Fractures of the tibial shaft are common. Due to the subcutaneous nature of the distal part of the anterior shaft, these fractures are often open.

 

Management: Shaft fractures

Tibial fractures are often due to high velocity trauma. Remember to look for other injuries, including chest and abdominal trauma. Check for other fractures and dislocations, especially of the ipsilateral knee and hip.

Closed Fractures

Conservative Treatment

Stable and minimally displaced fractures can be treated conservatively by reduction and an above knee cast. If the fracture is minimally displaced a general anesthetic may not be necessary. Use a general anesthetic if there is overlapping of bones, or difficulty is expected.

Start the above knee cast with the leg hanging over the bed The below knee portion can be completed first. Hang the leg over the end of the table. An assistant can pull downwards on the ankle to maintain the reduction Above Knee plaster for fracture tibia
    How to apply Above Knee plaster
  • 15 degrees flexion at knee
  • Ankle at 90 deg.
  • Extend proximally to groin
  • Ends distally at MP joints

Take a check X Ray to confirm your reduction. Keep the patient overnight, or instruct him to return for a circulation check the following day.

The next follow up can be at one or two weeks. Here the plaster is checked. X rays are taken in the cast. If there is angulation wedging can be done of the cast. If there is unacceptable loss of length this method will fail and a remanipulation or possibly open reduction and internal fixation is required.

Wedging a plaster.

Measure the angulation on the x ray (leg still in plaster). Extend a line at right angles to the shaft at both sides of the fracture onto the image of the plaster. This will be equivalent to the gap to open. The plaster is sawed open at eh fracture level - keep a intact hinge open at the opposite side. hinge the limb into alignment by opening the gap in he plaster and holding it with a wooden block. Check X rays are taken. Once the desired result is achieved repair the defect with plaster bandage.

Angulated tibial fracture Making the saw cut in plaster to open wedge tibial fracture X rays show acceptable length , but valgus angulation of the distal tibia. The wedge has been marked out. The cut will be made so that an opening wedge can be made on the lateral side of the plaster.
Deepening the cut in the cast to develop an opening wedge Deepening the cut. A hinge of intact plaster can be left at the (medial) apex
The alignment has bee improved by the wedge The wooden block keeps the pop wedge open Once the plaster gap has been opened; retain it with a wooden block. Now take a follow-up x ray. If satisfactory alignment is obtained, repair the plaster with more pop bandages

Once the doctor is satisfied with alignment, the patient is followed up as an outpatient. Once the fracture starts stabilising after the initial few weeks he is seen monthly. The plaster cast is kept on with only replacements when seen at the clinic. At this stage X rays can be taken out of plaster, as callus formation is better assessed on X ray without a cast.

For mid shaft or lower fractures a patellar bearing cast often speeds up union.


The Patellar Tendon Bearing Cast Plaster technician applying PTB plaster
The PTB cast is well mould ed between the gastrocnemeus heads, (to prevent rotation) and applies load to the patellar tendon area. A walking heel on the sole allows weight bearing

Open Tibial Fractures

 

 



Open Reduction

    Indications for Open reduction and internal fixation - Tibial Shaft
  • Inability to obtain a reduction
  • Inability to maintain a reduction
  • Vascular complications

 

Intramedullary pin for unstable tibia fracture
IM Pin

Recently there has been a swing towards intramedullary pinning of the tibia. The procedure has a low sepsis rate and pin breakages are rare. Any closed unstable fracture of the shaft (large butterfly segment or comminution) can be considered candidate for this method. It is difficult to successfully plate a tibia shaft as there is a high rate of sepsis due to its poor distal blood supply, and the proximity of the skin to the bone lets in sepsis.

 

Open Fractures

Tibial fractures are often open due to most of the anterior border of the shaft being subcutaneous. The wound must be inspected in the trauma ward and then covered with a sterile dressing. A broad spectrum antibiotic is given (first generation cephalosporin plus amiloglycocide if very contaminated) Prophylaxis against tetanus is also necessary.

Curetting tibial marrow cavity during debridement Curetting out the medullary cavity. The bone may have become contaminated when it embedded in the ground

In theater the leg is scrubbed before it is draped. The wound is incised to a larger size if it is too small for access. All dead tissue is excised. Viable muscle will bleed, and should contract if pinched with a forceps - if it does not it needs excision. Preserve nerve tissue and suture if transected. Vessels may need repair at his stage. Lose pieces of bone ( no muscle attachments) are discarded. Leave the wound open for secondary suture later. take tissue and pus swabs for areobic and anaerobic culture) The wound needs irrigation with copious water (10 litres or more). A pulsed lavage system is invaluable in getting fine contaminants out of the tissue. If there is a large soft (Gustillo 3b type or more ) tissue defect consult a plastic surgeon regarding a primary flap to close the defect. The limb is stablised - use an exfix if the wound is large or will need attention later (skin graft etc.) If the wound is small and easily closable a paster cast may be necessary. Open reduction is not recommended at this primary debridement. It may be done at a later stage (48 hr.+) in the less contaminated fracture (below Gustillo 3B).

A second debridement at 48 hours is recommended in all contaminated cases. Here further non viable tissue is identified and removed. Wounds may be sutured at this stage if the wounds appear clean.

Delayed and Non Union

The tibia should begin to show signs of callus formation on X rays from six weeks onwards. The fracture becomes less mobile when stressed and the pain diminishes. If the tibia does not show signs of union or does not progress as expected delayed union may be diagnosed.
Make sure there are not causes such as sepsis, medical conditions such as diabetes etc. Smoking inhibits fracture union and should be discouraged. Non union has occurred when there is no progress towards union and the fracture is pain free.

Established non union, the intact fibula has hypertrophied over time
Established nonunion. This man had fractured his tibia 20 years previously. He only had minimal pain. Note the hypertrophy of the fibula.  

Treatment of delayed union needs to address the cause. Conservative treatment such as a dynamic cast (patellar tendon bearing cast) may stimulate union. If this fails, surgical measures are necessary. If sepsis is the cause a sequestrectomy of the fracture area is needed. If there is abundant callus but none bridges the gap (hypertrophic delayed union -"Elephant's foot" type) more stability is called for. An open reduction and internal fixation may be needed. The two types of delayed union: Hypertrophic (mechanical cause) and Hypotrophic (avascular)Hypotrophic delayed unions ( where there is little callus) are due to vascular reasons (e.g.severe stripping of soft tissue in an open fracture) Here a bone graft as well as further stabilisation (ORIF or Exfix) will be needed. Mal alignment is a potent cause of non or delayed union, as there are shear and angulatory forces tearing apart all attempts by capillaries to bridge the fracture gap. In this case a realignment procedure with fixation by exfix, or intramedullary pin is called for.