You are in: eMedicine Specialties > Orthopedic Surgery > KNEE Tibial Shaft FracturesArticle Last Updated: Feb 22, 2005AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: Brian K Konowalchuk, MD, Staff Physician, Department of Orthopedic Surgery, University of Minnesota College of Medicine Brian K Konowalchuk is a member of the following medical societies: Alpha Omega Alpha Coauthor(s): Nicholas Wills, BS, University of Minnesota at Twin Cities; Brian Tollefson, MD, Flight Surgeon, United States Air Force; Marc Swiontkowski, MD, Chair, Professor, Department of Orthopedic Surgery, University of Minnesota at Minneapolis Editors: Charles T Mehlman, DO, MPH, Director, Musculoskeletal Outcomes Research, Associate Professor, Division of Pediatric Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Shepard R Hurwitz, MD, Executive Director Designate, American Board of Orthopaedic Surgery; Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital; Carlos J Lavernia, MD, FAAOS, Adjunct Clinical Professor, Department of Orthopedic Surgery, University of Miami School of Medicine; Medical Director, Orthopedic Institute at Mercy Hospital Author and Editor Disclosure Synonyms and related keywords: broken leg, broken bone, trauma, leg fracture, fractured leg, fractured tibia, broken tibia, compartment syndrome INTRODUCTIONSection 2 of 12
  An understanding of the diagnosis and treatment of tibial shaft fractures is of importance to primary care physicians and orthopedic surgeons alike. Often, the primary care provider first comes into contact with tibial shaft fractures and must make the diagnosis and early treatment decisions. High-speed lifestyles with motor vehicles, snowmobiles, and motorcycles and the growing popularity of extreme sports contribute to the increasing occurrence of tibial shaft fractures in today's society. In fact, the tibia is currently the most commonly fractured long bone in the body. For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education articles Broken Leg, Ankle Fracture, and Knee Dislocation. History of the ProcedurePlating tibial shaft fractures was the treatment of choice 2-3 decades ago. Recently, intramedullary nailing and external fixation have replaced fracture plating because they entail decreased technical difficulty, infection rates, and damage to local soft tissues (see Treatment, Intraoperative details, below). ProblemThe tibia is the most commonly fractured long bone in the body. Tibial shaft fractures are often the result of high-speed trauma but can also be insidious in onset, such as stress fractures in active individuals. During the initial evaluation, the patient with a tibial shaft fracture should be carefully evaluated for open wounds at the fracture site, neurovascular sufficiency, and elevated compartment pressures. Abnormalities in any of these areas constitute a surgical emergency. FrequencyThe tibia is currently the most commonly fractured long bone in the body. Alho et al have reported an annual incidence of 2 tibial shaft fractures per 1000 individuals (Alho, 1992). The average age of patients with tibial shaft fractures is approximately 37 years, and teenage males are reported to have the highest incidence (Court-Brown, 1995). EtiologyIn the etiology of tibial fractures, high-speed trauma is paramount. In areas where people drive cars at high speeds and engage in activities with high potential for leg trauma (eg, skiing, soccer), the number of tibial fractures seen in the emergency department is high. While a direct blow to the tibia is the most common cause, countless other etiologies for tibial shaft fractures are encountered. Two of the most prevalent include falls or jumps from significant height and gunshot wounds to the lower leg. ClinicalPatients with tibial shaft fractures report pain of varying degrees, but pain is usually severe. An inability to bear weight on the affected leg and a visible malformation of the leg are often present. Partial fractures may be less characteristic in presentation. The evaluating physician should always keep tibial fracture among the differential diagnoses after trauma, especially in a patient with an altered mental status who cannot provide a reliable history. If the patient's symptoms stem from a stress fracture, the patient may reveal a recent change in lifestyle or an increase in physical activity. The pain is worse with weightbearing exercise and improves with rest. A classic presentation is an athlete who did not participate in conditioning work during summer vacation and presents to the physician's office 2 weeks after beginning vigorous training in a fall sport. Whatever the presentation, taking a complete history and performing a thorough physical examination are important. The history should include the patient's description of the events that brought him or her to the office. Important details to obtain from the patient include exactly what the patient was doing at the time of the injury, the amount of time that has passed since the injury occurred, a description of pain, any associated paresthesias or numbness, and a history of previous conditions that predispose to this injury or complicate surgery. During the physical examination, the physician should not just focus on the leg because concomitant injury is common in tibial fractures. After the other aspects of the examination have been addressed, the physician should specifically attempt to assess the neurovascular status of the patient's injured leg. The results of these examinations are important because their outcomes determine the emergent level of the situation and dictate which surgical specialists must be consulted. The overlying skin should also be examined, with particular care taken in assessing any open wounds or color changes that may indicate a more serious injury. Classification and nomenclature Classifications for fractures are useful for consistent communication between physicians. They have been used to predict probability of fracture union and, hence, as a guide for fracture treatment (Blick, 1989; Court-Brown, 1991; Court-Brown, 1990; Schandelmaier, 1997; Tornetta, 1994; Whittle, 1992). The classic classification for open fractures was described by Gustilo et al (Gustilo, 1976), as follows:
The Orthopaedic Trauma Association has also adopted a system of classification for tibial shaft fracture. Their system, based on radiographic evaluation (Müller, 1990), divides fractures into 3 main categories (ie, A, B, and C). Each category is divided into 3 groups, and each group is then further divided into 3 subgroups.
INDICATIONSSection 3 of 12
Most closed tibial fractures can be treated nonoperatively with good result, but infection risk and fracture stability must be considered. Littenberg et al reviewed 2372 case reports of closed tibial fractures treated between 1966 and 1993. They compared clinical outcomes between cast treatment, open reduction and internal fixation, and intramedullary rod therapy. They showed cast treatment to be associated with fewer superficial infections than open reduction and internal fixation. Open reduction and internal fixation, however, demonstrated a higher union rate at 20 weeks (Littenberg, 1998). In some instances, the fracture cannot be properly treated with nonoperative methods. Operative fixation is required when fractures are unstable. Instability is defined as greater than 1.5 cm of shortening, more than 5° of varus or valgus angulation, 10° of anterior or posterior angulation, and/or less than 50% translation while the leg is in a cast. Factors that contribute to instability are the degree of comminution, the presence of ipsilateral fibular fractures, and the location of the fracture along the tibia. The original presenting radiograph is useful because often with cast or brace treatment, the original amount of shortening is what the fracture ultimately heals with; therefore, shortening greater than 1 cm is a relative indication for operative stabilization. Open fractures are surgical emergencies, and an orthopedic surgeon should be consulted immediately. Rarely, a type I fracture can be treated nonoperatively, but most patients should be scheduled for debridement and irrigation within 6 hours of the injury. Longer intervals have been shown to increase rate of infection (Kindsfater, 1995). Patients with Gustilo type II and III open fractures should always be taken to the operating room for irrigation, debridement, and possible surgical fixation (eg, intramedullary nailing, external fixation, plating). Situations in which an open fracture should not be emergently corrected are rare. In some cases, however, especially in the polytrauma scenario, definitive fracture treatment may be delayed. If surgery must be delayed, leg appearance and compartmental pressure must be monitored carefully. RELEVANT ANATOMYSection 4 of 12
The leg is divided into 4 distinct fascial compartments. The compartmental anatomy can become extremely important during a traumatic situation in which internal bleeding in the leg can lead to a compartment syndrome. The anterior compartment contains the dorsiflexors of the foot, including the tibialis anterior, extensor digitorum longus, extensor hallucis, and peroneus tertius. Also housed in the anterior compartment is the deep peroneal nerve. The major blood supply to the anterior compartment is from the anterior tibial artery and its associated vessels. The lateral compartment contains the peroneus longus and brevis muscles, which primarily serve in eversion of the foot. The superficial peroneal nerve is contained in this compartment and innervates these 2 muscles. The posterior aspect of the leg is divided into 2 compartments, superficial and deep. The deep compartment contains the plantarflexor muscles, including the tibialis posterior, flexor hallucis longus, and flexor digitorum longus. The peroneal and the posterior tibial arteries also course through this compartment with their corresponding veins. The superficial posterior compartment is the largest of the 4 compartments but contains only muscle. These plantarflexing muscles include the soleus, the gastrocnemius, and the plantaris. CONTRAINDICATIONSSection 5 of 12
Several contraindications to surgery are recognized for the treatment of tibial shaft fractures. All patients require a thorough preoperative evaluation and must be cleared for general anesthesia prior to any operation, including treatment of tibial shaft fractures. In cases of acute trauma, patients should be stabilized by the trauma team prior to fixation of a tibial shaft fracture. Incision and drainage of infected fracture sites is often indicated; however, hardware should never be placed into an infected wound. In cases in which infected hardware is removed, treat the infection with intravenous antibiotics and replace the hardware in a second surgery after the infection has been thoroughly treated. WORKUPSection 6 of 12
Lab Studies
Imaging Studies
TREATMENTSection 7 of 12
Medical therapyCasting Initially, all tibial shaft fractures should be stabilized with a long posterior splint with the knee in 10-15° of flexion and the ankle flexed at 90°. Admission to the hospital may also be necessary to control pain and to closely monitor for compartment syndrome. Closed fractures with minimal displacement or stable reduction may be treated nonoperatively with a long leg cast, but cast application should be delayed for 3-5 days to allow for early swelling to diminish. The cast should extend from the mid thigh to the metatarsal heads, with the ankle at 90° of flexion and the knee extended. The cast increases tibial stability and can decrease pain and swelling. Early ambulation with weightbearing as tolerated should be encouraged. Tibial shaft fractures treated with casting must be monitored closely with frequent radiographs to ensure that the fracture has maintained adequate alignment. Adequate callus formation generally takes 6-8 weeks before cast therapy can be discontinued. Despite proper casting techniques and adequate follow-up, not all nonoperatively treated tibial shaft fractures heal successfully. In addition, 6 weeks without knee motion often results in a stiff joint. In fact, Kyro et al described that 53% of patients reported a fair or poor result using long leg casts to treat tibial shaft fractures (Kyro, 1991). This and many other studies have shown that simply putting a tibial fracture in a long leg cast may lead to increased joint stiffness, some difficulty ambulating, and increased union times (Karaharju, 1979; van der Linden, 1979). Another type of cast, the patellar tendon–bearing cast, was proposed by Saramiento to be used early in treatment of tibial shaft fractures in place of the long leg cast. Saramiento reported good results for treatment of tibial shaft fractures with the patella tendon–bearing cast (Sarmiento, 1967). In general, however, better results are reported with internal fixation of displaced tibial shaft fractures than with nonoperative treatment. Hooper et al found that the results of treatment of displaced tibial shaft fractures were not as satisfactory as those with intramedullary nailing (Hooper, 1991). Bracing Three years after describing the patellar tendon–bearing cast, Saramiento proposed another treatment, the functional brace (Sarmiento, 1967). The functional brace has since replaced the long leg cast in many circumstances because it can be put on within 2-4 weeks of injury. It allows more movement of the knee and ankle while still protecting the tibial fracture. Movement of the knee and ankle may decrease the stiffness that patients encounter after the fracture is healed. However, the long leg cast is still used for the first few weeks until the fracture begins to stabilize. As with the patellar cast, Saramiento found very good results; however, others subsequently discovered problems, including a 40% nonunion rate in one trial (Kindsfater, 1995). While no definitive nonoperative treatment has been determined for tibial fractures, many authors have noted increased nonunion and healing time with casts and braces compared with surgical fixation (Kindsfater, 1995; Kyro, 1991; Karaharju, 1979). Therefore, casts and braces have limited use, especially with displaced fractures. The ideal candidate for nonoperative treatment is a young patient with a nondisplaced fracture. Surgical therapyOperative fixation is required when fractures are unstable. Preoperative detailsThe initial step in the operating room is to examine the injury with the patient under anesthesia. This gives the surgeon a better understanding of fracture stability without causing pain to the patient. In managing an open tibia fracture, the surgeon should then begin with extensive irrigation and debridement of devitalized tissue and bone. This step is very important to prepare the fracture for reduction and to combat infection (Edwards, 1983). If a tibial shaft fracture is associated with a break in the skin, the wound should be treated as an open fracture. The important factors to the successful treatment of contaminated open tibial fractures include radical debridement of necrotic tissue, pulsed lavage of the area to remove bacteria, and prophylactic intravenous antibiotics. Open fractures are surgical emergencies. Most patients should be scheduled for debridement and irrigation within 6 hours of the injury (see Indications, above). For antibiotics, frequently an aminoglycoside combined with a cephalosporin is adequate. For low-grade open fractures, antibiotics such as first-generation cephalosporins are used. For higher-grade injuries in which dirty wounds and infection are more likely, penicillin and aminoglycosides are appropriate. Repeat debridements (every 24 h, as needed) are often used in injuries with extensive soft tissue injury, in severely contaminated wounds, or in wounds with vascular compromise in which additional necrotic tissue may present itself. Soft tissue is usually covered (using sterile technique) within 1 week of injury. A splint should be used for stabilization. The splint usually remains intact until the patient is prepared in the operating room. Intraoperative detailsPlating tibial shaft fractures is a viable surgical option and was the treatment of choice 2-3 decades ago. The procedure involves using a large surgical incision, reducing the fracture, placing a metal plate over the fracture, and fixing the plate onto the bone with multiple screws. Because of the extensive soft tissue manipulation required, plating can be difficult for the surgeon and damaging to the local vascular supply. In fact, some authors believe that it is not indicated for open fractures because of an infection rate as high as 44% (Behrens, 1986). Recently, intramedullary nailing and external fixation have replaced fracture plating because they entail decreased technical difficulty, infection rates, and damage to local soft tissues. External fixation is a widely used and very successful method for treating some types of tibial shaft fractures. The procedure involves multiple pins attached to the external rods to maintain length and alignment. This therapy is particularly useful for proximal tibial fractures that may be difficult to align properly with an intramedullary nail. Another common indication for external fixation is a severely comminuted fracture pattern that is difficult to align for reaming and nailing. External fixation is also useful for tibias in which the intramedullary canal is too narrow to ream. Throughout the years, many different designs of external fixators have been used and studied without consensus opinion for any specific type (Court-Brown, 1990; Behrens, 1986; Benum, 1982; Court-Brown, 1985). Despite the various options available, external fixation is associated with higher rates of nonunion and malunion than intramedullary nailing (Benum, 1982; Gershuni, 1982; Clifford, 1987). These complications may be avoided, however, with proper reduction in the operating room (Lawyer, 1980) and with fracture fixation for at least 6 weeks (Court-Brown, 1985). Intramedullary nailing with locking screws has become the treatment of choice for most tibial shaft fractures. The prevalence of nonunion and malunion is greatly decreased compared with the other methods of fixation. Patients are also able to return to low-impact activities much sooner than with the other treatments. While intramedullary nailing is generally accepted as the standard of care for treating many types of tibial shaft fractures, specific techniques are not without controversy. The point of contention most frequently involves whether the tibia should be reamed before the intramedullary nail is placed. Animal studies have demonstrated an increase in blood flow to the periosteum and surrounding muscles with reaming (Hupel, 1998), which would presumably lead to a better result. But, in 1997, Keating et al performed a prospective randomized trial that compared reaming with nonreaming in open tibial fractures. In their study, no differences were noted in union time; rates of nonunion, malunion, or infection; or outcome. In a similar study performed on closed fractures, however, reamed tibial fractures had substantially better results than unreamed tibial fractures (Court-Brown, 1996). Regardless of preference for the reamed or unreamed technique, tibial nails remain the treatment of choice for open tibial fractures. Amputation is uncommon but is sometimes indicated for severe tibial fractures, especially those with large soft tissue injury or those in patients with vascular compromise, such as in diabetic patients. Amputation for grades I and II fractures is rare, but the rate of amputation is increased for grade III fractures. In fact, fractures requiring revascularization (type IIIc fractures) have a corresponding amputation rate of greater than 20% (Brinker, 1997; Lange, 1985). The Mangled Extremity Severity Score is a tool that has been developed to help the surgeon decide whether or not amputation is indicated, but it is only part of the equation. Surgical expertise and patient communication are of vital importance when making amputation decisions. Postoperative detailsAfter surgery, the patient should be monitored in the postanesthesia care unit until stable. Depending on the extent of the other injuries, the patient may be transferred to the surgical intensive care unit or to a regular ward bed. Initially, the patient's vital signs should be monitored repeatedly, with careful attention paid to any abnormalities. If a complication occurs, early discovery almost always improves the prognosis. On the first postoperative day, the patient should be examined by the surgical team and a complete blood count should be obtained. Once that patient has recovered from surgery and is considered safe to leave the hospital, he or she should be discharged to home or to a suitable rehabilitation facility. Follow-upDepending on surgeon preference, the patient is usually seen in a clinic 2-3 days after discharge, and radiographs are taken to view the reduction. If the reduced fracture is still properly positioned, the patient returns on a regular less-frequent basis for radiographic and clinical examination of the leg. Once the patient has healed, braces and external fixators may be removed. Many tibial nails are not removed and may remain in the patient indefinitely. COMPLICATIONSSection 8 of 12
The complication that should concern every physician treating a tibial shaft fracture is compartment syndrome. Compartment syndrome occurs when the pressure inside a particular fascial compartment of the leg is elevated to a point that it can cause restriction of blood flow and nerve damage. The usual causes of compartment syndrome include hematoma and soft tissue swelling. The signs of compartment syndrome are traditionally defined as increased pressure, pulselessness, paresthesia, pain, and pallor to the distal affected extremity; pulselessness and pallor are also associated with vascular injury. The most reliable signs are increasing pain with passive stretching of the muscles within the compartment and hypesthesia. The physician does not need to observe all of the signs to diagnose compartment syndrome. The physician should have a high index of suspicion for this complication, and aggressive surgical treatment is mandatory. Always remember that decreased pulses may not manifest until late in the process. Many surgeons now advocate the use of pressure monitors to aid in treatment decisions. Compartment pressures greater than 25-30 mm Hg are concerning and indicate the need for consultation with a surgeon. Treatment for compartment fractures involves fasciotomy. A fasciotomy is performed by making 2 longitudinal incisions in the affected leg, one laterally and one medially. The lateral incision allows the surgeon to access and decompress the anterior and lateral compartments, while the medial incision offers access to the posterior compartments. During this procedure, all 4 compartments must be opened to survey damaged vessels and to ensure decompression. Infection is a concern with any surgical procedure, especially with open fractures. The risk of infection also increases when surgical hardware (nails and fixator pins) is placed into the area. For this reason, irrigation, debridement, and intravenous antibiotics are vitally important. Also, the value of conscientious nurses and house staff cannot be overemphasized for the recognition and treatment of early infection. A common and frustrating complication of tibial fractures is nonunion. Nonunion is defined as a fracture that has been present for 9 months with no visible signs of healing for the past 3 months (Taylor, 1992). Some of the many causes of nonunion include infection, malnutrition, unstable fracture fixation, and incomplete fracture reduction. Treatment of nonunion is guided by the underlying cause. If the wound is infected, irrigation, debridement, and antibiotics are indicated. After the infection is cleared and any malnutrition is treated, a different method of fixation may be used. It should be noted, however, that adding hardware such as intramedullary nails or external fixator pins is almost never indicated in an infected leg. If nonunion is due to malalignment without infection or malnutrition, exchange nailing and bone grafting are the preferred treatments. Exchange nailing involves removing the previously used tibial nail, reaming the canal, and placing a new, larger nail in its place. This treatment has a very high success rate (Templeman, 1995) and has been advocated by many surgeons. The treatment of tibial shaft fractures of all forms has been fraught with complications. An analysis of prospective, randomized, controlled trials has demonstrated that the combined prevalence of nonunion was lowest with operative treatment, but the prevalence of infection was greatest with operative treatment. The prevalence of infection with plate fixation was greater than that with intramedullary nailing (Coles, 2000). To deal with the problem of nonunion, initial external fixation of open tibial shaft fractures has undergone subsequent conversion to intramedullary nailing. Studies have shown poor progression to union with this technique, as well as increased surgical complications (McGraw, 1988). Alternative treatment options should be considered before conversion of external fixation to intramedullary rodding. OUTCOME AND PROGNOSISSection 9 of 12
The outcome of tibial shaft fractures can be less than ideal under many circumstances. These fractures almost always heal with some angulation, rotation, or shortening, which alters load transmission across the extremity. Patients with tibial shaft fractures have been evaluated with respect to joint pain, disability, osteoarthritis, and joint stiffness. Studies have shown that long-term outcomes for tibial shaft fractures generally are good, but a small increase in osteoarthritis of unclear etiology in the knee and ankle has been observed (Milner, 2002). The cause of increased osteoarthritis appears to be multifactorial. Reamed intramedullary nails with interlocking screws provide an excellent means to control rotation and limb shortening (see Treatment, Intraoperative details, above). FUTURE AND CONTROVERSIESSection 10 of 12
Many different designs of external fixators have been used and studied without consensus opinion for any specific type. Intramedullary nailing is generally accepted as the standard of care for treating many types of tibial shaft fractures; however, specific techniques are not without controversy, especially whether the tibia should be reamed before the intramedullary nail is placed (see Treatment, Intraoperative details, above). MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
Tibial Shaft Fractures excerpt Article Last Updated: Feb 22, 2005 | |||||||||||||||||||||||||||||||||||
