10/28/2014

Tibial Shaft Fractures

Tibial Shaft Fractures

Author: Brian K Konowalchuk, MD; Chief Editor: Thomas M DeBerardino, MD more...
Updated: Oct 17, 2014

Background
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, as well as 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 patient education resources, see the Breaks, Fractures, and Dislocations Center, as well as Broken Leg, Ankle
Fracture, and Knee Dislocation.

History of the Procedure

Several decades ago, plating was the treatment of choice for tibial shaft fractures. Since then however,
intramedullary nailing and external fixation have replaced fracture plating because they are associated with
decreased technical difficulty, lower infection rates, and less damage to local soft tissues (see Treatment,
Intraoperative details, below).

Problem
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
evaluated carefully for open wounds at the fracture site, neurovascular sufficiency, and elevated compartment
pressures. Abnormalities in any of these areas constitute a surgical emergency.

Epidemiology
Frequency
The tibia is currently the most commonly fractured long bone in the body. Alho et al reported an annual incidence of
two tibial shaft fractures per 1000 individuals. [1] The average age of patients with tibial shaft fractures is
approximately 37 years, and teenage males are reported to have the highest incidence. [2]

Etiology
In 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 or soccer), the number of tibial fractures seen
in the emergency department is high. Although 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 are falls or jumps from significant
height and gunshot wounds to the lower leg.

Presentation
Patients 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 as part of the differential
diagnosis 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 report 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. [3]
Whatever the presentation, a complete history and 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 focus solely on the leg, because concomitant injury is
common with 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. [4, 5, 6, 7, 8, 9] The classic
classification for open fractures was described by Gustilo et al, as follows[10] :
Type I - The wound is clean and is shorter than 1 cm
Type II - The wound is longer than 1 cm and does not have extensive soft tissue damage
Type IIIa - The wound is wound associated with extensive soft-tissue damage, usually larger than 10 cm,

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with periosteal coverage (periosteum, the outermost layer of bone, has a rich vascular supply and is
important in bone growth and repair); this fracture type also includes less traumatic fractures with increased
chances of complications (eg, gunshot wounds, farmyard injuries, and fractures requiring vascular repair)
Type IIIb - This type is defined as bone with periosteal stripping that must be covered; these fractures nearly
always require flap coverage
Type IIIc - This type of injury requires vascular repair
The Orthopaedic Trauma Association has also adopted a system of classification for tibial shaft fracture. Their
system, based on radiographic evaluation, divides fractures into three main types as follows[11, 12] :
Type A - Unifocal fractures
Type B - Wedge fractures
Type C - Complex fractures
Each main type is divided into three groups, and each group is further divided into three subgroups. [11, 12]
For type A (unifocal) fractures, the groups are determined by the angle of the fracture and consist of spiral fractures
(A1), oblique fractures (A2), and transverse fractures (A3).
Type B (wedge fractures) are divided into intact spiral wedge fractures (B1), intact bending wedge fractures (B2),
and comminuted wedge fractures (B3). For both type A and type B fractures, the subgroups are determined by the
extent of fibular injury and the location of the fracture with respect to the tibia.
Among type C (complex) fractures, spiral wedge fractures make up group C1, and the number of fragments present
determines the subgroup. For example, a C1 fracture with two fragments would be classified as C1.1, a fracture
with three fragments as C1.2, and a fracture with more than three fragments as C1.3. Segmental fractures are
assigned to group C2. C2 fractures, like C1 fractures, are subclassified according the number of fracture fragments
present and the extent of comminution. For instance, highly comminuted fractures are labeled as C2.3.

Indications
Most closed tibial fractures can be treated nonoperatively with good results, but infection risk and fracture stability
must be considered. Littenberg et al reviewed 2372 case reports of closed tibial fractures and compared clinical
outcomes of cast treatment, open reduction and internal fixation, and intramedullary rod therapy. [13] They showed
cast treatment to be associated with fewer superficial infections than open reduction and internal fixation. Open
reduction and internal fixation (ORIF), however, demonstrated a higher union rate at 20 weeks.
In some instances, the fracture cannot be treated properly 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 it is often the case with cast or brace treatment that 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. In rare
instances, a type I fracture can be treated nonoperatively, but in most cases, the patient should be scheduled for
debridement and irrigation within 6 hours of the injury. Longer intervals have been shown to increase infection rates.
[14]

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 corrected on an emergency basis are rare. In some cases, however, especially in the
setting of polytrauma, definitive fracture treatment may be delayed. If surgery must be delayed, leg appearance and
compartmental pressure must be monitored carefully.

Relevant Anatomy
The leg is divided into four 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, the extensor digitorum
longus, the extensor hallucis, and the 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 the peroneus brevis, which primarily serve in eversion of
the foot. The superficial peroneal nerve is contained in this compartment and innervates these two muscles.
The posterior aspect of the leg is divided into two compartments, superficial and deep. The deep compartment
contains the plantarflexing muscles, including the tibialis posterior, the flexor hallucis longus, and the flexor
digitorum longus. The peroneal and posterior tibial arteries also course through this compartment with their
corresponding veins. The superficial posterior compartment is the largest of the four compartments but contains only
muscle. These plantarflexing muscles include the soleus, the gastrocnemius, and the plantaris.

Contraindications
Several contraindications for surgical treatment of tibial shaft fractures are recognized. All patients require a
thorough preoperative evaluation and must be cleared for general anesthesia before any operation, including
treatment of tibial shaft fractures. In cases of acute trauma, patients should be stabilized by the trauma team before
fixation of a tibial shaft fracture.
Incision and drainage of infected fracture sites are often indicated; however, hardware should never be placed into
an infected wound. In cases where infected hardware is removed, treat the infection with intravenous antibiotics and
replace the hardware in a second surgical procedure after the infection has been treated thoroughly.

Contributor Information and Disclosures

Author
Brian K Konowalchuk, MD Staff Physician, Department of Orthopedic Surgery, University of Minnesota
College of Medicine
Brian K Konowalchuk, MD is a member of the following medical societies: Alpha Omega Alpha

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Disclosure: Nothing to disclose.

Specialty Editor Board
Charles T Mehlman, DO, MPH Professor of Pediatrics and Pediatric Orthopedic Surgery, Division of Pediatric
Orthopedic Surgery, Director, Musculoskeletal Outcomes Research, Cincinnati Children's Hospital Medical Center
Charles T Mehlman, DO, MPH is a member of the following medical societies: American Academy of Pediatrics,
American Fracture Association, American Medical Association, American Orthopaedic Foot and Ankle Society,
American Osteopathic Association, Arthroscopy Association of North America, North American Spine Society,
Ohio State Medical Association, Pediatric Orthopaedic Society of North America, and Scoliosis Research Society
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center
College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Medscape Salary Employment
Shepard R Hurwitz, MD Executive Director, American Board of Orthopaedic Surgery
Shepard R Hurwitz, MD is a member of the following medical societies: American Academy of Orthopaedic
Surgeons, American Association for the Advancement of Science, American College of Rheumatology, American
College of Sports Medicine, American College of Surgeons, American Diabetes Association, American
Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Association for the Advancement of
Automotive Medicine, Eastern Orthopaedic Association, Orthopaedic Research Society, Orthopaedic Trauma
Association, and Southern Orthopaedic Association
Disclosure: Nothing to disclose.
Dinesh Patel, MD, FACS Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of
Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic
Surgeons
Disclosure: Nothing to disclose.
Chief Editor
Thomas M DeBerardino, MD Associate Professor, Department of Orthopedic Surgery, Consulting Surgeon,
Sports Medicine, Arthroscopy and Reconstruction of the Knee, Hip and Shoulder, Team Physician, Orthopedic
Consultant to UConn Department of Athletics, University of Connecticut Health Center
Thomas M DeBerardino, MD is a member of the following medical societies: American Academy of Orthopaedic
Surgeons, American Orthopaedic Association, and American Orthopaedic Society for Sports Medicine
Disclosure: Arthrex, Inc. Grant/research funds Other; Arthrex, Inc. Consulting fee Speaking and teaching;
Musculoskeletal Transplant Foundation Honoraria Board membership; Histogenics Grant/research funds None;
Advanced Biomedical Technologies Stock Options Medical Director, North America; Linvatec Consulting fee
Speaking and teaching; Aesculp Board membership
Additional Contributors
Marc Swiontkowski, MD Chair, Professor, Department of Orthopedic Surgery, University of Minnesota at
Minneapolis
Marc Swiontkowski, MD is a member of the following medical societies: American Academy of Orthopaedic
Surgeons, American College of Surgeons, American Orthopaedic Association, and Canadian Orthopaedic
Association
Disclosure: Nothing to disclose.
Brian Tollefson, MD Flight Surgeon, United States Air Force
Disclosure: Nothing to disclose.
Nicholas J Wills, MD Fellow, Twin Cities Spine Center
Disclosure: Nothing to disclose.

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