LL: TIBIAL AND FIBULA FRACTURES Flashcards
FRACTURE OF THE SHAFT OF THE TIBIA AND FIBULA
PATHOPHYSIOLOGY AND COMPLICATIONS
A common injury.
It is uncommon to fracture one bone in isolation.
CAUSE
Twisting force → spiral/oblique fracture, often each bone at different levels
Direct force → transverse fracture
DEFORMITY
Shortening due to pull of tibialis anterior, soleus and gastrocnemius.
Distal fragment pulled posteriorly by gastrocnemius and soleus.
COMPLICATIONS
Infection
Due to the anatomy of the area, these fractures are often compound. This
predisposes the area to infection. Excellent wound care and prophylactic
antibiotics may help to reduce the occurrence of osteomyelitis.
Delayed or non-union
Poor blood supply and poor muscle coverage in the distal part of the tibia
predisposes it to poor healing.
The risk is even greater if only one bone is fractured.
Popliteal artery damage
This can occur in fractures of the upper 1/3 of the tibia.
Compartment Syndrome
Due to the oedema or dressings that are too tight.
FRACTURE OF THE SHAFT OF THE TIBIA AND FIBULA
Conservative Treatment and contraindication
TREATMENT
When both bones are fractured, attention is directed to fixing the tibia.
Conservative treatment is the first choice where practical.
Conservative treatment
Never done if the fracture is open.
Above knee POP 6/52 and the patient is NWB, followed by cast brace 6-
8/52.
An alternative to the cast brace is a plaster shoe so that the patient can
begin weight bearing.
Firm union is usually only achieved at 3-4 months and may take up to 9
months.
CONTRA-INDICATIONS AND PRECAUTIONS
• Maintain elevation of the limb.
• NWB at least the first 6/52, thereafter communicate with surgeon.
• General contra-indications
FRACTURE OF THE SHAFT OF THE TIBIA AND FIBULA
Operative treatment & contraindications and precautions
Operative treatment
Surgery is required more often for spiral or oblique fractures which are less
stable than transverse fractures.
Semi-rigid plates and screws can be used but this results in much
stripping of the periosteum. Often this is augmented with POP with window
until union is evident on X-ray.
Intramedullary nails are often preferable to plating. It can be less invasive
if done using a ‘closed technique’. Nails are not always suitable for very
comminuted fractures, or for fractures that are very proximal or distal. The
additional support from POP is seldom necessary.
External fixation is a good option for open fractures.
CONTRA-INDICATIONS AND PRECAUTIONS
• NWB for a minimum of 6-8/52 and thereafter consult surgeon.
• Maintain elevation of the limb.
• Infection control.
FRACTURE OF THE TIBIA ALONE
Displacement is usually minimal and above knee POP is sufficient.
Guidelines are as for conservative treatment above. The intact fibula may
act as a strut and eliminate compressive force through the tibia. This may
cause delayed or non-union. Excision of part of the fibula may prevent this.
FRACTURE OF THE FIBULA ALONE
Pain relief is the main aim of treatment and to this end a below-knee walking
plaster or brace can be used for 3/52.
Complicated fractures of the fibula will be dealt with in the section on ankle
injuries.
TIBIAL PLATEAU FRACTURES
pathophysiology and complications
CAUSE Direct violence Fall from a height Fall with knee extended in elderly and osteoporotic patients DEFORMITY The knee is very swollen and may have a varus or valgus deformity TYPES Vertical shear Condylar depression Comminuted
COMPLICATIONS Compartment syndrome Collateral ligament tears Injury to common peroneal nerve Late knee instability Post-traumatic osteoarthritis
TIBIAL PLATEAU FRACTURES
treatment & contraindications and precautions
TREATMENT
The management depends on the amount of displacement of the tibial
plateau, the degree of instability and the feasibility of surgical fixation.
Minimally displaced fracture with < 5° varus/valgus instability or severely
comminuted fracture treated with skin or skeletal traction. Active knee
movement is encouraged within the traction early on to facilitate the smooth
healing of joint surfaces. The traction is maintained until the knee can flex to
90°. This usually takes 4-6/52. The patient is then mobilised NWB in a cast
brace for 6/52 and then NWB with no brace for 6/52.
CONTRA-INDICATIONS AND PRECAUTIONS
Do not remove traction.
Respect pain during active movement as fracture is not healed.
General contra-indications.
Unstable or significantly displaced fractures are usually treated with ORIF.
Vertical shear fractures are immobilised with screws and depression fractures
are punched out and grafted.
CONTRA-INDICATIONS AND PRECAUTIONS
NWB until surgeon says otherwise.
General contra-indications.
TIBIAL SPINE FRACTURES
These are avulsion fractures associated with ACL or PCL injuries.
The mechanism of injury is usually twisting, abduction or adduction of the
knee.
TREATMENT
ACL avulsion with minimally displaced fragment will be treated with an
above knee POP in full extension or a hinge brace in full extension for 6/52.
ACL avulsion with widely displaced fragment is treated with surgical
reduction and fixation and then above knee POP in extension or hinged brace
for 6/52.
PCL avulsion is treated with ORIF and then above knee POP in extension or
hinged brace for 6/52.
Weight bearing is determined by the surgeon.
Physiotherapy management is similar to that of an ACL repair.
ISOLATED FRACTURE OF THE FIBULAR HEAD
CAUSE
Direct blow
COMPLICATIONS
Damage to common peroneal nerve
TREATMENT
Analgesia
CONTRA-INDICATIONS AND PRECAUTIONS The following movements should not be resisted initially due to muscle attachments: Eversion Plantar flexion Knee flexion Hip extension
