TIBIAL SHAFT WITH OR WITHOUT FIBULAR FRACTURES
Introduction and anatomy
The tibia and fibula are the the bones of the leg which extended from the knee above to ankle below the tibia is more big than fibula the tibia is the medial bone but fibula is lateral one the tibia has shaft upper and lower end it is alone articulates with the femur at the knee joint the upper end has medial and lateral condyles the tuberosity of the tibia is at upper end of the
anterior border of the shaft and gives attachment to the ligamentum patella the shaft of the tibia is lies subcutaneous so lacerations over it heal poorly because of lack of vascularity in the subcutaneous tissues as only the periosteum supports the skin the lower end of the tibia has the medial malleolus the
inferior surface of the of the lower end of the tibia is smooth and forms with the malleloi the upper surface of the ankle joint
the fiblua is a long and thin bone has shaft upper and lower end and small head at it is upper end and has lateral melleolus at it is lower end the head of the upper end of the fibula articulate with the tibia below the head their is the neck around which winds the common peroneal nerve and damage to the nerve at this point as in fractures of the neck of the fibula or tight below knee plaster will result in foot drop
Causes
Introduction and anatomy
The tibia and fibula are the the bones of the leg which extended from the knee above to ankle below the tibia is more big than fibula the tibia is the medial bone but fibula is lateral one the tibia has shaft upper and lower end it is alone articulates with the femur at the knee joint the upper end has medial and lateral condyles the tuberosity of the tibia is at upper end of the
anterior border of the shaft and gives attachment to the ligamentum patella the shaft of the tibia is lies subcutaneous so lacerations over it heal poorly because of lack of vascularity in the subcutaneous tissues as only the periosteum supports the skin the lower end of the tibia has the medial malleolus the
inferior surface of the of the lower end of the tibia is smooth and forms with the malleloi the upper surface of the ankle joint
the fiblua is a long and thin bone has shaft upper and lower end and small head at it is upper end and has lateral melleolus at it is lower end the head of the upper end of the fibula articulate with the tibia below the head their is the neck around which winds the common peroneal nerve and damage to the nerve at this point as in fractures of the neck of the fibula or tight below knee plaster will result in foot drop
Causes
fractures tibia are result from high energy injuries in young adult by direct force as road traffic accidents (RTA) direct blow from car bumper which called bumper injuries or by kicks during football or sporting injuries or from fall from motorbike combining impaction and bending force in older patient can result from minor injuries due to osteoporosis fractures tibia and fibula are common associated with major soft tissue injuries or result from indirect force as torsion of body on fixed foot base eg fall during skiing or bending of fixed tibia and foot during sideway fall of body indirect tibial fractures tend to be spiral or oblique but direct force to the tibia and fibula produced oblique or transverse fractures and occur at the same level in both bones they can also associated with butterfly segment or more extensive comminution they are often open fractures due to external trauma to subcutaneous tibia or from a bony spike from within
Clinical features
like any fractures beside deformity is usually except if the fibula is intact because it acts as an internal splint
assess neurovascular status of the limb and associated soft tissue injuries skin loss may be seen
common site of fractures is at the junction of the proximal two third and distal one third
Investigations
Radiological X rays plain should be done on the whole tibia to avoid missed associated injuries the configuration of the fractures is depend on the type of the force applied to the bones as direct force common oblique or transverse fractures and indirect force common are spiral or oblique fractures
Treatment
The treatment depend on the stability of the fractures and whether it is open or closed fracturs
in closed stable fractures eg transverse fractures conservative management as a long leg cast above knee cast would be sufficient
in displaced fractures a variety of treatment are available as
in oblique and spiral fractures are potentially unstable but conservative treatment by above knee cast is an optional if there is minimal displacement
fractures of the tibia are more common open than in any other bone and skin closure is particularly difficult because the bone is subcutaneous
in displaced fractures treatment by stabilisation of tibial fractures there are several techniques as
tibial nail or intramedullary nailing :for diaphyseal fractures may allow early weight bearing
plate and screws: more useful for metaphyseal fractures
external fixation in case of open fractures or acute fractures associated with soft tissue injuries it has particular use with the combined diaphyseal and metaphyseal injury as a bridging fixator that allows the soft tissue to stabilise as
external fixator monolateral frame good temporay fixation may complicated by pin site infection and loosing
circular frame Ilizarov technique allow great control of
fragments does not disrupt soft tissue
Complications
Compartment syndrome very important in these fractures
Soft tissue injury: a tibial fracture is often associated with tissue damage and tissue loss
It is vital to aid fracture healing and avoid infection by early skin cover
Vascular injury: a displaced fracture of the proximal shaft may damage the trifurcation of the popliteal artery. This needs immediate arteriography and repair. inform the vascular team immediately
Delayed union and non-union: occurs less common in most of cases Often occurs secondary to the significant initial displacement, comminution and distraction, causing soft tissue injury and de-vascularisation of the fracture site
Mal-union: shortening, malrotation, varus and valgus deformity of > 10 degree may lead to secondary OA of the knee or ankle
Ankle and subtalar joint stiffness: due to prolonged immobilisation
wound infection
Isolated fibular fracture
treatment by conservative management such as a below knee walking cast for six week to aid pain relief and provide support
Open fracture of the tibia and fibula
Tibia/fibula fractures are often open as the bones are quite superficial and they should be managed along the general principles outlined below
Open fractures are orthopaedic emergencies and the orthopaedic team should be contacted at once
Photograph the wound is very important
Dress the wound with Betadine dressing and give IV antibiotics: first-generation cephalosporins and penicillin, plus gentamicin for high-grade/contaminated wounds. NB: many hospitals have their own antibiotic policy so check locally before prescribing
Check tetanus status and give booster if necessary
Open fractures must be debrided and the skeleton stabilised within 6 hours of injury
Classification can be according to the soft tissue defect left after debridement as in Gustilo and Anderson's classification
Gustilo and Anderson's (1976) classification of open fractures
Type I
Wound < 1 cm long
Little soft tissue damage
Simple fracture pattern with little comminution
Type II
Wound > 1 cm long
Not extensive soft tissue damage
Moderate contamination and fracture comminution
Type III
Extensive soft tissue damage
Contamination and fracture comminution
Type A: soft tissue coverage is adequate. Comminuted and segmental high-energy fractures are included regardless of wound size
Type B: extensive soft tissue injuries with massive contamination and severe fracture comminution require a local or free flap for coverage
Type C: arterial injury requires
Classification can be according to the soft tissue defect left after debridement as in Gustilo and Anderson's classification
Gustilo and Anderson's (1976) classification of open fractures
Type I
Wound < 1 cm long
Little soft tissue damage
Simple fracture pattern with little comminution
Type II
Wound > 1 cm long
Not extensive soft tissue damage
Moderate contamination and fracture comminution
Type III
Extensive soft tissue damage
Contamination and fracture comminution
Type A: soft tissue coverage is adequate. Comminuted and segmental high-energy fractures are included regardless of wound size
Type B: extensive soft tissue injuries with massive contamination and severe fracture comminution require a local or free flap for coverage
Type C: arterial injury requires
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