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Tibial/Fibular Shaft Fracture, Emergency Medicine

Basics

Description

- Type II: - Wound >1 cm - Moderate soft tissue damage - Little or no devitalized soft tissue

- 3rd most common long bone fracture in children - 2nd most common long bone fracture in nonaccidental trauma (usually apophyseal or metaphyseal corner) - Nonphyseal fracture patterns: - Compression (torus): Distal metaphysis - Incomplete tension " “compression (greenstick) - Plastic/bowing deformity of fibula may occur. - Complete fractures

- 4 leg compartments: Anterior, lateral, deep posterior, and superficial posterior - Anterior compartment: - Deep peroneal nerve - Sensation of 1st web space - Ankle and toe dorsiflexion - Anterior tibial artery feeds dorsalis pedis artery

- Closed fractures: - Gentle attempt at reduction if fracture is displaced (do not attempt multiple reductions; may increase risk for compartment syndrome). - Immobilization: - Well-padded long leg posterior splint - Knee in 10 " “20 ‚ ° of flexion

- Avoid circumferential cast. - If pain persists after immobilization, suspect: - Compartment syndrome - Avoid elevation of leg in suspected compartment syndrome; it lowers perfusion to the extremity. - Nerve compression

- Open fractures: - Remove contaminants and cover wound with moist, sterile dressing. - Antibiotics - Tetanus prophylaxis - Immobilization with well-padded long leg posterior splint - Immediate orthopedic surgery consultation for debridement and fracture fixation

Fracture Description

Tibia ‚

  • 80% have associated fibular fractures
  • Open (24% are open) vs. closed
  • Extent of soft tissue damage
  • Gustilo " “Anderson classification of open fractures:Type I:Wound <1 cmLittle soft tissue damageNo crush injuryType II:Wound >1 cmModerate soft tissue damageLittle or no devitalized soft tissueType III " ”severe soft tissue injury:A " ”adequate soft tissue coverage of boneB " ”tissue loss/periosteal strippingC " ”neurovascular injury requiring surgery
  • Anatomic location:Proximal, middle, or distal 3rdArticular extension
  • Displacement
  • Degree of shortening
  • Angulation
  • Configuration:Spiral, transverse, or obliqueComminuted, with butterfly fragment or multiple fragments

Fibula ‚

  • Proximal:Associated with peroneal nerve injuryDisruption of ankle syndesmosis (Maisonneuve fracture)
  • Middle
  • Distal
  • 3rd most common long bone fracture in children
  • 2nd most common long bone fracture in nonaccidental trauma (usually apophyseal or metaphyseal corner)
  • Nonphyseal fracture patterns:Compression (torus): Distal metaphysisIncomplete tension " “compression (greenstick)Plastic/bowing deformity of fibula may occur.Complete fractures
  • Physeal fracture patterns:Tibial shaft fractures may extend to the physis in Salter " “Harris II pattern.

Etiology

  • High- vs. low-energy injury
  • Amount of soft tissue injury is prognostic and determined by the degree of energy involved.
  • Indirect force " ”frequently low-energy trauma:Rotary and compressive forces often result in oblique and spiral fractures.
  • Skiing, fall, child abuse
  • Direct force " ”high-energy trauma:Direct blow to leg often results in transverse and comminuted fractures.
  • Pedestrian vs. auto, motor vehicle crash (MVC):Bending force over a fulcrum often produces comminution with a wedge-shaped butterfly fragment.
  • Skiers boot top, football tackle, MVC
  • Bicycle spoke injury:Foot and lower leg get caught between frame and wheel spokeCrush injury is the primary problem.Initial benign appearance of the soft tissues is often deceiving:Full-thickness skin loss can occur in days.Orthopedic surgery consultation should be obtained for all spoke-injury patients with associated fractures.
  • Toddler fracture:Spiral fracture involving the distal 3rd of the tibia with intact fibula secondary to rotational force (turning on planted foot)Age range is 9 mo " “6 yr, most often when learning to walk.Fractures in midshaft or more transverse are suggestive of nonaccidental trauma.

Diagnosis

Signs and Symptoms

History

  • History of trauma
  • Pain is usually immediate, severe, and well localized to the fracture site.

Physical Exam

  • Visible or palpable deformity at the fracture site
  • Significant soft tissue damage with high-energy trauma
  • Inability to bear weight if tibia involved:May be able to walk if isolated fibular fracture
  • Foot drop on affected leg from injury to the peroneal nerve as it wraps around the fibular head
  • Compartment syndrome
  • Rely on parents for historical information.
  • Child may present limping with no obvious deformity.

Essential Workup

  • Careful assessment of soft tissues
  • Careful neurovascular exam (compare with contralateral side)
  • Examine for associated injuries.
  • Completely expose patient and put into gown.
  • Assessment for compartment syndrome
  • Compartment syndrome
  • Occurs in 8% of diaphyseal fractures, more common in younger patients
  • Relatively common complication of tibial fractures and may not appear until 24 hr after injury
  • Pain disproportionate to that expected
  • Patient may have swollen, tight compartment, but does not always have pain on palpation of compartment.
  • Pain on passive stretch of foot, toes
  • Sensory deficit
  • Motor weakness is a late finding.
  • Pulselessness is not a sign of compartment syndrome:Palpable pulses are almost always present in compartment syndrome unless there is underlying arterial injury.
  • 4 leg compartments: Anterior, lateral, deep posterior, and superficial posterior
  • Anterior compartment:Deep peroneal nerveSensation of 1st web spaceAnkle and toe dorsiflexionAnterior tibial artery feeds dorsalis pedis artery
  • Lateral compartment:Superficial peroneal nerveSensation of dorsum of footFoot eversion
  • Deep posterior compartment:Tibial nerveSensation to sole of footAnkle and toe plantar flexionPosterior tibial and peroneal arteries
  • Superficial posterior compartment:Branch of sural cutaneous nerveSensation to lateral foot

Diagnosis Tests & Interpretation

Lab

Include creatine phosphokinase levels if concerned about compartment syndrome ‚

Imaging

  • Anteroposterior and lateral views of the leg, knee, and ankle
  • Bone scan at 1 " “4 days for toddler fracture and stress fractures if radiographs unrevealing
  • CT scan for complex fracture pattern to evaluate for rotational malalignment
  • CT or MRI for pathologic fracture
  • MRI for stress fractures may be necessary.

Diagnostic Procedures/Surgery

Compartment pressures: ‚

  • Pressures >30 mm Hg are an indication for orthopedic consultation and fasciotomy.
  • Delta P or difference between diastolic BP and compartment pressure <20 is indicative of compartment syndrome
  • Repeated pressure measurements over time, taken within 5 cm of fracture site, are necessary.

Oblique radiograph to detect nondisplaced fractures ‚

Differential Diagnosis

  • Stress fracture
  • Pathologic fracture
  • Osteomyelitis
  • Sarcoma
  • Pathologic fracture
  • Osteomyelitis
  • Nonaccidental trauma

Treatment

Pre-Hospital

  • Look for associated injuries in high-energy mechanisms.
  • Assess for neurologic or vascular compromise.
  • Adequate immobilization is essential to prevent further injury.

Initial Stabilization/Therapy

  • Manage airway and resuscitate as indicated.
  • Life-threatening injuries take precedence.
  • Immobilize extremity.
  • Apply ice
  • Strict NPO
  • Pain control

Ed Treatment/Procedures

  • Closed fractures:Gentle attempt at reduction if fracture is displaced (do not attempt multiple reductions; may increase risk for compartment syndrome).Immobilization:Well-padded long leg posterior splintKnee in 10 " “20 ‚ ° of flexionAvoid circumferential cast.If pain persists after immobilization, suspect:Compartment syndromeAvoid elevation of leg in suspected compartment syndrome; it lowers perfusion to the extremity.Nerve compressionCrutches
  • Open fractures:Remove contaminants and cover wound with moist, sterile dressing.AntibioticsTetanus prophylaxisImmobilization with well-padded long leg posterior splintImmediate orthopedic surgery consultation for debridement and fracture fixation
  • Isolated fibular fracture:Usually treated symptomatically:Padded splintElevationIceNo weight bearing until swelling resolvesCrutches if not bearing weight

Medication

  • Gram-positive cocci coverage for open fractures: Cefazolin 2 g loading dose then 1 g (peds: 50 mg/kg/d) IV/IM q8h
  • Gustilo " “Anderson type III, add gram-negative rod coverage: Gentamicin 3 " “5 mg/kg (peds: 2.5 mg/kg) IV q8h
  • Farming accident, add Clostridium spp coverage: Penicillin G 10 million IU (peds: 250,000 " “400,000 IU/kg/d) IV q6h
  • Tetanus 0.5 mL IM and tetanus immune globulin 250 U IM as indicated by the type of wound and the number of primary immunizations
  • If penicillin allergic: Vancomycin 1 g (peds: 10 mg/kg) IV q12h

Follow-Up

Disposition

Admission Criteria

  • Multiple trauma
  • High-energy mechanism
  • Soft tissue involvement
  • Risk for compartment syndrome
  • All open fractures
  • Displaced, angulated, transverse, shortened, comminuted, and otherwise unstable fractures
  • Intra-articular involvement
  • Neurovascular compromise
  • Inadequate pain control
  • Pathologic fracture
  • Nonaccidental trauma in children

Discharge Criteria

  • Minimally displaced fracture with low-energy injury mechanism
  • Close orthopedic follow-up
  • Return parameters for compartment syndrome in a reliable patient
  • If fracture is >48 hr old, compartment syndrome is unlikely to develop; if it has not occurred, discharge criteria may be more liberal.

Follow-Up Recommendations

  • Most pediatric fractures are treated with long leg cast for 4 " “6 wk.
  • Nondisplaced and minimally displaced fractures in adults may be treated with long leg cast and closed reduction.
  • Open contaminated fractures may be treated with external fixation and debridements.
  • Treatment with intramedullary nail allows for early mobilization and weight bearing as tolerated.
  • Kirschner wires are sometimes used in the treatment.

Pearls and Pitfalls

  • High incidence of associated injuries in high-energy trauma:Associated injuries commonly include:Femoral fractures ( "floating knee injury " ť)Head traumaSpine fracturesDeep venous thrombosis occurs in 10 " “25% of patients following tibial fracture.

Additional Reading

  • Browner ‚ BD. Fractures of the tibial shaft. In: Skeletal Trauma. 4th ed. Philadelphia, PA: WB Saunders Co.; 2008.
  • Green ‚ NE, Swiontkowski ‚ MF. Fractures of the tibia and fibula. In: Skeletal Trauma in Children. Philadelphia, PA: Elsevier; 2008.
  • Newton ‚ EJ, Love ‚ J. Emergency department management of selected orthopedic injuries. Emerg Med Clin North Am. 2007;25(3):763 " “793, ix " “x.
  • Park ‚ S, Ahn ‚ J, Gee ‚ AO, et al. Compartment syndrome in tibial fractures. J Orthop Trauma. 2009;23(7):514 " “518.

Codes

ICD9

  • 823.20 Closed fracture of shaft of tibia alone
  • 823.22 Closed fracture of shaft of fibula with tibia
  • 823.32 Open fracture of shaft of fibula with tibia
  • 823.21 Closed fracture of shaft of fibula alone
  • 823.30 Open fracture of shaft of tibia alone
  • 823.31 Open fracture of shaft of fibula alone

ICD10

  • S82.209A Unsp fracture of shaft of unsp tibia, init for clos fx
  • S82.209B Unsp fx shaft of unsp tibia, init for opn fx type I/2
  • S82.409A Unsp fracture of shaft of unsp fibula, init for clos fx
  • S82.409B Unsp fx shaft of unsp fibula, init for opn fx type I/2
  • S82.201A Unsp fracture of shaft of right tibia, init for clos fx
  • S82.201B Unsp fx shaft of right tibia, init for opn fx type I/2
  • S82.202A Unsp fracture of shaft of left tibia, init for clos fx
  • S82.202B Unsp fx shaft of left tibia, init for opn fx type I/2
  • S82.251A Displaced comminuted fracture of shaft of right tibia, init
  • S82.251B Displ commnt fx shaft of r tibia, init for opn fx type I/2
  • S82.252A Displaced comminuted fracture of shaft of left tibia, init
  • S82.252B Displ commnt fx shaft of l tibia, init for opn fx type I/2
  • S82.253A Displaced comminuted fracture of shaft of unsp tibia, init
  • S82.253B Displ commnt fx shaft of unsp tibia, 7thB
  • S82.401A Unsp fracture of shaft of right fibula, init for clos fx
  • S82.401B Unsp fracture of shaft of r fibula, init for opn fx type I/2
  • S82.402A Unsp fracture of shaft of left fibula, init for clos fx
  • S82.402B Unsp fx shaft of left fibula, init for opn fx type I/2
  • S82.451A Displaced comminuted fracture of shaft of right fibula, init
  • S82.451B Displ commnt fx shaft of r fibula, init for opn fx type I/2
  • S82.452A Displaced comminuted fracture of shaft of left fibula, init
  • S82.452B Displ commnt fx shaft of l fibula, init for opn fx type I/2
  • S82.453A Displaced comminuted fracture of shaft of unsp fibula, init
  • S82.453B Displ commnt fx shaft of unsp fibula, 7thB

SNOMED

  • 271577005 Fracture of shaft of tibia and fibula (disorder)
  • 208632002 Open fracture of tibia and fibula, shaft (disorder)
  • 6990005 Fracture of shaft of tibia (disorder)
  • 67394003 Fracture of shaft of fibula (disorder)
  • 111646002 open fracture of shaft of fibula (disorder)
  • 22234005 Open fracture of shaft of tibia (disorder)