INJURIES OF THE LEG

FRACTURES OF SHAFTS OF TIBIA AND

FIBULA
A. Tibia is the weight bearing bone of the leg.
B. Connected to the fibula by the proximal and distal tibiofibular joints.
 PROXIMAL TIBIO-FEMORAL JOINT
• It is a plane synovial joint formed by the articulation of the head of the
fibula with the posterolateral aspect of the tibia.
• The joint capsule reinforce by the anterior and posterior tibiofibular
ligaments.
• The motions at this joint are small and is described as superior and
inferior sliding of the fibula and as fibular rotation.
 DISTAL TIBIO-FEMORAL JOINT
- It is a syndesmosis or fibrosis union between the concave facet of the tibia
and the convex facet of the fibula.
- The two bones are not in actual contact but are separated by fibro adipose
tissue.
- The stabilization is primarily by the surrounding ligaments.
- Ligaments are : 1) Anterior and Posterior tibiofibular ligament.
2) Interosseous membrane
[It directly supports both the proximal as well as distal joint]
- The fractures of tibia and fibula are commonly due to RTA and are often
open fractures.
 CHARACTERISTIC OF THE BONES
1) Sub cutaneous bones: Tibia is a subcutaneous bone and hence usually
results in open fractures . There is often loss of bone through the wound .
2) Fractures in this region are often associated with massive skin loss.
3) Precarious blood supply: The distal 1/3rd of tibia is particularly prone to
delayed and non-union because of its weak blood supply. Main supply is the
medullary vessels. The periosteal blood supply is poor because of few
muscle attachments on the distal third . But fibula has number of
attachments and hence has good blood supply.
4) Hinge joints proximally and distally – Even slight amount of rotational mal-
alignment of the leg fracture becomes noticeable.
 MECHANISM OF INJURY
• DIRECT – RTA (fracture occurs at the same level in tibia and fibula.
Object causing the fracture lacerates the skin hence resulting in an
open fracture.

• INDIRECT – A bending or torsional force on the tibia may result in an

oblique or spiral fracture respectively. The sharp edges may cut
through the skin and hence cause an open fracture.
 PATHOANATOMY
• Fracture may be open or closed.
• Occurs at different levels: -upper
- middle
- lower
• Only one bone either tibia or fibula.
• If displacement occurs it can be sideways, angulatory or rotational.
• It may remain undisplaced.
CLINICAL FEATURES
1) History of injury to the leg.
2) Pain and swelling , deformity
3) A wound communicating with the underlying bone may be present.

RADIOGRAPHS
X- ray is used to evaluate the configuration of the fracture which helps in
reduction.
 CLASSIFICATION OF OPEN FRACTURES
A) Ellis :-
Grade I – MINOR – Undisplaced,not angulated ,minor comminution , minor
open fractures.
Grade II – MODERATE – Total displacement , small degree of comminution ,
minor open wound.
Grade III – MAJOR – Complete displacement , major comminution , major
open fracture.
• B) Tscherne classification :- takes into account soft tissue injuries.

C0 – Simple fracture with no soft tissue injury.

C1 – Mild to moderate fracture with superficial abrasions.

C2 – Moderately severe fractures with deep contusions.

C3 – Severe fracture with severe destruction of the soft tissue.

 TREATMENT
CLOSED FRACTURE
• Usually closed reduction is done.
• The fracture is reduced under
anaesthesia and immobilized by
above knee plaster cast.
• In children union occurs by 6 wks.
and in adults by 16-20 wks.
• If the reduction is not achieved on
the fracture displaces
• In plaster ORIF is indicated.
OPEN FRACTURE
• The aim is to convert the open fracture to
closed fracture and to maintain good
alignment.
• The grades of open fracture:
• Grade 1 – wound dressing through a
window in an above knee plaster cast and
antibiotics.
• Grade 2 – wound debridement and
primary closure (if less than 6hrs. old)
and on above knee plaster cast. Wound
may need a window through plaster.
• Grade 3 – wound debridement, dressing
and external fixation, wound left open
 MANAGEMENT
• ATMs elevation
• Quadriceps static exercises.
• Non-weight bearing crutches walking after 2 weeks.
• Weight bearing only after union is consolidated.
TECHNIQUE OF CLOSED REDUCTION
• Patient under anaesthesia lies in supine with his knees flexed over the end of the
table.
• Surgeon sitting on a stool.
• Leg kept in traction using a halter, made of ordinary bandage around the ankle.
• The fracture is manipulated to achieve good alignment and plaster is applied.
 If on check X-ray angulation is seen, plaster wedging is done, the plaster is cut
circumferentially and the wound is opened on the concave side of the angulation
and reduced. The plaster is then reinforced with additional plaster bandages.
 If about after 6 weeks, the above knee plaster is removed and below knee
patellar tendon bearing cast is put.
OPERATIVE TREATMENT
• ORIF is indicated when satisfactory alignment of fracture is not
possible by closed Rx.
• Plate or intramedullary nail is done dependency on upon the type of
fracture.
• Interlock nailing provides the possibility of internally fixing a wide
spectrum of fracture.
MANAGEMENT
1. Restore normal ROM at knee and ankle joint.
2. Improve strength, power and endurance of muscles.
3. Stability in ambulatory activities, near normal gait patterns.
CONSERVATIVE MANAGEMENT
MAXIMUM MODERATE MINIMUM

Isometrics to gluteus , quadriceps AROM with minimum pain. Weight bearing full only after union
and hamstring muscle. 3-6 months

Assisted SLR Self passive stretch exercise. Gait , balance and functional
training.

Ankle toe movements NWB crutch walking PRE

PROM without too much pain. Gait training.

Initial muscle strengthening

exercise.
POST-SURGICAL MANAGEMENT
• Knee mobilization by 2 weeks
• Partial weight bearing by 8 weeks and full weight by 12 weeks.
ANKLE JOINT
• It refers specifically to the talocrural joint, formed by the articulation
between the tibia, fibula and the talus.
• It is a synovial hinge joint with one degree of freedom.

 PROXIMAL ARTICULAR SURFACES

• The proximal segment is composed of the concave surface of the distal
tibia and fibular malleoli.
• The proximal and distal tibiofemoral joints are anatomically distinct from
the ankle joint, but these two linked joints function exclusively to serve the
ankle.
• The proximal and distal tibiofibular joints do not add any degrees of
freedom and if they fuse, it can affect the normal ankle function by
limiting the ability of the talus to move within the ankle mortise.
 PROXIMAL TIBIO-FEMORAL JOINT
• It is a plane synovial joint formed by the articulation of the head of the
fibula with the posterolateral aspect of the tibia.
• The joint capsule reinforce by the anterior and posterior tibiofibular
ligaments.
• The motions at this joint are small and is described as superior and
inferior sliding of the fibula and as fibular rotation.
DISTAL TIBIO-FIBULAR JOINT
- It is a syndesmosis or fibrosis union between the concave facet of the
tibia and the convex facet of the fibula.
- The two bones are not in actual contact but are separated by fibro
adipose tissue.
- The stabilization is primarily by the surrounding ligaments.
- Ligaments are : 1) Anterior and Posterior tibiofibular ligament.
2) Interosseous membrane
[It directly supports both the proximal as well as distal joint]
- The fractures of tibia and fibula are commonly due to RTA and are
often open fractures.
CAPSULE LIGAMENTS
• The capsule is fairly thin and especially weak anteriorly and posteriorly.
• The ligaments that support the proximal and distal tibiofibular joints are
important for stability of the mortise and since for stability of the ankle.
• Two major ligaments are: 1. medial collateral ligament
2. lateral collateral ligament
• MCL is most commonly called deltoid ligament. It has superficial and deep
fibres which arise from the border of tibial malleoli and inserts anteriorly on
the navicular bone and distally and posteriorly on the talus and calcaneus.
• It helps control medial distraction stresses and also helps check motion at
the extremes of the joint range.
• The LCL is composed of 3 bands :
1. Anterior talofibular ligament
2. Posterior talofibular ligament
3. Calcanofibular ligament
• The LCL helps control varus stresses that result in lateral distraction of
the joint and helps check extremes of the joint ROM.