increased compartment pressure is evident during compartment syndrome; external palpation frequently aids in diagnosis. However, a soft extremity on palpation does not rule out compartment syndrome.

Serial examinations should be performed on patients with high-risk injuries and in those with equivocal symptoms.

If compartment syndrome is suspected, an emergent orthopedic consult and measurements of compartment pressures should be obtained. Compartment syndrome must be treated promptly with an emergency surgical fasciotomy. If left untreated, increased compartment pressures can cause ischemia and necrosis of structures within that facial compartment along with permanent disability.[14, 38, 39, 40, 43]

Risk factors for compartment syndrome of the lower leg include tibial diaphysis fracture, soft tissue injury, and crush injury.[14]

Pediatric patients with open fractures have significantly increased risk of developing compartment syndrome.[14]

In one study, study 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 patients was 5.8 years. These authors stated that patients who have minimally displaced tibial fractures, whose pain is adequately controlled, and who can be moved safely with parental supervision may be discharged from the emergency department. None of the children younger than 12 years developed acute compartment syndrome; however, study 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; admission and observation may be considered.[43]

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 (ORIF). Patients with articular depression greater than 3 mm may be considered for surgery.  

Elderly patients have increased risk of treatment failure from traditional ORIF techniques. Total knee arthroplasty is an alternative surgical option that provides the advantage of early weightbearing relative to traditional ORIF. This approach may reduce complications from immobility, such as venous thrombosis, postoperative pneumonia, and deconditioning.[44]

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.[41]

(See the images of tibial plateau fractures below.)

Tibial eminence fracture

For nondisplaced fractures (and stable knee joint), immobilize the knee.

Obtain an orthopedic consultation for an unstable knee or a 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 ORIF.

In one study of patients with tibial tubercle fractures, mean age at surgery was 14.6 years, and the fracture most commonly reported was type III (50.6%). Compartment syndrome was present in 3.57% of cases.[45]

Intraindividual tibia asymmetry in both geometric and alignment parameters has been noted. The surgeon must be aware of this for preoperative planning. The high correlation between tibia and fibula length allows the ipsilateral fibula to aid in estimating original tibia length post injury. Future studies need to establish whether this asymmetry is clinically relevant when the contralateral side is used as the reference in corrective surgery.[46]

Proximal tibia fracture

Intra-articular fractures require reduction and internal fixation.

Other methods used to surgically repair proximal tibia fractures include external fixation, plating, and intramedullary nailing.

Closed treatment involves reduction and 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. A few days without weightbearing activity until swelling resolves should be recommended, followed by weightbearing activity as tolerated.

A short leg walking cast usually is not required; however, some orthopedists may prefer a short leg walking cast or a cam walker with weightbearing.

Tibia and fibula stress fracture

The keystone of treating stress fractures is temporary cessation of the offending activity.

Crutches may be used at first to allow the patient to be nonweightbearing.

Drugs used to treat fractures include nonsteroidal anti-inflammatory agents and analgesics. Proper antibiotics and tetanus prophylaxis should be administered for open fractures.

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

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 is obtained.

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.

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 deltoid or midlateral thigh muscles. In infants, preferred site of administration is midthigh laterally.