Emergency Department 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. 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.)
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 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 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.
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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.
