FRACTURE IN LEG

TIBIA AND FIBULA

C H I L S YA S H A J I
GROUP : 404
T R A U M ATO L O G Y
 INTRODUCTION
Anatomy
Mechanism Of Injury
Clinical Evaluation
Radiological Evaluation
Classification
Gustilo And Anderson Classification Of Open Fractures
Tscherne Classification Of Closed Fractures
Treatment
Complications
 ANATOMY
The tibia is a long tubular bone with a triangular cross section. It has a subcutaneous
anteromedial border and is bounded by four tight fascial compartments (anterior, lateral,
posterior, and deep posterior)
Blood supply
The nutrient artery arises from the posterior tibial artery, entering the posterolateral cortex distal
to the origination of the soleus muscle. Once the vessel enters the intramedullary (IM) canal, it
gives off three ascending branches and one descending branch. These give rise to the endosteal
vascular tree, which anastomose with periosteal vessels arising from the anterior tibial artery.
The anterior tibial artery is particularly vulnerable to injury as it passes through a hiatus in the
interosseous membrane.
 ANATOMY (cont.)
The peroneal artery has an anterior communicating branch to
the dorsalis pedis artery. It may therefore be occluded despite
an intact dorsalis pedis pulse
The distal third is supplied by periosteal anastomoses around
the ankle with branches entering the tibia through
ligamentous attachments.
There may be a watershed area at the junction of the middle
and distal thirds (controversial).
If the nutrient artery is disrupted, there is reversal of flow
through the cortex, and the periosteal blood supply becomes
more important. This emphasizes the importance of
preserving periosteal attachments during fixation.
 ANATOMY (cont.)
The fibula is responsible for 6% to 17% of
a weight-bearing load. Its major function is
for muscle attachment.
The common peroneal nerve courses
around the neck of the fibula, which is
nearly subcutaneous in this region; it is
therefore especially vulnerable to direct
blows or traction injuries at this level.
 MECHANISM OF INJURY
Direct
High-energy bending: Motor vehicle accident
Transverse, comminuted, displaced fractures commonly occur.
Highly comminuted or segmental patterns are associated with extensive soft tissue compromise.
Must rule out compartment syndrome and open fractures.
Penetrating: Gunshot
The injury pattern is variable, but usually comminuted.
Low-velocity missiles (handguns) do not pose the same degree of problem from bone or soft tissue
damage that high-energy (motor vehicle accident) or high-velocity (shotguns, assault weapons)
mechanisms may cause.
 MECHANISM OF INJURY(cont.)
Low-energy bending: Three- or four-point
Short oblique or transverse fractures occur, with a possible butterfly fragment.
May be comminuted and associated with extensive soft tissue compromise.
Compartment syndrome and open fractures may occur.
Fibula shaft fractures: These typically result from direct trauma to the lateral aspect of the leg. Spiral
fractures are seen proximally with rotational ankle fractures or low-energy twisting tibial injuries.
Indirect
Torsional mechanisms
Twisting with the foot fixed and falls from low heights are causes.
These spiral, nondisplaced fractures have minimal comminution associated with little soft tissue
damage.
Type 1 open fractures seen.
Stress fractures
In military recruits, these injuries most commonly occur
at the metaphyseal – diaphyseal junction, with sclerosis
being most marked at the posteromedial cortex.
In ballet dancers, these fractures most commonly occur
in the middle third; they are insidious in onset and are
overuse injuries. “Dreaded black line” is pathognomonic
Plain radiographic findings may be delayed several
weeks. Magnetic resonance imaging (MRI) is very
sensitive for detecting these injuries

Example of anterior tibial stress

fracture in ballet dancer
 CLINICAL EVALUATION
Evaluation of neurovascular status is critical. Dorsalis pedis and posterior tibial artery pulses must
be evaluated and documented, especially in open fractures in which vascular flaps may be
necessary. Common peroneal and tibial nerve integrity must be documented.
Assess soft tissue injury. Fracture blisters may contraindicate early open reduction of peri articular
fractures.
Monitor for compartment syndrome. Pain out of proportion to the injury is the most reliable sign
of compartment syndrome. Compartment pressure measurements that have been used as an
indication for four-compartment fasciotomy have been a pressure within 30 mm Hg of diastolic
pressure (P 30 mm Hg). Deep posterior compartment pressures may be elevated in the presence of a
soft superficial posterior compartment.
Tibial fractures are associated with a high incidence of knee ligament injuries.
About 5% of all tibial fractures are bifocal, with two separate fractures of the tibia
 RADIOGRAPHIC EVALUATION
Radiographic evaluation must include the entire tibia (anteroposterior
[AP] and lateral views) with visualization of the ankle and knee joints.
Oblique views may be helpful to further characterize the fracture pattern.
Post reduction radiographs should include the knee and ankle for
alignment and preoperative planning.
A surgeon should look for the features on the AP and lateral radiographs:
The presence of comminution: This signifies a higher-energy injury.
The distance that bone fragments have displaced from their anatomic
location: Widely displaced fragments suggest that the soft tissue attachments
have been damaged and the fragments may be avascular.
Osseous defects: These may suggest missing bone or open wounds
 RADIOGRAPHIC EVALUATION
(cont.)
Fracture lines may extend proximally to the knee or distally to the ankle joints.
The quality of the bone: Is there evidence of osteopenia, metastases, or a previous fracture
Osteoarthritis or the presence of a knee arthroplasty: Either may change the treatment method
selected by the surgeon.
Air in the soft tissues: These are usually secondary to open fracture but may also signify the presence of
gas gangrene, necrotizing fasciitis, or other anaerobic infections.

Computed tomography and MRI usually are generally not necessary. CT may be useful in
metaphyseal fractures if articular extension is suspected.
Technetium bone scanning and MRI scanning may be useful in diagnosing stress fractures
before these injuries become obvious on plain radiographs.
Angiography is indicated if an arterial injury is suspected, based on ankle-branchial indexes
(ABIs) or diminished pulses.
 CLASSIFICATION
Poor sensitivity, reproducibility, and interobserver reliability have been reported for most
classification schemes.
Descriptive
Open versus closed
Anatomic location: proximal, middle, or distal third
Fragment number and position: comminution, butterfly fragments
Configuration: transverse, spiral, oblique
Angulation: varus /valgus, anterior/posterior
Shortening
Displacement: percentage of cortical contact
Rotation
Associated injuries
 TYPES OF TIBIA – FIBULA
FRACTURES
Cozen’s fractures are most common under the age of 6. This kind of fracture occurs at the top of
the tibia, often when too much pressure is applied to the side of the knee, creating a bending
force.
Toddler fractures typically occur in children under the age of 4. This type of fracture often
happens because the leg twists while the child is stumbling or falling. Toddler fractures occur
near the middle of the tibia and can be difficult to see on an x-ray.
Tibial tubercle fractures typically occur during adolescence. The tibial tubercle is a bony bump
on the upper part of the shin where the quadricep muscle is attached to the bone by the patellar
tendon. A tibial tubercle fracture is a break or crack at this location. It is most common when a
child’s tibial tubercle is growing and the bone around that area is soft. Until the bone becomes
stronger, a strong tug by the tendon can cause this part of the bone to break. This fracture
typically occurs when trying to jump to dunk a basketball ball or do a flip.
 GUSTILO AND ANDERSON
CLASSIFICATION OF OPEN FRACTURES
Type I: Clean skin opening of<1 cm, usually from inside to outside;
minimal muscle contusion; simple transverse or short oblique fractures
Type II: Laceration >1cm long, with extensive soft tissue damage;
minimal to moderate crushing component; simple transverse or short
oblique fractures with minimal comminution
Type III: Extensive soft tissue damage, including muscles, skin, and
neurovascular structures; often a high-energy injury with a severe
crushing component
IIIA: Extensive soft tissue laceration, adequate bone coverage; segmental
fractures, gunshot injuries, minimal periosteal stripping
IIIB: Extensive soft tissue injury with periosteal stripping and bone
exposure requiring soft tissue flap closure; usually associated with massive
contamination
IIIC: Vascular injury requiring repair
 TSCHERNE CLASSIFICATION OF
CLOSED FRACTURES
This classifies soft tissue injury in closed fractures and takes into account indirect versus direct
injury mechanisms.
Grade 0: Injury from indirect forces with negligible soft tissue damage
Grade I: Closed fracture caused by low-moderate energy mechanisms, with superficial abrasions
or contusions of soft tissues overlying the fracture
Grade II: Closed fracture with significant muscle contusion, with possible deep, contaminated
skin abrasions associated with moderate to severe energy mechanisms and skeletal injury; high
risk for compartment syndrome
Grade III: Extensive crushing of soft tissues, with subcutaneous degloving or avulsion, with
arterial disruption or established compartment syndrome
 TREATMENT
Nonoperative
Fracture reduction followed by application of a long leg cast with progressive weight bearing
can be used for isolated, closed, low-energy fractures with minimal displacement and
comminution.
Cast with the knee in 0 to 5 degrees of flexion to allow for weight bearing with crutches as soon
as tolerated by patient, with advancement to full weight bearing by the second to fourth week.
After 3 to 6 weeks, the long leg cast may be exchanged for a patella bearing cast or fracture
brace.
Union rates as high as 97% are reported, although with delayed weight bearing related to
delayed union or nonunion. Hind foot stiffness is the major limitation seen.
 TREATMENT (cont.)
Acceptable Fracture Reduction
Less than 5 degrees of varus /valgus angulation is recommended.
Less than 10 degrees of anterior/posterior angulation is recommended (5 degrees preferred).
Less than 10 degrees of rotational deformity is recommended, with external rotation better tolerated than
internal rotation.
Less than 1 cm of shortening; 5 mm of distraction may delay healing 8 to 12 months.
More than 50% cortical contact is recommended.
Roughly, the anterior superior iliac spine, center of the patella, and base of the second proximal phalanx
should be collinear.

Tibia Stress Fracture

Treatment consists of cessation of the offending activity.
A short leg cast may be necessary, with partial-weight-bearing ambulation.
Surgery is reserved for those refractory to non-operative treatment or those that displace.
 TREATMENT (cont.)
Time to Union
The average time is 16 ± 4 weeks: This is highly variable, depending on fracture pattern and soft tissue
injury.
Delayed union is defined as >20 weeks.
Nonunion: This occurs when clinical and radiographic signs demonstrate that the potential for union is
lost, including sclerotic ends at the fracture site and a persistent gap unchanged for several weeks.
Nonunion has also been defined as lack of healing 9 months after fracture.

Fibula Shaft Fracture

Treatment consists of weight bearing as tolerated.
Although not required for healing, a short period of immobilization may be used to minimize pain.
Nonunion is uncommon because of the extensive muscular attachments.
 TREATMENT (cont.)
Operative
Intramedullary Nailing
IM nailing carries the advantages of preservation of periosteal
blood supply and limited soft tissue damage. In addition, it carries
the biomechanical advantages of being able to control alignment,
translation, and rotation. It is therefore recommended for most
fracture patterns.
Locked versus unlocked nail
Locked nail: This provides rotational control; it is effective in preventing
shortening in comminuted fractures and those with significant bone loss.
Interlocking screws can be removed at a later time to dynamize the
fracture site, if needed, for healing.
Nonlocked nail: This allows impaction at the fracture site with weight
bearing, but it is difficult to control rotation. Nonlocked nails are rarely
used.
 TREATMENT (cont.)
Reamed & unreamed nail
Reamed nail: This is indicated for most closed and open fractures. It allows
excellent IM splinting of the fracture and use of a larger-diameter, stronger nail.
Unreamed nail: This is thought to preserve the IM blood supply in open
fractures where the periosteal supply has been destroyed. It is currently
reserved for higher-grade open fractures; its disadvantage is that it is
significantly weaker than the larger reamed nail and has a higher risk of implant Reamed nail
fatigue failure.This to be acceptable in closed tibial fractures

Flexible Nails (Enders, Rush Rods)

Multiple curved IM pins exert a spring force to resist angulation and rotation,
with minimal damage to the medullary circulation.
These are rarely used because of the predominance of unstable fracture patterns
and success with interlocking nails.
They are recommended only in children or adolescents with open physes unreamed nail
 TREATMENT (cont.)
External Fixation
Primarily used to treat severe open fractures, it can also be indicated in closed fractures complicated by
compartment syndrome, concomitant head injury, or burns.
Union rates: Up to 90%, with an average of 3.6 months to union.
The incidence of pin tract infections is 10% to 15%.

Plates and Screws

These are generally reserved for fractures extending into the metaphysis or epiphysis.
Reported success rates as high as 97%.
Complication rates of infection, wound breakdown, and malunion or nonunion increase with higher-
energy injury patterns.
 TREATMENT (cont.)
Tibia Fracture with an Intact Fibula
If the tibia fracture is nondisplaced, treatment consists of
long leg casting with early weight bearing. Close
observation is indicated to recognize any varus tendency.
Some recommend IM nailing even if tibia fracture is
nondisplaced.
A potential risk of varus malunion exists (25%),
particularly in patients >20years

Fasciotomy
Evidence of compartment syndrome is an indication for
emergent fasciotomy of all four-muscle compartments of
the leg (anterior, lateral, superficial, and deep posterior)
through one or multiple incision techniques. Following
operative fracture fixation, the fascial openings should not
be reapproximated.
 COMPLICATIONS
Malunion: This includes any deformity outside the acceptable range. Seen with Nonoperative
treatments and metaphyseal fractures.
Nonunion: This is associated with high-velocity injuries, open fractures (especially Gustilo
grade III), infection, intact fibula, inadequate fixation, and initial fracture displacement.
Infection (more common following open fracture).
Soft tissue loss: Delaying wound coverage for greater than 7 to 10 days in open fractures has
been associated with higher rates of infection. Local rotational flaps or free flaps may be needed
for adequate coverage.
Stiffness at the knee and or ankle may occur with Nonoperative care.
Knee pain: This is the most common complication associated with IM tibial nailing.
 COMPLICATIONS(cont.)
Hardware breakage: Nail and locking screw breakage rates depend on the
size of the nail used and the type of metal from which it is made. Larger
reamed nails have larger cross screws; the incidence of nail and screw
breakage is greater with unreamed nails that utilize smaller-diameter locking
screws.
Reflex sympathetic dystrophy: This is most common in patients unable to
bear weight early and with prolonged cast immobilization. It is characterized
by initial pain and swelling followed by atrophy of limb. Radiographic signs
are spotty demineralization of foot and distal tibia and equinovarus ankle. It
is treated by elastic compression stockings, weight bearing, sympathetic
blocks, and foot orthoses, accompanied by aggressive physical therapy
Fat embolism.
Claw toe deformity: This is associated with scarring of extensor tendons
or ischemia of posterior compartment muscles.
 COMPLICATIONS(cont.)

Compartment syndrome: Involvement of

the anterior compartment is most common.
Highest pressures occur at the time of open
or closed reduction. It may require
fasciotomy. Muscle death occurs after 6 to 8
hours. Deep posterior compartment
syndrome may be missed because of
uninvolved overlying superficial
compartment, and results in claw toes.
 REFERENCE
https://med-mu.com/wp-content/uploads/2018/07/MBF46234234-21.pdf
https://ota.org/sites/files/2021-06/General%20A1%20Fracture%20Classifications.pdf
https://
www.netterimages.com/gustilo-and-anderson-classification-of-open-fracture-labeled-thompson-1
e-orthopaedics-frank-h-netter-10547.html
https://
trauma-acute-care.imedpub.com/reamed-vs-unreamed-intramedullary-nailing-of-femoral-fracture
s-in-the-elderly.pdf
https://
www.childrenshospital.org/conditions-and-treatments/conditions/b/broken-tibia-fibula-shin-bone
-calf