Basics
Description
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 cm
- Little soft tissue damage
- No crush injury
- Type II:
- Wound >1 cm
- Moderate soft tissue damage
- Little or no devitalized soft tissue
- Type III " ”severe soft tissue injury:
- A " ”adequate soft tissue coverage of bone
- B " ”tissue loss/periosteal stripping
- C " ”neurovascular injury requiring surgery
- Anatomic location:
- Proximal, middle, or distal 3rd
- Articular extension
- Displacement
- Degree of shortening
- Angulation
- Configuration:
- Spiral, transverse, or oblique
- Comminuted, with butterfly fragment or multiple fragments
Fibula ‚
- Proximal:
- Associated with peroneal nerve injury
- Disruption 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 metaphysis
- Incomplete 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 spoke
- Crush 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 nerve
- Sensation of 1st web space
- Ankle and toe dorsiflexion
- Anterior tibial artery feeds dorsalis pedis artery
- Lateral compartment:
- Superficial peroneal nerve
- Sensation of dorsum of foot
- Foot eversion
- Deep posterior compartment:
- Tibial nerve
- Sensation to sole of foot
- Ankle and toe plantar flexion
- Posterior tibial and peroneal arteries
- Superficial posterior compartment:
- Branch of sural cutaneous nerve
- Sensation 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 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
- Crutches
- 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
- Isolated fibular fracture:
- Usually treated symptomatically:
- Padded splint
- Elevation
- Ice
- No weight bearing until swelling resolves
- Crutches 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 trauma
- Spine fractures
- Deep 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)