Fracture tibia & fibula

By
Sulaiman Usaid G.
Kamulegeya sharif
 Outline
• Anatomy
• Proximal tibial fractures
• Fractures of tibia and fibula
• Distal tibial fractures
• Open tibial fractures
 Tibial anatomy
• Most common of all long bone fractures. Next common to
intracapsular fracture neck femur.
• More controversial, exceeded only by fracture neck femur.
• Its one third surface is subcutaneous and hence incidence of open
fracture is high.
• Distal one-third has a deficient blood supply and a fracture in this area
is known for delayed union and nonunion.
• Bounded above and below by hinge joints and hence no malunion is
acceptable.
• Conservative treatment was the mainstay and is now reserved for low
energy stable, simple,undisplaced of less displaced fracture.
• Operative treatment is indicted for most fractures with high energy
trauma
 Fibula anatomy
• The fibula is responsible for 6% to 17% of a
weight-bearing load.
• 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
 The leg
• The leg is composed of three compartments of
muscles;
– i) anterior compartment.
– ii) Lateral compartment.
– iii) posterior compartment.
Anterior compartment;
Lateral compartment of the leg;
Posterior compartment of the leg;
This is divided into two groups;
• The superficial group.
• The deep group.
 Tibial fractures
• Proximal tibial fractures
• Fractures of tibia and fibula
• Distal tibial fractures
• Open tibial fractures
 PROXIMAL TIBIAL FRACTURES
• Proximal tibia consists of the medial and
lateral condyles along with the upper tibial
articular surface and includes the proximal 10-
12 cm of the tibia.
• These fractures are frequently intraarticular
and usually unite well considering the
cancellous nature of the bone.
• Incidence
– 1% of all fractures and 8% of fractures in elderly people.
• Mechanism of Injury
– It is due to valgus or varus force with axial loading
• Causes
– 52%- due to auto-pedestrian injuries (Bumper injuries)
– 17%- due to fall from heights.
– 31%—miscellaneous causes (football or sport injuries).
Other Classifications
• Schatazker's classification: This is widely followed
in North America and has six types:
– Type I : Split fracture of lateral condyle.
– Type II : Displaced lateral condyle fracture.
– Type III : Isolated lateral condyle depression.
– Type IV : Medial condylar fracture.
– Type V : Bicondylar fractures.
– Type VI : Bicondylar fracture with diaphyseal
metaphyseal extension.
Clinical Features
• Pain
• Swelling
• Deformity
• Haemarthrosis
• Decreased movements of the knee and instability in valgus
or varus
• There could be features of compartment syndrome of the
leg
• Disturbed peripheral vascular and nerve functions of the
leg
Clinical evaluation
• ABCDEs, neuromascular status is an
emergency, AMPLE(allergies, meds, past
history, last meal, events) analgesia.
• Neurovascular examination is essential
• Compartment syndrome must be ruled out,
particularly with higher-energy injuries.
• Assessment for ligament injury is essential
Associated injuries
• Meniscal tears
• Associated ligamentous injury to the cruciate or collateral
ligaments
• Young adults, whose strong subchondral bone resists
depression, are at the highest risk of collateral or cruciate
ligament rupture.
• medial tibial plateau fracture are associated with peroneal nerve
injury
• Peroneal nerve injuries are caused by stretching; these will
usually resolve over time.
• Arterial injuries
Radiologic evaluation
• AP and lateral radiographs of the knee; help to demonstrate
majority of tibial condyle fractures.
• Oblique view may be required to localize the fractures. To study
the depth of depression
• CT scan; useful for delineating the degree of fragmentation or
depression of the articular surface, as well as for preoperative
planning
• Valgus or varus stress films; To know the knee ligament injuries
• Aspiration; may reveal blood or fat. If fat is present, it indicates an
intra-articular fracture.
• Angiography; if pulses are feeble or absent
Management
• Aim
– To produce a knee that extends fully and flexes to
at least 120°.
– Restoration of normal articular surface and
ligament repair are both important in preventing
late instability
Conservative treatment
• Indicated for plateau fractures with < 4 mm depression or
displacement.
• Undisplaced fracture: Above knee, POP cast with 5° flexion or cast
bracing is used.
• Displaced fracture: Closed reduction, with or without skeletal
traction and a long leg cast is used
• In depressed fractures: For less than 8 mm depression, above knee
cast.
• For depression of more than 8 mm with a large split fragment,
skeletal traction is applied. For more than 8 mm with smaller split
fragment, ORIF is done with bone grafting after elevation of the
depression.
• Partial weight bearing (30 to 50 lb) for 8 to 12 weeks
is allowed, with progression to full weight bearing.
Surgery
• indications:
– Articular depression from <2 mm to 1 cm.
– Instability >10 degrees of the nearly extended knee
compared to the contralateral side.
– Open fractures should be treated surgically.
– Compartment syndrome
– Associated vascular injury
• Operative treatment principles
– Reconstruction of the articular surface, followed by
reestablishment of tibial alignment, is the goal.
– Treatment involves buttressing of elevated articular segments with
bone graft or bone graft substitute.
– Fracture fixation can involve use of plates and screws, screws
alone, or external fixation.
– The choice of implant is related to the fracture patterns, the
degree of displacement, and familiarity of the surgeon with the
procedure.
– Adequate soft tissue reconstruction including preservation and/or
repair of the meniscus as well as intraarticular and extraarticular
ligamentous structures should be addressed
• Schatzker type I to IV fractures can be fixed
with percutaneous screws or lateral placed
periarticular plate.
• Type V and VI fractures can be managed using
plate and screws, a ring fixator, or a hybrid
fixator. Limited internal fixation can be added
to restore the articular surface.
lateral placed periarticular plate.
ring fixator
hybrid fixator
• Open reduction and internal fixation with
cancellous screws, single or dual buttress
plating are the time tested methods
• External fixation with circular or semi-circular
frames are also another useful options.
• Skeletal traction is useful in grossly
comminuted fractures
Complications
• DVT
• Knee stiffness
• Infection
• compartment syndrome
• peroneal nerve palsy
• popliteal artery laceration
• nonunion (rare), malunion
• degenerative arthritis
 FRACTURES OF TIBIA AND FIBULA
Epidemiology
• Fractures of the tibia and fibula shaft are the most
common long bone fractures.
• In an average population, there are about 26 tibial
diaphyseal fractures per 100,000 population per year.
• Men are more commonly affected than women, with the
male incidence being about 41 per 100,000 per year and
the female incidence about 12 per 100,000 per year.
• The average age of a patient sustaining a tibia shaft
fracture is 37 years, with men having an average age of 31
years and women 54 years
• Mechanism of Injury
– RTA—37.5%
– Sports—24.7%
– Assaults—4.5%
– Falls—rest
• Direct force
– High-energy: motor vehicle accident
– Transverse, comminuted, displaced fractures
commonly occur
– The incidence of soft tissue injury is high
• 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
• Fibula shaft fractures: These typically result
from direct trauma to the lateral aspect of the
leg.
 Tscherne classification of closed fracture

• 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 tissues
Gustilo and Anderson Classification of Open
Fractures
Clinical Features
• pain and the obvious sign is the deformity
• Damage to the blood vessels and nerves is not
that common, but fibular neck fracture may
injure the lateral popliteal nerve; and if the
posterior tibial vessels are injured,
compartmental syndrome may develop.
Clinical evaluation
• Evaluate neurovascular status
• Assess soft tissue injury
• Monitor for compartment syndrome. Pain out
of proportion to the injury is the most reliable
sign of compartment syndrome.
• Tibial fractures are associated with a high
incidence of knee ligament injuries.
Radiographic evaluation
• AP and lateral views with visualization of the ankle
and knee joints.
• Oblique views may be helpful to further characterize
the fracture pattern.
• Postreduction radiographs should include the knee
and ankle for alignment and preoperative planning
• CT and MRI usually are not necessary.
• Angiography is indicated if an arterial injury is
suspected.
Management
• Aims
– To limit soft tissue damage and preserve skin
cover
– To obtain and hold fracture alignment
– To recognise compartment syndrome
– To start early weight bearing to promote healing
– To start joint movement ASAP.
Conservative mgt
• 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.
• Long Leg Plaster Casts
– Indications
• Most closed fractures
• Undisplaced fracture
• Fractures with minor or moderate displacements.
• Low energy trauma.
• 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 4 to 6 weeks, the long leg cast may be
exchanged for a patella-bearing cast or
fracture brace.
Reduction in displaced fractures:
• Two methods of closed reduction.
• (1) the patient is supine and is under general
anesthesia. With the limb held parallel to the
table, the fracture is reduced by traction and
counter traction method (by an assistant) and a
long leg cast is applied.
– The disadvantage with this technique is due to the
gravitational forces, posterior angulations develop at
the fracture site.
• (2) Commonly followed method
• The patient is supine or sitting. The patient is
brought to the edge of the table and both the
legs are kept dangling.
• Through a halter, the clinician holds the leg of
the patient and manipulates the fracture. A
long leg cast is then put with the knee in slight
flexion and the ankle at 90°
Sarmiento's Total Contact below Knee Cast
• After reduction of the fracture and application of a
long leg cast for 2-3 weeks, a total below knee cast
which is moulded around the tibial condyles and
patella in the fashion of patellar tendon bearing
prosthesis is applied (PTB casts or brace) and
movement of the knee joint and weight bearing is
permitted.
• He reported a union rate of 97.5 percent and the
average healing time was 14-15 weeks.
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
Isolated Fibular Fractures
• Seen in
– Avulsion fracture of proximal fibula.
– Syndesmotic fibular fracture on ankle injuries.
– True isolated fibular fractures.
• Nonoperative treatment is enough
• Operative treatment if nonunion develops
Surgical Treatment
• As mentioned earlier, only 5% of the cases
require operative treatment in tibial fractures.
• Absolute Indications
– Tibial fracture with vascular or neural injuries.
– Segmental fractures.
– Inadequate reduction
– Associated knee problems.
– Associated tibial plafond fracture
• Reamed versus unreamed nail
– Reamed nail: 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 designed 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 fatigue failure.
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.
• Its popularity in the United States has waned with the
increased use of reamed nails for most open fractures.
• Union rates: Up to 90%, with an average of 3-6 months
to union.
• The incidence of pin tract infections is 10% to 15%.
Complications
• Delayed union
• Nonunion
• Infected nonunion
• Malunion
• Shortening
• Infection
• Compartmental syndromes
• Joint stiffness
• Refracture
• Fat embolism
• Claw toes—due to tethering of long extensors over callus
 DISTAL TIBIAL FRACTURES
• PILON FRACTURES: These
are severe injuries and are
predominantly due to high
energy axial loading forces
following the RTA or fall
from height unlike the
malleolar fractures, which
are mainly due to low
energy rotational forces.
• These are also called as
distal tibial explosion
fractures.
Incidence
• It accounts for less than 10 percent of all
lower limb fractures.
• Males are more commonly affected than
females.
• Mean age is 35-40 years
 MECHANISM
• Axially directed force
Intra articular fractures
More soft tissue injury
High energy/ open injuries

• Rotational force
Spiral fractures
Variable amount of soft tissue
injuries/ open fractures
 classification
Ruedi and Allgower classifications;
• Type I: Undisplaced cleavage fracture of the
joint.
• Type II: Displaced but minimally comminuted
fractures.
• Type III: Highly comminuted and displaced
fractures.
RUDI ALLGOWER CLASSIFICATION

Type 1

Type 2

Type3
AO/OTA Classification:
This is the most recent classification and it consists of
the following varieties.
 Type A: Extra-articular fractures.

 Type B: Partial intra-articular fractures.

 Type C: Total intra-articular fractures.

 CLINICAL PRESENTATION

Pain
Swelling
Deformity
……………
Blisters
Open
wound
Associated
injuries
Investigations
 Routine X-rays of the ankle consists of the AP,
lateral and ankle mortise views.
 CT scan is more useful and gives more
information about the nature and extent of the
injury than mere X-rays
IMAGING
 X Ray  CT Scan
PRIMARY MANAGEMENT

Closed fractures Open fractures

 Bulky padding  Debridement & Lavage

 POP splint/ BB splint  Temporary Ex fix
 Temporary Exfix  Antibiotics
 Strict elevation  Relook after 48 hrs
 Pain relief  Plastic surgery opinion
 Elevation
NON OPERATIVE
 Plaster of paris cast/ Synthetic cast
Undisplaced/Minimally displaced
Rudi Allgower type 1/type 2
AO C3
Poor GC

 Loss of reduction
Stiffness
PRE-OP CONSIDERATIONS
 Delay for reduction in swelling, wrinkle signs
 5-10 days (usually within 3 weeks)
 Elevation and splint
 Calcaneal traction/ Ex fix
 Management of blisters
PRINCIPLES

Anatomical reduction

Stable internal fixation

Minimal soft tissue damage

Early pain-free mobilization

SURGICAL OPTIONS
 Open reduction and internal fixation

 Percutaneous fixation

 MIPO

 IM Nail

 External fixator
ORIF
 Should be done with restraint!!
 Done after Soft tissue normalizes
 Low profile plates
 Locking plates
 Fibula first
 One stage or 2 stage
 Anteromedial or Posterolateral approach
Anteromedial Approach
 Fracture involves the
medially aspect
 Plate on subcutaneous
surface
Anterolateral approach

•For
fractures
involving
posterolate
ral corners

Plate
•

under
extensor
muscles
PERCUTANEOUS SCREW FIXATION
 For mildly displaced
fractures A, B1,B2, C1

 Indirect reduction by
external fixator or
distractor is very
useful
MIPO
 Type A, B and sometimes Type C1, C2
 Indirect reduction by ligamentotaxis
 Plate on medial surface
IM Nail

IM Nail
supplemen
ted with
screws
EXTERNAL FIXATOR
 Type A3, B3,C3
 Poor soft tissue condition
 COMPLICATIONS

Malunion
Ankle
stiffness
Arthritis
Skin
necrosis
Wound
dehisence
OPEN TIBIAL FRACTURES
 Open fracture is a surgical emergency and presents
as a problem that is much more difficult than
closed fractures. It is defined as a fracture, which
communicates with the external atmosphere due to
break in the soft tissue cover.
 The break in the soft tissues could be from inside to
outside or outside to inside
CLASSIFICATION (GUSTILLO AND
ANDERSON’S)
 Type I: Wound is less than 1 cm in size. It is usually due to a low-
velocity trauma.
 Type II: Wound is more than 1 cm and less than 10 cm but there is
no devitalisation of soft tissue and is associated with very little
contamination. These are due to high-energy trauma.
 Type III: Wounds moderate and severe in size (> 10 cm) and the
soft tissues are devitalized and contaminated.
 Type IIIA: Extensive soft tissue injury but with adequate soft tissue
to cover the fractured bone.
 Type IIIB: Extensive soft tissue damage and loss. Bone cannot be
covered and is exposed to the atmosphere.
 Type IIIC: Compound fractures with arterial injuries
 No classification invites so much of debate as for
open fractures with only 60 percent of the surgeons
across the globe accepting it.
 Hence, newer modifications are now being
suggested like:
 The modified Gustillo Anderson’s classification.
 The Trafton classification (this combines the Gustillo
Anderson’s and Tscherne classification).
 AO classification of soft tissue injury with alphanumeric
classification of fractures.
 APPROACH IN COMPOUND FRACTURES

 Compound fractures are usually serious injuries and are due

to high-velocity trauma. They may be associated with
multisystem and multi-skeletal injuries. The approach should
be more cautious and the following protocol is
recommended.
 General physical examination: This is of vital importance
since the patient is usually in shock. Levels of
consciousness, pulse, blood pressure, breathing,
(ABCDEs)etc. should be recorded.
 Examination of other systems: Examinations should be
carried out for head injury, neck and face injury, chest injury,
blunt injury abdomen, pelvic fractures and spine fractures.
Investigations
 Laboratory tests like Hb percentage, blood group,
bleeding time and clotting time, HIV, HbS Ag.
 X-ray of the part as for other fractures and in
addition look for missing pieces of bone in open
fractures
 FAST
management
 Antibiotics and anti-
tetanus.
 Debridement; thru washing
with saline and removal of
dead tissues and debris.

 Stabilisation preferably
using external fixation
 Soft tissue cover using
flaps or grafts.
 Rehabilitation.
Finally the ankle fractures
Incidences of ankle fractures are;
 More commonly in elderly women.

 About 2/3 are isolated malleolar fracture.

 About 1/4 are bimalleolar fracture.

 Trimalleolar fracture seen only in 7 percent.

 Open fracture 2 percent

Mechanism of Injury
 Ankles are usually
injured due to low injury
rotational forces due to:
Twisting injury while
walking, running, sports,
athletes, etc.
 Fall from a height:
Ankle injuries are
indirect injuries here
brought about by the
displacing talus.
 Classification Ankle injuries
They are classified after the mechanism causing them. Hence, There are six
movements of the ankle and the hind foot.
 Plantar flexion and dorsiflexion are the up and down movements of the
foot.
 Movement causing the toes to point inwards is called internal rotation
and movement causing the toes to point outwards is called external
rotation.
 Supination is the movement, which raises the medial aspect of the foot
and the heel off the ground.
 In pronation, the motion is to bring the lateral aspect of the foot and the
heel from the ground.
 In adduction, the hind foot is moved towards the midline and in
abduction is moved laterally.
 Pure vertical loading position as in landing, jumping, falling, etc. will
Clinical Features
 The patient usually gives history of inversion
injury, following which there is pain, swelling,
deformity of the ankle.
 Movements are decreased, Drawer's test, inversion
and eversion stress tests may be positive.
 Note the color and condition of the skin.
 Examine the entire leg.
Investigations
 X-ray; Anteroposterior, lateral and mortise non-
weight bearing views of the ankle are
recommended in the radiographs.
 CT scan, MRI and arthroscopy evaluation is
extremely helpful.
Treatment Goals
 Anatomical positioning of the talus beneath the
tibia.
 To obtain a joint line that is parallel to the ground.

 Smooth articular surface.

If these three things are not achieved, post-traumatic

osteoarthritis results.
• Fracture due to external rotation:
This is more common and can be managed both by
conservative and operative methods.
 Conservative method: This consists of reversal of the

injuring forces by closed reduction and a below knee

plaster cast application. A walking cast is applied after a
period of one month.
 Surgical method: In this, both the malleoli are fixed, first

the lateral malleolus is fixed with pin or screws and later

the medial malleolar fracture is fixed with a single screw
perpendicular to the fracture line. Below knee splint is
given initially and later a cast is applied.
Fracture primarily due to abduction:

 These are less common than the fractures due to

external rotation. Nevertheless, the principles of the
treatment remain the same. Adduction force is
required to bring about reduction and if closed
reduction fails, open reduction is preferred.
 During the open reduction, both the malleoli are
fixed.
Fracture primarily due to adduction:

 Unlike external rotation and abduction, adduction

violence is more frequently an isolated event. Wedging
of small-comminuted fragments into the fracture line
often prevents closed reduction, so that open reduction
and internal fixation (ORIF) is required more
frequently.
 Medial malleolus is approached first, since it is more
unstable, and the fracture is fixed with two screws, one
at right angle to the tibial cortex and another at right
angle to the fracture line. Lateral fibular fracture is
stabilized with plate and screws.
 • Fracture resulting from primarily vertical
compression:
This may be isolated or associated with other forces
described above. The anterior and posterior tibial plafond
margins are fractured. Two types are described:
 Posterior marginal fracture for undisplaced fracture,

below knee cast is sufficient. For more than 25 percent

of articular surface involvement, ORIF with two
screws is preferred.
 Anterior marginal fracture (tibial plafond injury): It

may include a crush of the anterior lip or it may

include a major fragment. If crushed, calcaneal traction
is given and if there is a large fragment, ORIF is
required
complications
Complications of ankle fractures include;
 post-traumatic arthritis,

 reflex sympathetic dystrophy,

 neurovascular injury (injury to posterior tibial

vessels and nerve),

 nonunion (due to soft tissue interposition),

 malunion, etc
references
