AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Lower leg fractures include fractures of the tibia and fibula. Of these two bones, the tibia is the only weightbearing bone. Fractures of the tibia generally are associated with fibula fracture, because the force is transmitted along the interosseous membrane to the fibula.

The skin and subcutaneous tissue are very thin over the anterior and medial tibia and as a result of this, a significant number of fractures to the lower leg are open. Even in closed fractures, the thin, soft tissue can become compromised. In contrast, the fibula is well covered by soft tissue over most of its course with the exception of the lateral malleolus.

The tibia and fibula articulate at the proximal tibia-fibular syndesmosis.

Fractures of the tibia can involve the tibial plateau, tibial tubercle, tibial eminence, proximal tibia, tibial shaft, and tibial plafond.

For more information, see Medscape's Trauma Resource Center.

Frequency

United States

Fractures of the tibia are the most common long bone fractures. Isolated midshaft or proximal fibula fractures are uncommon.

Mortality/Morbidity

• Limb loss may occur as a result of severe soft-tissue trauma, neurovascular compromise, popliteal artery injury, compartment syndrome, or infection such as gangrene or osteomyelitis. Popliteal artery injury is a particularly serious injury that threatens the limb and is easily overlooked.
• The common peroneal nerve crosses the fibular neck. This nerve is susceptible to injury from a fibular neck fracture, the pressure of a splint, or during surgical repair. This can result in foot drop and sensation abnormalities.
• Delayed union, nonunion, and arthritis may occur. Among the long bones, the tibia is the most common site of fracture nonunion.

Age

Toddler fracture (distal spiral fracture of the tibia) is most common in children aged 9 months to 3 years.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• Mechanisms of injury for tibia-fibula fractures can be divided into 2 categories:
• • Low-energy injuries such as ground levels falls and athletic injuries
  • High-energy injuries such as motor vehicle injuries, pedestrians struck by motor vehicles, and gunshot wounds
• Patient may report a history of direct (motor vehicle crash or axial loading) or indirect (twisting) trauma.
• Patient may complain of pain, swelling, and inability to ambulate with tibia fracture.
• Ambulation is possible with isolated fibula fracture.
• Tibial plateau fractures occur from axial loading with valgus or varus forces, such as in a fall from a height or collision with the bumper of a car. The lateral tibial plateau is fractured more frequently than the medial plateau.
• Tibial tubercle fractures usually occur during jumping activities such as basketball, diving, football, and gymnastics. This type of fracture is more common in adolescents than in adults.
• Tibial eminence fractures occur with trauma to the distal femur while the knee is flexed such as falling off of a bicycle. Another mechanism for this fracture is hyperextension. Tibial eminence avulsion fractures occur most often in children aged 8-14 years but can occur in a skeletally mature patient.
• Tibial shaft fractures usually present with a history of major trauma. An exception to this is a toddler's fracture, which is a spiral fracture that occurs with minor trauma in children who are learning to walk.
• Tibial plafond fractures refer to fractures involving the weightbearing surface of the distal tibia. This type of injury usually results from high-energy axial loading but may result from lower-energy rotation forces.
• Maisonneuve fractures are rare and considered unstable ankle injuries. This type of injury usually involves a pronation-external rotation force.
• Stress fractures of the tibia and fibula may occur as a result of repetitive submaximal stresses that may occur while participating in athletics. The history may reveal some change in training routine.

Physical

• When examining a patient for a lower leg fracture one should first examine the patient for edema, ecchymosis, and point tenderness. Gross deformities should be noted and splinted. A careful neurovascular assessment should be performed, and an emergent fracture reduction should be performed if neurovascular deficits are present.
• A careful examination should be performed for open wounds. Open fractures require antibiotics and an emergent orthopedic consultation.
• Tibial plateau fractures often present with a knee effusion. Tenderness will be present along the medial or lateral tibial plateau. Approximately 20% of tibial plateau fractures are associated with ligamentous injuries.
• Tibial tubercle fracture will have tenderness over the anterior tibia approximately 3 cm distal to the articular surface. In more severe tibial tubercle fractures, full extension of the knee is not possible. The patella may be high riding.
• Tibial eminence fracture may present with a knee effusion and pain and may represent an avulsion of the tibial attachment of the anterior cruciate ligament.
• Tibial shaft fractures are the most common long bone fracture and usually involve the fibula as well. Tibial fractures present with localized pain, swelling, and deformity.
• Maisonneuve fractures involve a fracture of the proximal fibula in association with a fractured medial malleolus (or injured deltoid ligament) and diastasis of the distal tibiofibular syndesmosis. Patients present with proximal fibular pain in addition to medial ankle pain. This is an unstable ankle injury.
• Tibial plafond fractures will have tenderness along the distal tibial and may have severely decreased range of motion in the ankle.

Causes

• Direct forces such as those caused by falls and MVCs
• Indirect or rotational forces

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Shin splints
Stress fracture

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Imaging Studies

• Perform radiographs of the knee, tibia/fibula, and ankle as indicated.
• Computed tomography
• • Computed tomography is indicated for severely injured patients if unable to get diagnostically sufficient radiographs of the knee. 
  • In patients with tibial plateau fractures and tibial plafond fractures, computed tomography can help further evaluate the extent of the fracture. 
  • In tibial plateau fractures, radiographs may underestimate the degree of articular depression when compared with computed tomography. This is important because articular depression of greater than 3 mm may be considered for surgery.
• For stress fractures
• • Radiographic findings are usually seen after 2-8 weeks of symptoms, and radiographs may not be very sensitive during the early stages of symptoms.
  • Radionucleotide scanning and MRI are more sensitive in diagnosing stress fractures and stress injuries than radiographs.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Prehospital Care

• Address airway, breathing, and circulation.
• Check and document neurovascular status.
• Apply sterile dressing to open wounds.
• Apply gentle traction to reduce gross deformities; splint the extremity.
• Administer parenteral analgesics for an isolated extremity injury in a hemodynamically stable patient.

Emergency Department Care

• Open fractures must be diagnosed and treated appropriately. Tetanus should be updated and appropriate antibiotics given. This should involve antistaphylococcal coverage and consideration of an aminoglycoside for more severe wounds. Orthopedics should be consulted for emergent debridement and wound care. Fractures with tissue at risk for opening should be protected to prevent further morbidity.
• Compartment syndrome can develop in fractures of the lower leg.
• • Signs of compartment syndrome include crescendo symptoms, pain with passive movement of involved muscles, paresthesias, and pallor, and a very late finding is pulselessness. Increased compartment pressure is present during compartment syndrome; therefore, external palpation frequently aids in the diagnosis. However, a soft extremity on palpation does not rule out compartment syndrome.
  • Serial examinations should be performed on patients with high-risk injuries or patients with equivocal symptoms.
  • If compartment syndrome is suspected, obtain an emergent orthopedic consult and measure compartment pressures. Compartment syndrome must be treated promptly with an emergency surgical fasciotomy. If untreated, the increased compartment pressures can cause ischemia and necrosis of the structures within that facial compartment and permanent disability.
• Tibial plateau fracture
• • Immobilize nondisplaced fractures and have the patient remain nonweightbearing.
  • Obtain an orthopedic consultation for displaced (depressed) fractures, which require open reduction and internal fixation. Articular depression of greater than 3 mm may be considered for surgery.
• Tibial eminence fracture
• • For nondisplaced fractures (and stable knee joint), immobilize the knee.
  • Obtain an orthopedic consultation for an unstable knee, or displaced fracture for possible surgical fixation.
• Tibial tubercle fracture
• • For nondisplaced fractures, immobilize the knee.
  • Obtain an orthopedic consultation for a displaced fracture to consider open reduction and internal fixation.
• Proximal tibia fractures
• • Intra-articular fractures require reduction and internal fixation.
  • Other methods to surgically repair proximal tibia fractures include external fixation, plating, and intramedullary nailing.
  • Closed treatment involves reduction and the placement of a long leg cast. Intact extensor mechanisms can make it difficult to maintain good fracture alignment.
• Tibial shaft fractures that are closed may be treated with cast immobilization if alignment is good or with intramedullary nailing.
• Isolated midshaft or proximal fibula fracture
• • Immobilization in a long leg cast generally is not required. Recommend a few days without weightbearing activity until swelling resolves, followed by weightbearing activity as tolerated.
  • Short leg walking cast usually is not required; however, some orthopedists may prefer a short leg walking cast or cam walker with weight bearing.
• Tibia and fibula stress fractures
• • The keystone of treating stress fractures is the temporary cessation of the offending activity.
  • Crutches may be used initially to allow the patient to be non–weight-bearing.

Consultations

• Tibia and fibula fractures
• • Obtain emergent orthopedic consultation for open fractures.
  • Consultation is also generally indicated for closed fractures.
• Emergent consultation is needed in suspected compartment syndrome.
• Advise patient to obtain orthopedic follow-up care of isolated fibula fractures.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Drugs used to treat fractures include nonsteroidal anti-inflammatory agents and analgesics. In addition, administer proper antibiotics and tetanus prophylaxis for open fractures.

Drug Category: Nonsteroidal anti-inflammatory agents (NSAIDs)

These drugs have analgesic and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may involve inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.

Drug Category: Analgesics

Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained fractures.

Drug Category: Immunoglobulins

Patients who may not have been immunized against Clostridium tetani products should receive tetanus immune globulin.

Drug Category: Toxoids

This agent is used for tetanus immunization. Booster injection in previously immunized individuals is recommended to prevent this potentially lethal syndrome.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Tibia and fibula fractures
• • Open fractures require debridement and irrigation in operating room.
  • Inpatient admission may be advised to observe development of compartment syndrome.

Further Outpatient Care

• Patient should see primary care physician or be referred to an orthopedic surgeon within 1 week for further evaluation and treatment of isolated fibula fractures.

Transfer

• Transfer is reasonable if approved by patient (for insurance or other reasons) or if a hospital bed or an orthopedic surgeon is unavailable at the transferring institution.

Complications

• Neurovascular compromise
• Compartment syndrome
• Peroneal nerve injury
• Infection
• Gangrene
• Osteomyelitis
• Delayed union, nonunion, or malunion
• Amputation or skin loss
• Posttraumatic arthritis
• Fat embolism

Prognosis

• Tibia and fibula fractures
• • Prognosis is generally good yet is dependent on degree of soft-tissue injury and bony comminution.
  • Prognosis is good for isolated fibula fractures.

Patient Education

• For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education article Broken Leg.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to recognize and treat associated life-threatening injuries
• Failure to consider ankle injury with proximal fibula fracture (Maisonneuve fracture)
• Failure to recognize open injuries and obtain timely orthopedic consultation
• Failure to recognize compartment syndrome

Special Concerns

• Toddler fracture
• • Typically, this type of fracture is nondisplaced spiral fracture of distal tibia unrelated to child abuse.
  • Midshaft tibial fractures, unrelated to a history of major trauma, should alert emergency physician to possibility of child abuse.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Accousti WK, Willis RB. Tibial eminence fractures. Orthop Clin North Am. Jul 2003;34(3):365-75. [Medline].
• Accousti WK, Willis RB. Tibial eminence fractures. Orthop Clin North Am. Jul 2003;34(3):365-75. [Medline].
• Fredericson M, Jennings F, Beaulieu C, Matheson GO. Stress fractures in athletes. Top Magn Reson Imaging. Oct 2006;17(5):309-25. [Medline].
• Germann CA, Perron AD, Sweeney TW. Orthopedic pitfalls in the ED: tibial plafond fractures. Am J Emerg Med. May 2005;23(3):357-62. [Medline].
• Haller PR, Harris CR. The tibia and fibula. In: Emergent Management of Skeletal Injuries. St Louis: Mosby-Year Book; 1995:499-517.
• Khalily C, Behnke S, Seligson D. Treatment of closed tibia shaft fractures: a survey from the 1997 Orthopaedic Trauma Association and Osteosynthesis International--Gerhard Kuntscher Kreis meeting. J Orthop Trauma. Nov 2000;14(8):577-81. [Medline].
• Konstantakos EK, Dalstrom DJ, Nelles ME, Laughlin RT, Prayson MJ. Diagnosis and management of extremity compartment syndromes: an orthopaedic perspective. Am Surg. Dec 2007;73(12):1199-209. [Medline].
• Krieg JC. Proximal tibial fractures: current treatment, results, and problems. Injury. Aug 2003;34 Suppl 1:A2-10. [Medline].
• McKoy BE, Stanitski CL. Acute tibial tubercle avulsion fractures. Orthop Clin North Am. Jul 2003;34(3):397-403. [Medline].
• Miller NC, Askew AE. Tibia fractures. An overview of evaluation and treatment. Orthop Nurs. Jul-Aug 2007;26(4):216-23; quiz 224-5. [Medline].
• Mustonen AO, Koskinen SK, Kiuru MJ. Acute knee trauma: analysis of multidetector computed tomography findings and comparison with conventional radiography. Acta Radiol. Dec 2005;46(8):866-74. [Medline].
• Newton EJ, Love J. Emergency department management of selected orthopedic injuries. Emerg Med Clin North Am. Aug 2007;25(3):763-93, ix-x. [Medline].
• Roberts DM, Stallard TC. Emergency department evaluation and treatment of knee and leg injuries. Emerg Med Clin North Am. Feb 2000;18(1):67-84, v-vi. [Medline].
• Russell TA. Fractures of the tibia and fibula. In: Fractures in Adults. 4^th ed. Philadelphia, Pa: Lippincott-Raven; 1996:2127-2201.
• Sproule JA, Khalid M, O'Sullivan M. Outcome after surgery for Maisonneuve fracture of the fibula. Injury. Aug 2004;35(8):791-8. [Medline].
• Taketomo CK, Hodding JH, Kraus DM. Naproxen. In: Pediatric Dosage Handbook. Vol 6. 1999-2000:632-633.
• Yang JP, Letts RM. Isolated fractures of the tibia with intact fibula in children: a review of 95 patients. J Pediatr Orthop. May-Jun 1997;17(3):347-51. [Medline].

Article Last Updated: Mar 11, 2008