COMPARTMENTAL ANATOMY

The anterior compartment contains the dorsiflexors of the ankle and toes: the tibialis anterior,
extensor hallucis longus (in its distal half), and extensor digitorum communis with
accompanying peroneus tertius. Its neurovascular bundle consists of the anterior tibial artery
and veins, joined in the proximal part of the compartment by the deep peroneal nerve. The
artery is assessed distally by the dorsalis pedis pulse. However, flow may be retrograde from
the deep plantar arch and thus be present in spite of anterior tibial artery loss. The deep
peroneal nerve supplies an autonomous sensory zone dorsally on the foot between the bases
of the first and second toes. It provides motor control for the anterior compartment muscles as
well as the short toe extensors. During most of its course through the anterior compartment,
the neurovascular bundle lies deep on the interosseous membrane lateral to the tibialis
anterior. However, as this muscle becomes tendinous and thinner in the proximal third of the
distal quarter, the neurovascular bundle advances anteriorly across the lateral surface of the
tibia, where it may be harmed by pins inserted through the bone. A little more distally, it lies
anteriorly on the tibia between the tendons of the tibialis anterior and extensor hallucis
muscles.
The lateral compartment, superficial to the fibula, contains the peroneus brevis and longus
muscles, the evertors of the foot. The peroneus longus begins proximally on the lateral aspect
of the fibular head. The common peroneal nerve passes under this muscle where it covers the
neck of the fibula. Proximally, the peroneus brevis is deep to the longus, until, distally, it
becomes anterior. Thus, behind the lateral malleolus, the brevis is the anterior of the two
tendons. The superficial peroneal nerve, which provides sensory input from the remainder of
the dorsum of the foot and motor function to the peronei, lies within the lateral compartment,
but no major vascular structures are present.
The superficial posterior compartment contains the triceps surae, or primary ankle flexors,
gastrocnemius, soleus, and plantaris muscles. The sural nerve lies between layers of the
posterior fascia of this compartment and provides sensation to the lateral heel. No major
artery lies within this compartment, which is the most distensible and least likely to develop
elevated pressures after injury.
The deep posterior compartment lies underneath (anterior to) the superficial compartment
and distal to the popliteal line, with its muscles applied to the posterior surfaces of the tibia,
interosseous membrane, and fibula. Within it lie the posterior tibial vessels and tibial nerve,
which provides motor function to the compartmental muscles and the plantar intrinsic
muscles and sensory input from the sole of the foot. Also present are the peroneal vessels.
The deep posterior compartment muscles are the flexor digitorum longus medially, the flexor
hallucis longus laterally, and, deep to these, the tibialis posterior. From proximal to distal, the
tibial neurovascular bundle first lies posterior to the popliteus and then posterior to the medial
border of the tibialis posterior. The tibial nutrient artery leaves the posterior tibial shortly after
it is formed and reaches the bone through the proximal part of the tibialis posterior. The
tendon of the tibialis posterior passes across the tibia and under the flexor digitorum longus to
lie anterior to it and establishes the well-known relationship of the deep posterior
compartment structures behind the medial malleolus: tibialis posterior, flexor digitorum
longus, posterior tibial artery and tibial nerve, and flexor hallucis longusTom, Dick, ANd
Harry ( Table 58-1 ).

The bony pattern of tibial fractures is evident radiographically. In addition to the fracture's
location and displacement, its shape and comminution should be noted. The pattern may be
spiral, oblique, transverse, or segmental. Comminution ranges from none to total
circumferential involvement. Johner and Wruhs used fracture morphology to classify tibial
shaft fractures treated with the Association for the Study of Internal Fixation (AO/ASIF)
techniques.[230] This classification has been adopted by Mller and associates[332] and the
AO/ASIF group in their comprehensive classification of long bone fractures, and
subsequently by the Orthopaedic Trauma Association.[355] It is now the accepted classification
system for scientific studies of tibia shaft fractures ( Fig. 58-7 ).Its results correlate
moderately well with outcome, but other factors are also important in addition to fracture
pattern. Johner and Wruhs recognized the relationship between fracture pattern and injury
mechanism: a spiral pattern caused by torsion; an oblique or transverse pattern caused by
various modes of bending, often with direct injury; and a segmental or transverse highly
comminuted pattern caused by crushing. They also used the extent of comminution, which
correlates with absorbed energy, as an indicator of severity. Their resulting classification has
three major categories: A, simple, noncomminuted patterns; B, patterns with butterfly or
wedge fragments; and C, comminuted patterns, including segmental fractures ( Fig. 58-8 ).
Although somewhat cumbersome to use with the 27 separate categories in its final form, this
classification is demonstrably well suited to the assessment of results after internal fixation of
closed tibial shaft fractures. It is not a comprehensive tibial fracture classification because it
does not include the severity of soft tissue injury, although the authors clearly emphasize the
important influence this has on results. Fracture displacement is also not considered, perhaps
because it has little effect on the outcome of fractures treated by expert internal fixation.
However, it may be quite significant if nonoperative treatment or ill-conceived operation is
chosen. Also excluded from Johner and Wruhs' classification is the location of the fracture.
Proximal and distal fractures, which can encroach on the knee or ankle and can preclude use
of IM nailing, may deserve recognition as separate categories of injury. From Johner and
Wruhs' reported results, it is evident that spiral and oblique fractures have the best prognosis
after internal fixation. Their A1, A2, B1, and C1 fractures had 91 percent to 100 percent good
or excellent outcomes. Transverse fractures had intermediate results, with A3 and B2 gaining
80 percent to 92 percent good or excellent outcomes. Comminuted or crushing injuries had
significantly worse results, with good or excellent outcomes in 75 percent of B3, 68 percent
of C2, and 50 percent of C3 tibial fractures.[230] A fracture classification system ought to
predict results and guide treatment. Because injuries respond differently to different
treatments, the choice of treatment may affect the validity of a grading system. For example,
Johner and Wruhs found faster recovery of transverse, higher-energy fractures treated with
IM nails and reported higher infection (17%) and implant failure (5%) rates after plate
fixation of type B3 injuries that might have had lower rates of complications if treated with
closed locked IM nailing.

FIGURE 58-7 AO/OTA classification of tibial shaft fractures. 42 signifies location as tibial
shaft. Three types are assigned: A, Simple two-part fracture, B, One separate wedge or
butterfly fragment, C, More comminution is present. Each type is subclassified into groups
and subgroups, the former according to Johner and Wruhs. (From Mullr, M.E.; Nazarian, S.;
Koch, P.; Schatzker, J. The Comprehensive Classification of Fractures of Long Bones. Berlin,
Springer-Verlag, 1990, p. 159).

FIGURE 58-8 Johner and Wruhs' classification system for tibial shaft fractures, based on
fracture pattern without directly considering displacement or soft tissue wound severity.
MVA, motor vehicle accident. (Redrawn from Johner, R.; Wruhs, O. Clin Orthop 178:725,
1983.) This system forms the basis of the AO/OTA classification.
TIBIAL FRACTURES WITH COMPARTMENT SYNDROMES
Whenever it develops, on initial presentation or during the subsequent course of a patient
with a tibial fracture, a compartment syndrome requires emergency management. [1670] [3140]
[3170] [4960]
The diagnosis of compartment syndromes has been discussed previously, and the
reader is also referred to Chapter 13 . A compartment syndrome may develop in any tibial
fracture, whatever the apparent severity or mechanism, whether open or closed.[46] Vigilance
is necessary during the first several days after every tibial fracture. Risk factors are proximal
fractures, especially if very displaced, and segmental fractures. Young muscular men are
more commonly involved. Compartment syndrome occasionally may develop soon after IM
nailing. More common is transiently elevated tissue pressure, which resolves.[328] At the first
suggestion of increasing severe pain or neurovascular compromise, it is essential to loosen
any cast or splint, cutting or spreading it to leave a wide, troughlike support for the injured
limb. If this fails to provide complete relief, the surgeon must consider whether the patient
has an established or developing compartment syndrome, whether arterial inflow is
obstructed, or whether there is a nerve injury that mimics the motor and sensory changes of a
compartment syndrome and that also may prevent awareness of ischemic pain.
Increasing pain, swelling, and progressive motor and sensory deficits are diagnostic for a
compartment syndrome, for which emergency fasciotomies are indicated. Absence of
peripheral pulses raises serious concern about arterial occlusion, although diminished or
absent pulses can also be found in well-established compartment syndromes. The best course
is to perform immediate fasciotomies, followed by an intraoperative arteriogram if pulses do
not return when normal compartmental pressures are restored.
COMPARTMENT PRESSURE MEASUREMENT

Rather than an absolute tissue pressure measurement, it is important to consider the

difference (P) between tissue pressure and mean arterial pressure, because this is a better
indicator of the risk of tissue ischemia.[208] McQueen and Court-Brown have recommended
using the more obtainable difference between diastolic arterial pressure and tissue pressure. If
this differential pressure falls to 30 mm Hg or less, they recommend fasciotomies. A
number of their continuously monitored patients had compartmental pressures in the 40 s and
50 s, without symptoms, and with differential pressures over 30 mm Hg. Only 1 of their 116
tibial fracture patients had a lower differential pressure and required fasciotomy.[316]
Continued vigilance and repeated measurements or continuous monitoring are needed if the
patient's neurologic status prevents using the usual clinical symptoms and signs for discovery
of compartment syndrome. However, there does not seem to be much benefit from
continuous compartmental pressure measurement in patients who are alert and under
observation.[196]
Rapid measurement of intracompartmental pressure can be helpful for identifying those
patients with some of the signs and symptoms of compartment syndrome but without
elevated tissue pressures, who will not benefit from fasciotomy. Such patients should be
checked carefully for external pressure over a superficial nerve, especially the peroneal nerve
at the proximal fibula. Although low absolute compartmental pressures (less than 30 to 35
mm Hg) might dissuade the surgeon from fasciotomy, it is important to remember that the
pressure may still be rising. Patients who are hypotensive may develop compartment
syndromes with lower absolute pressures. Patients with more direct muscle injury may also
have a lower tolerance for elevated pressure, the duration of which must also be considered.
Since pressure is highest in the region of the tibial fracture, it should be measured in this area.
FASCIOTOMY
Adequate fasciotomy allows unfettered swelling of injured muscles without elevation of
interstitial fluid pressure. Local capillary blood flow is preserved. This permits survival of
nerve and muscle tissues that are sensitive to ischemia. A wide, truly decompressive
fasciotomy is needed if intracompartmental pressure is or may become dangerously elevated.
Unlike fasciotomies for exercise-related compartment syndromes, those required after tibial
fractures are extensive. It is safest and most appropriate to treat any such leg as though all
four compartments are involved. Therefore, all four compartments are released to ensure
decompression. Two incisions, medial and lateral, are recommended by many
traumatologists. These should be placed on the mid-medial and mid-lateral sides of the limb,
over muscle to facilitate split-thickness skin coverage if necessary. The fascia must be
divided for the entire length of each compartment ( Fig. 58-14 ) (see Chapter 13 ). A fourcompartment fasciotomy using a single lateral incision that is directed both anterior and
posterior to the fibula has also been proposed. This approach has two drawbacks: it is less
likely to provide adequate decompression than the two-incision technique, and it adds
significant soft tissue damage by requiring circumferential fibular dissection. Although
fibulectomy may theoretically decompress all four compartments, it is never appropriate in
the setting of a tibial fracture, because loss of the fibula may compromise reconstruction of
the injured leg.

FIGURE 58-14 A, Anteroposterior photo showing incision placement for double-incision

fasciotomy. This permits reliable decompression of all four fascial compartments of the leg.
B, Cross-section diagram. To ensure that an adequate bridge of anterior skin is left, place the
incisions on the mid-medial and mid-lateral sides of the leg. Sufficient length of fasciotomy
incisions and release of internal fascial envelopes, such as that around the tibialis posterior,
are also important. (A, Artwork modified from Lumley, J.S.P. Surface Anatomy, 3rd ed.
Edinburgh, Churchill Livingstone, 2002. Photograph by Sarah-Jane Smith.)
OPEN TIBIAL FRACTURES
The tibial shaft is the most common site of significant open fractures (reviewed in detail in
Chapter 14 ). The important features of its management are discussed here in some detail.
Evaluation and treatment are outlined in Figure 58-15 , our recommended algorithm for open
tibial fractures. Like closed tibial fractures, the spectrum of severity is wide, with several
factors affecting outcome. Therefore, while general principles hold true, allowances must be
made for the specific features of an individual patient's injury. [4710] [4950] Gunshot wounds
7

produce tibial fractures that are technically open. However, if they are due to low-energy
missiles, dbridement is rarely required and management is similar to that of closed fractures
with similar comminution and displacement. [0680] [1540] More severe gunshot wound fractures
require standard open fracture care. This topic is reviewed in Chapter 16 .

FIGURE 58-15 Algorithm for the management of open tibial fractures. After debridement,
decisions must be made about fixation and wound closure. Any bone loss should be
considered in planning. Delayed bone grafting or bone transport may be needed, depending
on the volume of bone loss. If the fracture permits, intramedullary nailing is usually
preferred. External fixation is an appropriate option for provisional or definitive stabilization
for non-nailable open fractures. If a plate is used, it should usually be deferred until the
wound has healed. Wound closure should be done as soon as dbridement is adequate, and
without significant delay. Technique of wound closure will depend on severity and defect
size.

The initial evaluation is carried out as described previously. The wound is covered with a
sterile dressing, a splint is applied to the leg, and periodic neurovascular monitoring is
instituted. Appropriate tetanus prophylaxis is provided: tetanus toxoid (0.5 mL), if more than
5 years have elapsed since the last tetanus toxoid injection, or if this time is unknown. If prior
immunization is unknown or incomplete, tetanus immunoglobulin (250 units) should be
administered. Separately, active immunization is then completed with a tetanus toxoid series.
Intravenous antibiotics are begun. Unless allergies indicate an alternative choice, a first- or
second-generation cephalosporin is routinely administered, with an aminoglycoside for more
severe wounds and high-dose penicillin if clostridial contamination is likely.[471] An
alternative to a first-generation cephalosporin and an aminoglycoside is the use of a thirdgeneration cephalosporin alone (e.g., cefotaxime).
FIXATION FOR OPEN FRACTURES
Fractures that have an appropriate bone configuration should be stabilized with an IM nail.
While many have advocated nonreamed nailing for open tibial fractures, this has not been
proven to decrease problems with infection or nonunion. [1070] [1120] [1210] [1240] [2050] [2470] Proximal
and distal open tibial fractures are usually best stabilized with external fixation, which may
be used as a temporary or permanent stabilization alternative. If the fracture extends into the
articular surface of the knee or ankle, then anatomic reduction and lag screw fixation should
generally be done as soon as possible after injury, especially if the wound is severe and
coverage problems are anticipated.
The next decision after reconstructing the joint surface is more difficult. The entire tibial
injury may be stabilized by external fixation, either from the metaphyseal fragment to the
diaphysis or by ligamentotaxis, with the fixator anchored beyond the tibia to the femur
proximally or the calcaneus distally. While a buttress plate can be used to internally fix these
fractures, the risk of infection is high enough with plating of open fractures that it is safer to
use initial external fixation, with plating delayed until after the wound has healed. Rarely,
with low-energy wounds and stable fracture configurations, nonoperative fracture fixation
(also discussed later) may be considered as a way to maintain alignment of an open tibial
fracture, but it does not provide enough stability of bone and soft tissue to produce the
optimal environment for early wound healing and resistance to infection. Especially for more
distal fractures, the ankle should be splinted to minimize soft tissue motion in the wound
area. Ultimately, the choice of fixation for an open tibial fracture is a compromise between
that required for the fracture and that required for the soft tissue, with the latter taking
precedence.
WOUND CARE FOR OPEN FRACTURES
Whatever fixation is chosen, it is conventionally advised that the open fracture wound should
not be closed primarily but should instead be left open to avoid tension on the soft tissue and
resulting microvascular embarrassment. An additional benefit is the opportunity to reassess
adequacy of dbridement and soft tissue viability early in the postinjury course. The timehonored practice of delayed wound closure has been supported by the experimental studies of
Edlich and coworkers[134] and the clinical study of Russell and associates.[410] However, a
wound left open must usually be returned to the operating room for delayed closure, and it
also is at risk of becoming nosocomially infected, often with hospital-acquired, antibioticresistant organisms. Thus, interest in primary closure of properly selected and managed

wounds is developing among experienced trauma surgeons, and it is well recognized that
delayed closure of open fracture wounds should occur within a very few days after injury.[118]
Several technical aspects of open wound care are important. Desiccation of exposed tissue
must be prevented. Continuous wet dressings can be used, but these typically dry and may
increase the risk of wound contamination. An immediate split-thickness skin graft, allograft
or xenograft skin, or artificial skin substitutes (e.g., Epigard, Biobrane, etc.) should be
considered. Particularly helpful is the bead-pouch technique described by Ostermann,
Seligson, and coworkers. [2070] [3560] [4320] Keating and colleagues have confirmed that this
technique of open wound management significantly reduces the risk of infection in severe
open tibial fractures treated with reamed IM nails.[244] At completion of dbridement,
tobramycin-loaded polymethyl methacrylate beads are placed in the wound, which is then
sealed with a transparent, adhesive film dressing (e.g., Opsite or Tegaderm). This is then
covered with a bulky absorbent dressing, which can be changed in case of leakage, but the
bead pouch itself is left intact until the wound is reexplored under sterile conditions in the
operating room. Although tobramycin beads can be made by the surgical team in the
operating room, their advance preparation by hospital pharmacy staff allows them to be
delivered in sterile peel-wrap packages for immediate use. (The typical concentration is 2.4 g
of tobramycin powder in one full mix of methacrylate cement).[244] Yet another, increasingly
popular alternative is the use of low pressure, vacuum-sealed wound dressings. [0110] [0940] [1160]
[2100]
They appears to offer significant help with less invasive management of severe lower
extremity wounds, by reduction of edema and promotion of granulation tissue overgrowth,
thus permitting split-thickness skin coverage of wounds that might otherwise require
significant flaps.[117]
Continuing management of the open fracture wound depends on its severity. Type I and many
type II wounds can be left covered with sterile dressings and then closed 5 to 7 days after
injury either with sutures or by application of a meshed split-thickness skin graft, if the
wound edges are not easily brought together. All patients with type III wounds or any
questionable type II wound should be returned to the operating room usually in 24 to 48
hours for thorough reassessment with adequate anesthesia. This procedure involves gently
irrigating out all clot, carefully looking for and removing any necrotic tissue, reassessing
fracture reduction and stability, and then resuming open wound management in a way that
prevents desiccation, as just described. At this time it is too early to proceed with delayed
primary closure, although if the wound is clean and viable, application of a meshed splitthickness skin graft may be considered.
During this first return to the operating room, which should be repeated as many times and as
frequently as needed to obtain a clean wound containing only viable tissue, plans for
definitive wound closure are formulated and carried out as soon as appropriate. [1010] [1240] [5220]
During dressing change and dbridement under anesthesia in the operating room, consulting
physicians can inspect the wound together with the primary fracture surgeon and collaborate
on decision making. Type IIIA wounds can usually be closed by suture or by meshed splitthickness skin graft, while Type IIIB wounds usually require muscle flap coverage with either
a healthy local muscle or a microvascular free flap. [1700] [3690] [5140] (Many surgeons use this as a
working definition of Type IIIB wounds.) The timing of such a closure should be as prompt
as possible, once adequate dbridement is ensured. As mentioned above, there is growing
published support for very early, or even immediate, closure of such wounds, after adequate
dbridement. [1750] [2110] [2140] [4480] However, application of a muscle flap makes subsequent
wound evaluation more difficult. When there is a significant possibility of retained nonviable
10

tissue, less hasty coverage is advisable.[326] One should not delay once it is clear that the
wound is free of necrotic tissue. Failure to achieve adequate dbridement and gain wound
coverage within the first 1 or 2 weeks after injury is associated with a higher risk of problems
after flap coverage. The greatest difficulty comes with severe wounds in which it is difficult
to determine tissue viability until after several dbridements. It is not entirely clear whether
the delay or the more severe wound or both are responsible for the acknowledged higher rate
of wound complications.
Attempts to gain coverage with local tissues by using relaxing incisions or local rotational
flaps may be unwise, especially when the amount of soft tissue damage is more severe. [1260]
[3690]
These can result in loss of additional soft tissue. Preservation of injured local skin is best
achieved by avoiding incisions that create superficial, narrow, or distally based flaps, by
taking pains to place incisions over muscle, and by using tension-free closure with splitthickness skin over viable muscle or, if this is not possible, by transposing healthy muscle
into the wound as a pedicle or free flap, depending on location and available tissue.
EARLY MANAGEMENT FOR BONE DEFECTS
Loss of bone may occur at the time of the fracture, or during necessary dbridement. It is
almost always wisest to remove completely any devascularized, contaminated cortical bone.
Bone loss must be recognized, and plans made for subsequent managementalmost never is
there a role for bone grafting before the wound has completely healed. There may, however,
be a role for application of bone morphogenic proteins at the time of delayed primary wound
closure.[177] Depending on the amount of bone lost, and the type of fixation chosen, various
alternatives must be considered for addressing the defect (see Table 58-4 ). These range from
observation, for small amounts of loss, particularly if treated with reamed IM nailing, to
grafting or bone transport for larger defects. Absence of either an intercalary segment or a
substantial paraxial portion requires restoration of bone substance to obtain fracture union or
to prevent pathologic fracture through a seriously weakened area. Soft tissue defects are
frequently present and may need repair before bone grafting. [0210] [0960] [5220] [5340] There are
occasional reports of replacing extruded fragments of the tibia after sterilization. [0850] [1890]
Although this may work, the risks of infection and delayed reincorporation of the bone
increase the attractiveness of other alternatives. Such fragments may be used to aid reduction,
and then discarded after fixation is applied.[20]
TIBIAL CAST APPLICATION
Advance preparation is a great aid to reduction and cast application. Before beginning, it is
necessary to have close at hand ample cast padding, usually as 4-inch rolls; plaster or
fiberglass rolls, 4 to 6 inches wide; plaster splints or fiberglass cast material if desired; a
bucket of cool water; and a cast saw. The patient's radiographs should be visible on a
viewbox. A seat is helpful for the person applying the cast. The task requires at least two
people: one to hold the leg and the other to apply the cast. The patient must be as comfortable
as possible, and his or her cooperation and understanding should be encouraged. An
intravenous line should be in place. Analgesia is often best provided with intravenous
narcotics (e.g., morphine sulfate, 3 to 8 mg, titrated as needed). Naloxone and medications
and equipment for resuscitation should be readily available. A hematoma block with 1 percent
lidocaine may be considered, with scrupulous attention to sterile technique and awareness of
the risk of systemic effects (myocardial depression, seizures).

11

The patient is positioned recumbent on an examining or operating table. Both legs are
evaluated, so that that rotational alignment and contours of the normal limb can guide
reduction and cast molding. This can be facilitated by hanging both legs over the end of the
table. Alternatively, the injured leg can be abducted at the hip and hung over the table's side.
There must be enough room to allow padding and plaster to be rolled around the upper calf.
The cast is applied in two parts. Almost always (except for very proximal fractures) the lower
part is applied first. The assistant holds the forefoot, steadying the leg and maintaining its
alignment, especially regarding rotation and plantigrade foot position. With knee flexion, the
tibia can rotate significantly on the femur. It is therefore important to assess rotational
alignment using the relationship of second toe to tibial tubercle, as demonstrated by the
opposite limb. The assistant's fingers are placed under the plantar surface, with the thumb
over the dorsum of the foot. Thus, plantar flexion and inversion (supination) are controlled,
both of which tend to occur and subsequently interfere with weight-bearing in this cast.
Although ankle equinus is occasionally the alternative to apex-posterior angulation of a distal
tibial fracture site, it is usually avoidable if, as Sarmiento suggests, the initial cast is applied
with the foot in neutral.[420]
The assistant maintains foot position as chosen while ample cast padding is rolled onto the
foot (including the thumb and fingers of the assistant) and up as high on the leg as the flexed
knee will allow ( Fig. 58-16A ). Developing soft tissue edema and the leg's characteristic
bony prominences argue for thick padding, as does the likelihood that the cast will need to be
cut in the near future, while the leg is still swollen. Because the patient will be supine, extra
padding is required posterior to the heel, where much of the limb's weight will be borne
during recumbency. The malleoli, the fibular head and neck with the surrounding peroneal
nerve, and the subcutaneous tibial border also require extra padding. The padding is palpated
to ensure its adequacy, supplemented if necessary, and then a thin cast (8 to 10 layers of
plaster or 5 to 8 layers of fiberglass) is rolled on from the metatarsophalangeal joints to an
inch or two below the top of the padding at the knee. The plantar surface may be extended to
support the toes, but the dorsum should be placed or trimmed proximal to all five
metatarsophalangeal joints.

12

FIGURE 58-16 Gravity reduction and cast application. Most acute tibial shaft fractures will
reduce fairly satisfactorily when hung over the side of an examining table with the foot
correctly rotated and supported in neutral position. A, The leg must hang far enough away
from the table to allow circumferential access. A pad under the proximal aspect of the thigh
helps. An assistant must hold the foot and steady the leg. The surgeon ensures that the
alignment is correct and applies ample cast padding, especially over the posterior of the heel,
the malleoli, the proximal end of the fibula, the fracture site, and the lines where the cast will
be cut. Plaster or fiberglass casting tape is rolled over the padding with a segment of padding
left exposed just below the knee to be overlapped later by the above-knee part of the cast.
Gentle molding by the surgeon often improves alignment, especially by making the distal
medial tibial surface slightly concave to match that of the normal leg. Six to eight layers of
plaster, or a bit less fiberglass tape, is usually sufficient, perhaps with extra reinforcement at
the knee and ankle. B, Once the lower portion of the cast is firm, it is used to hold the limb in
correct rotation and with the knee flexed approximately 15. Cast padding is then rolled over
the thigh on top of a proximal segment of stockinet to provide a well-padded top cuff. The
patella and hamstring tendons need extra padding. Cast material is then applied
approximately two thirds of the way up the thigh, with the cast material overlapping the
lower part of the cast by 4 to 6 inches. The stockinet and padding are turned down over the
top of the cast and secured with a turn of the casting tape to avoid a sharp edge. The leg must
be supported until the cast is hard. Rotational alignment is then checked by comparison with
the opposite leg. Anteroposterior and lateral radiographs of the full tibia are obtained and
assessed for angulation, displacement, and shortening.

Some surgeons believe that plaster is easier to apply and mold than fiberglass. However, it
should be left thin to simplify alterations and avoid unnecessary weight. Overlying fiberglass
reinforcement can be applied in 1 or 2 days, once it is clear that the cast will be left in place.
As the plaster sets, molding is carried out to make the shape of the medial border of the cast
concave, similar to the patient's opposite leg; a straight cast produces valgus malalignment.
The surgeon should ensure that the foot position has been maintained. Improved wateractivated fiberglass casting tape offers a lighter and more durable alternative to plaster. I
believe it is now quite acceptable as an initial tibial fracture cast, although, like plaster,
adequate padding and careful application are essential.
Once the lower leg portion of the cast is firm, it can be lifted and held horizontally, with the
knee flexed 10 to 15 and the thigh sufficiently clear of the table surface to allow padding to
be extended proximally an inch beyond the intended top of the cast, approximately two thirds
of the way up the thigh ( Fig. 58-16B ). Cast material is then rolled on, overlapping by 4 to 6
inches the top of the previously applied lower portion. It is essential that there be adequate
padding at the junction of the two segments, but no padding should lie between the layers of
the cast material.
As soon as is practical, AP and lateral radiographs are obtained of the entire tibia within the
cast and a decision is made as to the provisional adequacy of reduction and cast application.
Only if there is marked deformity or risk of skin compromise should the appearance of these
radiographs lead to changing the cast. Adjustments such as wedging, applying a new cast, or
changing to another mode of treatment are better deferred until swelling has resolved.
13

The long leg cast just applied may need to be loosened to accommodate potential or actual
swelling of the injured limb. Although it is wise always to anticipate such swelling, many
low-energy tibial fractures can remain in an intact, well-padded cast. Routine splitting of all
initial tibial casts results in unnecessary manipulation and may compromise the cast's
stability.
A cast may be loosened in several ways. If swelling is severe and likely to progress, the cast
should be converted to a posterior trough splint. This is done by removing the anterior third
of the cast and bending both sides outward, wide enough to permit removal of the leg and to
avoid any pressure on the sides of the limb. The padding is cut anteriorly and folded outward
as well, so the padding is not a source of constriction, and to allow examination of the limb.
Removal of part of the medial cast wall at the ankle can allow assessment of the posterior
tibial pulse, if this is needed ( Fig. 58-17 ). A practical concern about removing strips and
windows from casts is that the stability of the cast may be compromised. The result can be a
plaster cast that fails to immobilize the injured limb. Such an outcome does not prevent pain
and may cause additional tissue trauma. Fiberglass used as the initial cast material, or as
reinforcement, can improve the mechanical properties of the initial cast. Whatever material is
used, the adequacy of immobilization must be frequently reassessed.

FIGURE 58-17 Optimal posterior splint. A cast can be loosened somewhat by cutting its
anterior surface from top to bottom, using a cast spreader to open the cut, and bending the
sides out and stretching the cast padding to loosen it as well. However, this technique may
not accommodate significant swelling. If swelling is a concern or if it is necessary that a
severely injured limb be observed while maintaining an adequate splint, the long leg cast can
be converted into a trough splint, after it has hardened, by removing an anterior strip
approximately one third of the cast's circumference. The cast padding is cut and turned back,
and the sides of the cast are bent outward to eliminate pressure on the leg. The trim line is
placed posteriorly, if needed, in the area of the posterior tibial pulse to permit its palpation in
case of potential vascular injury.

Removal of an anterior strip of plaster interferes with ongoing use of the cast. An alternative
is to split the cast anteriorly after it has hardened, which usually takes 1 or 2 hours for plaster,
and then widen this cut sufficiently with cast spreaders so that the padding is stretched and
subsequent loosening of the cast will be easy. This univalved cast may be salvaged after
swelling recedes by squeezing it together and encircling it with adhesive tape just tightly
enough to provide adequate support. Once a final adjustment has been made, fiberglass
reinforcement is added to make the cast strong enough to begin ambulation. It is important to
14

realize that this technique of cast spreading does not provide adequate decompression in the
presence of serious swelling, or if the cast material cannot be bent open. Somewhat better
decompression may be provided by bivalving a cast, with medial and lateral longitudinal
cuts placed just a bit anteriorly to the mid-lateral lines of the cast to maximize stiffness and
durability of the posterior portion, but not so far anteriorly that the opening is too narrow for
removal of the leg. A bivalved cast can be loosened as needed and held securely together with
several encircling loops of adhesive tape. In addition to longitudinal cuts in the cast, windows
may be removed to check questionable areas of skin, to relieve pressure over a bony
prominence, or to assess pulses. The removed cast window should be retained and taped
securely in place when the opening is not in use. Doing this adds to the strength of the cast
and maintains enough overlying pressure to avoid window edema, or swelling of the soft
tissues into the window defect.
If a cast is left intact around a fresh tibial fracture, there must be fail-safe arrangements for it
to be released if the patient develops significant pain or neurovascular compromise. Although
tibial fracture patients typically require hospitalization, one may occasionally be sent home
with a low-energy injury, if he or she is able to use crutches and perform transfers, and has
adequate assistance and prompt transportation back to the hospital. Whether as an outpatient
or in the hospital, the patient should keep the injured leg slightly elevated and should be
observed closely for increasing pain, decreasing sensation, and loss of palpable toe muscle
strength. Pain after a tibial fracture is largely relieved by adequate splinting. Narcotic
analgesics are usually required, but standard doses of parenteral or oral drugs should be
effective and should be required progressively less frequently. After 1 or 2 days, oral
narcotics should be sufficient, perhaps with a timed-release capsule form that may last
through the night. Lack of response to analgesia suggests neurovascular problems.
Definitive Treatment for Tibial FracturesNONOPERATIVE (FUNCTIONAL CAST OR
BRACE)
Sarmiento, perhaps the most eloquent advocate and teacher of nonoperative functional
treatment of tibial fractures, reports impressive results in selected patients with less displaced,
usually lower-energy tibial shaft fractures. He advises that functional closed treatment be
limited to closed injuries that have no more than 15 mm of initial shortening, or are axially
stable, reduced transverse fractures.[424] Displacement in his series averaged only 28 percent
25 percent. He stated that high-energy tibial fractures and fractures in patients with multiple
injuries or ipsilateral femur fractures were usually treated with surgical fixation, which was
also indicated for fractures with excessive initial shortening, segmental bone loss, and
neurovascular damage and for those whose alignment was not maintained satisfactorily in the
initial cast or subsequent brace.
Functional treatment of tibial fractures has proved very satisfactory for properly selected
patients, yielding low rates of nonunion, infection, and significant malunion.[418] However, it
is important to recognize that this treatment protocol has been effective only for selected lowenergy tibial fractures. [0160] [4240] [4800] [4810] [4820] When other alternatives are available, it is
inappropriate for tibial fractures with significant associated soft tissue injury. Using the
modified Ellis classification system described previously, functional bracing, as a primary
treatment, should be restricted to tibial fractures of minor severity. Rarely, more severe
injuries can also be managed in this way, but only if they are axially stable and can be easily
controlled during weight-bearing in the cast or brace.

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Functional bracing begins with a closed gravity realignment and application of an initial cast,
as described previously. In addition to injury severity, the adequacy of reduction in this cast
and the patient's subsequent clinical course are the most important determinants of whether
closed functional treatment is appropriate. The amount of soft tissue damage determines the
shortening that may occur. Ultimate shortening is usually predictable from the amount of
shortening apparent on the initial radiographs. Brace treatment is rarely appropriate if there is
more than 15 mm of shortening, as measured by fragment overlap or by a scanogram in the
cast. Poor control of angulation in a long leg cast is also a contraindication to functional
bracing, unless it is corrected by reapplication of cast or brace. Angulation on either AP or
lateral radiograph should not exceed 5.
Significant comminution and displacement of more than 30 percent of the shaft diameter are
further contraindications to closed functional treatment because of their association with
delayed healing when this treatment is used.[482] Closed functional treatment should be used
with caution for distal tibial fractures, as maintenance of satisfactory alignment may prove
difficult. It is also rarely appropriate for patients with bilateral lower extremity injuries who
will usually walk sooner on a nailed tibial fracture, for patients with high-energy injuries with
extensive closed or open soft tissue injuries, and for patients with ipsilateral femur fractures.
Elderly and infirm patients may be better able to care for themselves after fracture fixation if
it permits weight-bearing sooner with greater comfort and less encumbrance.[395] Unreliable
patients, who may not return faithfully for follow-up visits during the 4 to 7 months typically
required for fracture healing, may have lower risks if internal fixation can be done in a way
that permits unrestricted weight-bearing. If such fixation is not possible, then internal fixation
may not be as safe as closed treatment.
Fracture braces and functional casts rely on soft tissues, primarily the interosseous
membrane, to prevent shortening while the surrounding cast controls angulation and rotation.
[421]
When soft tissue disruption is considerable, a simple closed reduction cannot stabilize a
displaced oblique or spiral fracture or one with significant comminution. A displaced
transverse fracture may rarely have its length and stability restored with a closed reduction
and cast application under anesthesia, if end-on-end apposition can be maintained. This has
been advocated for such injuries. However, these injuries may heal slowly, and are well
treated with closed IM nailing. Thus, it seems generally appropriate to offer definitive
fixation with the first, and hopefully only, anesthetic. Toivanen has demonstrated that IM
nailing is less costly than closed reduction, if the latter requires an anesthetic.[480]
Functional cast or brace treatment is also advisable after removal of an external fixator. (Its
use for this purpose is discussed in the section, External Fixation.)
FRACTURE-BRACING TECHNIQUE
The following protocol for closed functional treatment of tibial shaft fractures is similar to
that which Sarmiento and his coworkers have developed. [4200] [4230] The first stage involves
application of a gravity reduction cast, as previously described. An acceptable reduction must
be confirmed. Initially, the patient rests his/her leg with elevation slightly above heart level.
Ice packs applied to the cast may increase comfort. Narcotic analgesics are usually required.
Progressively increasing ambulation is encouraged, with weight-bearing as tolerated using a
removable cast boot, and crutches or a walker as needed. The patient is asked to elevate the
limb when not walking and to do isometric exercises with the immobilized muscles and
active and passive exercises for the toes. He or she should be reassured about the inevitable
16

motion of fracture fragments felt inside the cast, and the benefits of progressive weightbearing on the fractured limb. In addition to the exercise program, physical therapy may help
with gait training on level surfaces, on stairs, and for transfers. Once patients are comfortable
and mobile enough to manage at home, and any necessary assistance has been arranged, they
are discharged to outpatient follow-up. They are instructed to report promptly any cast
problems, increasing pain, motor or sensory deficit, or excessive swelling that is not rapidly
relieved by rest, elevation, and milder analgesics. An office or clinic visit 1 or 2 weeks after
discharge permits reassessment of comfort, gait, swelling, neuromotor function, cast integrity,
and clinical as well as radiographic alignment.
Although some patients may benefit from a PTB walking cast, as originally advocated by
Sarmiento, a prefabricated functional PTB brace from knee to foot, with a hinged ankle, has
largely replaced this, unless a satisfactorily fitting brace is not available or offers inadequate
control, as may happen with a very distal fracture ( Fig. 58-18 ). The PTB cast or brace is
applied when the patient can comfortably bear partial weight in the long leg cast and early
fracture consolidation has begun. This usually occurs between 3 and 5 weeks after injury.
Proximal tibial fractures may be better controlled in a long leg cast. If knee motion is desired
for such patients, hinges and a thigh cuff can be added to its below-knee portion. An effective
method for doing this is to use a fiberglass below-knee cast, molded as shown in Figure 5818A , to which are attached the hinges and adjustable thigh cuff of a commercially available
modular fracture brace. A prefabricated fracture brace that follows Sarmiento's principles
usually provides excellent fracture control while permitting satisfactory function for the
majority of patients with low-energy tibial shaft fractures. Alternatively, a custom-molded
bivalve total contact brace can be fabricated by an orthotist. This may have either a fixed or a
hinged ankle, depending on the degree of immobilization desired. Such braces can be helpful
for patients who are hard to fit with prefabricated ones. Zagorski showed equivalent
stabilizing efficiency of plaster casts, custom and prefabricated fracture braces, plus no
additional benefit from the classic PTB proximal extensions, for experimental mid-shaft tibial
fractures.[531]

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FIGURE 58-18 A, A patellar tendon-bearing (PTB) functional cast is applied after the soft
tissue swelling has resolved and the fracture has become somewhat sticky and less tender.
If a neutral ankle position was achieved with the initial cast, it should be easy to maintain in
the PTB cast. Such a walking cast is pointless unless the foot is plantigrade, which is
necessary for weight-bearing. The top of the cast is trimmed anteriorly at the level of the
distal portion of the patella, a little lower than originally described by Sarmiento and low
enough posteriorly to permit 90 knee flexion. The upper part of the PTB cast is molded into
a triangular cross section so that it flares upward and outward over the anterior surfaces of the
tibial plateau (inset). This alteration produces a bulge over the proximal end of the fibula and
peroneal nerve while providing a molded fit for the anterior surfaces of the proximal part of
the tibia, thus supporting it and gaining rotational control. The PTB cast is used chiefly for
distal fractures in which a brace with ankle motion might not provide adequate control and
for patients in whom commercially available prefabricated braces do not fit. B, A
prefabricated fracture brace is usually applied to tibia fractures instead of a PTB cast. It may
not fit well or provide adequate support for a distal fracture, and it typically requires proximal
trimming or padding for comfort and fracture support. The brace is applied over a thick
elastic stocking. A sneaker or walking shoe goes on over the heel cup and helps maintain
alignment of the brace on the leg.

Radiographs through the cast or brace are initially checked every 2 to 3 weeks to ensure
maintenance of satisfactory alignment. Minor degrees of angulation can be corrected with
18

cast changes or wedging. However, the latter may render the cast less suitable for weightbearing, so that once the fracture is sticky enough to permit only bending rather than
translation of fragments, it is better to change the cast or move on to a brace rather than adjust
alignment with wedging. Significant difficulty obtaining or maintaining satisfactory fracture
alignment with cast or brace suggest the advisability of surgical reduction and fixation.
The fracture brace is applied when the patient can walk in a long leg cast, and satisfactory
fracture alignment has been maintained. This involves removing the cast, and applying a
thick elastic fracture-brace sock. Next, the fracture brace is secured snugly over it. Trimming,
and occasionally padding the brace or molding it with the aid of a heat gun, may be needed
for comfort and optimal fracture control. The heel cup and ankle hinge must be sized and
adjusted correctly. A lace-up athletic shoe helps hold the brace in place. Brace tightness is
adjusted as needed by the patient to provide comfortable support. Progressive weight-bearing
is again encouraged. Crutches and cane can be discarded when tolerated and gait is
satisfactory. Many believe that significant weight-bearing within 6 weeks of injury promotes
fracture healing. [4230] [4240]
Radiographs are obtained in the brace initially and again in 1 or 2 weeks, at which time it is
also essential to reconfirm that the brace fits well, without skin or nerve irritation, and that the
patient is maintaining and adjusting it properly. Thereafter (usually from 6 to 8 or more
weeks after a low-energy tibial shaft fracture), it is usually possible to monitor the patient
with visits and radiographs every 4 to 6 weeks. The brace is continued until the patient is
fully weight-bearing without discomfort; tenderness and warmth are absent at the stable
fracture site; and radiographs in the AP, lateral, and both oblique projections confirm union
with mature bridging callus (see later discussion of assessment of fracture healing).
At this point, if significant residual muscle weakness and atrophy persist, the patient's
endurance is not yet normal, and the skeleton is weaker than normal as a result of disuse
atrophy. Therefore, a continuing rehabilitation program with avoidance of risk and contact
sports is advised, while encouraging repetitive progressive loading. These graded,
progressively increasing exercises should continue until the patient's activity level and
tolerance reach an appropriate goal. This often requires 6 to 12 months from the time of
injury.
Skin problems associated with braces are usually rare but should be watched for. If they
develop, padding or other brace adjustments may be required. All patients need at least two
socks, one to wash and the other to wear.

19