Summary Diaphyseal tibial fractures are the most common long bone fracture. Diagnosis is confirmed by plain radiographs of the tibia and adjacent joints. Treatment is generally operative with intramedullary nailing. In rare cases, external fixation or ORIF is more appropriate depending on the location and orientation of the fracture. Epidemiology Incidence most common long bone fx make up about 17% of all lower extremity fractures account for 4% of all fractures seen in the Medicare population Demographics M > F age bracket bimodal distribution login to view 2 more bullets Anatomic location proximal 1/3 tibia fractures account for 5-10% of tibial shaft fractures Etiology Pathophysiology mechanism of injury low energy (fall from standing, twisting, etc) login to view 4 more bullets high energy fx (MVA, fall from height, athletics, etc) login to view 5 more bullets pathoanatomy proximal third tibia fractures login to view 2 more bullets distal third tibia fracture login to view 3 more bullets associated conditions soft tissue injury login to view 1 more bullet compartment syndrome login to view 4 more bullets bone loss ipsilateral skeletal injury login to view 6 more bullets Anatomy Osteology tibial shaft is triangular in cross-section proximal medullary canal is centered laterally important for start point with IM nailing anteromedial tibial crest is composed of dense, cortical bone and rests in a subcutaneous position, making it useful as a landmark tibial tubercle sits anterolaterally, approximately 3 cm distal to joint line attachment of patellar tendon gerdy's tubercle lies laterally on proximal tibia attachment of iliotibial band pes anserinus lies medially on proximal tibia attachment of sartorius, semitendinosus, and gracilis Muscles anterior compartment tibialis anterior extensor digitorum longus (EDL) extensor hallicus longus (EHL) lateral compartment peroneus longus peroneus brevis superficial posterior compartment gastrocnemius (medial/lateral heads) soleus plantaris deep posterior compartment popliteus tibialis posterior flexor digitorum longus (FDL) flexor hallicus longus (FHL) Ligaments superficial medial collateral ligament (MCL) attaches approximately 5-7 cm distal to joint line deep to the pes anserinus adjacent fibula supports attachments for the lateral collateral ligament complex and long head of biceps femoris Blood Supply anterior tibial a. peroneal a. posterior tibial a. medial sural a. lateral sural a. Nervous System superficial peroneal n. deep peroneal n. tibial n. sural n. Biomechanics proximal tibiofibular joint gliding synovial joint tibia is responsible for about 80-85% of lower extremity weight-bearing interosseous membrane fibrous structure interconnecting tibia/fibula which provides axial stability tibiofibular syndesmosis fibula rests in distal tibial incisura and is stabilized by syndesmotic ligaments login to view 4 more bullets syndesmotic stability can be affected by distal, spiral tibial shaft fractures Classification Fracture classification is primarily descriptive based on pattern and location OTA Classification 42A Simple fracture patterns 42B Wedge patterns 42C Complex/comminuted patterns Oestern and Tscherne Classification of Closed Fracture Soft Tissue Injury Grade 0 Injuries from indirect forces with negligible soft-tissue damage Grade I Superficial contusion/abrasion, simple fractures Grade II Deep abrasions, muscle/skin contusion, direct trauma, impending compartment syndrome Grade III Excessive skin contusion, crushed skin or destruction of muscle, subcutaneous degloving, acute compartment syndrome, and rupture of major blood vessel or nerve Gustilo-Anderson Classification of Open Tibia Fractures Type I Limited periosteal stripping, clean wound < 1 cm Type II Minimal periosteal stripping, wound >1 cm in length without extensive soft-tissue injury damage Type IIIA Significant soft tissue injury (often evidenced by a segmental fracture or comminution), significant periosteal stripping, wound usually >5cm in length, no flap required. Type IIIB Significant periosteal stripping and soft tissue injury, flap required due to inadequate soft tissue coverage (STSG doesn't count). Treat proximal 1/3 fxs with gastrocnemius rotation flap, middle 1/3 fxs with soleus rotation flap, distal 1/3 fxs with free flap. Type IIIC Significant soft tissue injury (often evidenced by a segmental fracture or comminution), vascular injury requiring repair to maintain limb viability For prognostic reasons, severely comminuted, contaminated barnyard injuries, close-range shotgun/high-velocity gunshot injuries, and open fractures presenting over 24 hours from injury have all been included in the grade III group. Presentation Symptoms severe leg pain inability to bear weight deformity Physical exam inspection deformity / angulation / malrotation contusions blisters open wounds palpation check firmness of each compartment to evaluate for compartment syndrome motion fracture crepitus noted neurovascular peripheral nerve exam login to view 5 more bullets dorsalis pedis and posterior tibial pulses - compare to contralateral side login to view 2 more bullets Imaging Radiographs recommended views full-length AP and lateral views of the affected tibia AP, lateral and oblique views of ipsilateral knee and ankle repeat radiographs recommended after splinting or fracture manipulation CT indications intra-articular fracture extension or suspicion of plateau/plafond involvement distal 1/3 or spiral tibia fracture login to view 1 more bullet also used to identify nonunion findings high variation in reported incidence of posterior malleolus fracture with distal 1/3 spiral tibia fractures (25-60%) Treatment Nonoperative closed reduction / cast immobilization indications login to view 7 more bullets outcomes login to view 6 more bullets Operative I&D + antibiotics indications login to view 13 more bullets outcomes login to view 3 more bullets external fixation indications login to view 3 more bullets techniques login to view 3 more bullets outcomes login to view 3 more bullets IM Nailing indications login to view 8 more bullets techniques login to view 5 more bullets outcomes login to view 12 more bullets open reduction and internal fixation indications login to view 3 more bullets outcomes login to view 9 more bullets augmentation with rhBMP-2 indications login to view 1 more bullet outcomes (controversial, as recent studies have not fully supported these findings) login to view 5 more bullets amputation indications login to view 5 more bullets outcomes login to view 7 more bullets Technique Closed reduction/cast immobilization technique long leg casting initially may convert to functional (patellar tendon bearing) brace at around 4 weeks close follow-up with repeat radiographs to ensure no displacement login to view 2 more bullets Irrigation and debridement timing within 24 hours of initial injury to decrease risk of infection technique sharp debridement of nonviable soft tissue & bone thorough irrigation of contaminated wound may require multiple debridements immediate closure of open wounds is acceptable if minimal contamination is present and is performed without excessive skin tension login to view 1 more bullet External fixation technique bypass fracture, likely adjacent joint (i.e. open 1/3 tibial shaft fracture with placement of proximal 1/3 tibia and calcaneus/metatarsal pins to span fracture) construct stiffness increased with larger pin diameter, number of pins on each side of fracture, rods closer to bone, and a multiplanar construct complications pin site infections common Intramedullary nailing approach infrapatellar nailing login to view 18 more bullets suprapatellar nailing (transquadriceps tendon) login to view 4 more bullets technique starting point login to view 4 more bullets fracture reduction login to view 10 more bullets reaming login to view 5 more bullets nail insertion login to view 1 more bullet locking screws login to view 6 more bullets Open reduction and internal fixation approach lateral vs. medial login to view 1 more bullet technique generally, minimally invasive plating is used to preserve soft tissues login to view 2 more bullets complications higher risk for wound issues, particularly in open fractures neurovascular risk login to view 1 more bullet Amputation approach below knee amputation (BKA) vs. above knee amputation (AKA) based on degree of soft tissue damage technique standard BKA vs. ertl/bone block technique complications infection hematoma phantom pain Complications Anterior knee pain incidence >30-50% with IM nailing risk factors infrapatellar nailing with patellar tendon splitting and paratendon approach login to view 1 more bullet more common if nail left proud proximally login to view 1 more bullet treatment removal of nail login to view 1 more bullet Malunion incidence all tibial shaft fractures - between 8-10% higher in proximal 1/3 tibia fractures - up to 50% login to view 2 more bullets distal 1/3 fractures have a higher rate of valgus malunion with IM nailing compared to plating risk factors definitive management with casting or external fixation login to view 2 more bullets starting point too medial with IM nailing poor reduction intraoperatively treatment prevention is most important login to view 1 more bullet if malalignment is noted immediately after surgery, return to operating room is appropriate with removal of nail, reduction and nail reinsertion if malunion is appreciated at later followup, eventual nail removal and tibial osteotomy can be considered Nonunion (no healing at 9 months) incidence estimated between 2-10% risk factors open fracture cortical contact <50% transverse fracture pattern treatment rule out infection nail dynamization if axially stable exchange nailing if not axially stable login to view 3 more bullets posterolateral bone grafting if significant bone loss BMP-7 (OP-1) has been shown equivalent to autograft login to view 1 more bullet compression plating has been shown to have a 92-96% union rate after open tibial fractures initially treated with external fixation fibular osteotomy of tibio-fibular length discrepancy associated with healed or intact fibula Malrotation incidence highest after IM nailing of distal 1/3 tibia fractures login to view 1 more bullet treatment should always assess rotation in operating room login to view 1 more bullet may have reduced risk with adjunctive fibular plating Compartment syndrome incidence estimated between 1-9% login to view 1 more bullet risk factors high energy injuries significant soft tissue injuries treatment emergent four-compartment fasciotomy Nerve injury incidence true incidence unknown believed to be a rare complication risk factors LISS plate application without opening for distal screw fixation near plate holes 11-13 put superficial peroneal nerve at risk of injury due to close proximity saphenous nerve can be injured during placement of locking screws transient peroneal nerve palsy can be seen after closed nailing login to view 1 more bullet deep peroneal nerve can be injured with overpenetration of posterolaterally-directed proximal external fixator pins treatment usually nonoperatively with variable recovery expected may need AFO if foot drop present Infection incidence approximately 5% risk factors open fracture severe soft tissue injury with contamination longer time to definitive soft tissue coverage treatment may require I&D or eventual removal of hardware use of wound vacuum-assisted closure does not decrease risk of infection