Tibial fracture

Tibial fractures are the most common type of long bone fractures. They are usually caused by direct trauma and may occur proximally (tibial plateau fracture), at the shaft, or distally. The fracture may solely involve the tibia or the fibula, or it may involve both. As only a small amount of tissue covers the bone structures, there is a higher risk of open fracture, neurovascular injury, compartment syndrome, and wound infection. Depending on the location and stability of the fracture, treatment may involve casting, intramedullary nailing, open reduction and internal fixation, or external fixation.

• Isolated fibula fracture
• Isolated tibia fracture
  • Open or closed
  • Displaced or nondisplaced
  • Proximal or shaft
• Combined tibia and fibula fracture
• Tibial plateau fracture

• See “Fracture signs.”
• High risk of open fracture (and consequently infection) given minimal soft tissue surrounding the tibia and fibula

Toddler fracture ^[1][2]

• Definition: a nondisplaced fracture of the distal tibial shaft, usually following acute trauma (e.g., falling, tripping), causing rotation of the body around a fixed foot
• Epidemiology: commonly seen in children between nine months and three years of age ^[2]
• Etiology: trauma (e.g., low energy fall from a chair or table, tripping while running)
• Clinical features
  • Irritability
  • Abnormal gait (limping or inability to bear weight)
  • Localized tenderness over the distal tibial shaft
• Diagnostics
  • Often goes undetected due to subtle clinical and radiographic findings
  • Imaging
    • AP, lateral, and oblique x-ray
    • MRI and/or CT: indicated in cases of prolonged symptoms and suspicion of infection (e.g., osteomyelitis)
• Treatment: immobilization with a long cast, controlled ankle movement walker boot, short cast, or splint ^[3]

• Clinical examination: peripheral perfusion, motor function, and sensation
• X-rays: knee and ankle (anteroposterior and lateral views)
  • Even when no obvious fracture is detected, tibial plateau fractures may cause lipohemarthrosis. This is visible as a fat-fluid level on x-ray.
• MRI: can be useful to assess injuries to the meniscus and the ligaments associated with tibial plateau fractures.
• Joint aspiration: can be performed
  • Bloody effusion (hemarthrosis) with fatty spots indicates an osteochondral fracture.

See “General principles of fractures.”

• Conservative treatment
  • Isolated fibula fractures: splinting and partial weight bearing
  • Nondisplaced proximal tibial fractures: hinged knee brace and no weight bearing for 6 weeks
  • Nondisplaced tibial shaft fractures: long leg cast (if the long leg cast fails to ensure proper healing, then surgical treatment is indicated)
• Surgical treatment
  • Indication: open or displaced tibial shaft fractures
    • Open fractures require urgent irrigation and debridement
    • Open reduction and internal fixation with plate, screw, or intramedullary nail
    • External fixation may be used, especially for complex fractures.

See “General principles of fractures.”

• Patients with tibial fractures should be monitored for:
  • High risk of compartment syndrome in any of the compartments, given that the tibia is surrounded by the anterior, lateral, and deep posterior compartments of the lower leg
  • Fat embolism
  • Peroneal nerve injury (foot drop)
  • Deep vein thrombosis
  • Nonunion
  • Post-traumatic arthritis ^[4]
• See “Fracture complications.”

We list the most important complications. The selection is not exhaustive.