Tibial fracture is a violation of the integrity of a larger shin bone. In most cases, the fibula breaks along with the tibia. The damage is manifested by sharp pain, swelling, deformation, crepitation and pathological mobility in the shin area. Foot support is impossible. To clarify the diagnosis, radiography is prescribed. Treatment can be operative (fixation of fragments with pins, plates and external fixation devices) or conservative (skeletal traction followed by the application of a plaster cast).
ICD 10
S82 Fracture of the lower leg, including the ankle joint
Meaning
Tibial fracture is a common injury that is of great importance, both because of its prevalence and because of possible negative consequences. In the absolute majority of cases, it is accompanied by displacement of fragments (along the length, angular, rotational). Tibial fracture are often combined with other injuries: pelvic fractures, fractures of other limb bones, rib fractures, chest injury, blunt abdominal trauma, etc. Treatment of fractures of the lower leg bones is carried out by traumatologists.
Causes
The cause of tibial fracture, as a rule, are high-energy injuries (car accidents, falls from heights, industrial accidents, man-made and natural disasters). Damage occurs due to significant direct, bending and twisting effects, which causes a high proportion of complex lesions (open, comminuted, oblique and helical fractures). All of the above in some cases causes unfavorable outcomes: shortening and curvature of the limb due to improper fusion, lack of fusion and formation of false joints, etc.
Pathanatomy
The tibia is formed by two bones – the fibula and tibia. The tibia is larger, more massive. It bears the main load on the limb, participates in the formation of the ankle and knee joints. The fibula has an auxiliary value and is the place of attachment of muscles. As a rule, with injuries to the lower leg, both bones break, but the preservation of limb function primarily depends on the restoration of the integrity and shape of the tibia.
Classification
Fractures of the tibial body are almost always unstable and are accompanied by a more or less pronounced displacement of fragments. Depending on the location of the fracture line and the number of fragments, the following types of injuries are distinguished in traumatology and orthopedics:
- Transverse fracture. The fracture line is perpendicular to the axis of the bone. With simultaneous violation of the integrity of the fibula, as a rule, instability of fragments is observed. If the fibula is not damaged, relatively stable damage is possible without significant displacement of the fragments.
- Oblique fracture. The fracture line is located at an angle. The fracture is unstable, there is a tendency to increase the displacement.
- A helical fracture. Occurs when a twisting force is applied. The fracture line has the form of a spiral. The damage is usually unstable.
- Comminuted fracture. Under the influence of the traumatic force, three or more bone fragments are formed. A comminuted fracture is characterized by extreme instability.
In addition, there are open and closed injuries of the tibia. With closed fractures, the skin is not damaged, with open fractures, the integrity of the skin is violated, the fracture area communicates with the external environment. Open fractures are often accompanied by serious soft tissue injuries, with such injuries there is a higher risk of complications: wound suppuration, osteomyelitis, improper fusion, lack of fusion, etc.
Symptoms
The patient complains of sharp pain. The lower leg is deformed: shortened, twisted (the foot is turned inward or outward in relation to the knee joint), angularly curved. In the area of damage, crepitation and pathological mobility are determined. Support and movement are impossible. Swelling increases over time: immediately after injury, swelling may be absent, then the shin increases in volume, bruises appear on the skin. With open injuries on the lower leg, there is a wound in which bone fragments can be seen.
Diagnostics
The diagnosis is confirmed by tibia x-ray. The study of the images allows us to determine the number of fragments and the nature of the displacement, the presence or absence of a concomitant fracture of the fibula, as well as the involvement of the ankle and knee joints. In some cases (usually with joint damage), the patient may be additionally referred for a CT scan of the joint. If nerve and vascular damage is suspected, a consultation with a vascular surgeon, neurologist or neurosurgeon is prescribed.
Treatment
At the pre-hospital stage, the victim is given painkillers, immobilization of the lower leg is carried out with a special tire or improvised means (for example, two boards). It is necessary that the lower part of the tire “captures” the ankle joint, and the upper part reaches the upper third of the thigh. With open fractures, foreign bodies and large impurities are removed from the skin around the wound, the wound is closed with a sterile bandage. With heavy bleeding, a tourniquet is applied to the thigh. In the presence of traumatic shock (it can develop with multiple and combined injuries), anti-shock measures are carried out.
The tactics of inpatient treatment depends on the level and nature of the damage and can be conservative or operative. With stable tibial fracture without displacement (extremely rare), immobilization with a plaster cast is possible. In other cases, it is necessary to apply skeletal traction. The spoke is passed through the heel bone, the leg is placed on a tire. The average value of the initial load for an adult is 4-7 kg and depends on the body weight, the degree of muscle development, the type and nature of the displacement of fragments. Subsequently, if necessary, the weight of the cargo can be reduced or increased.
In the future, two options are possible. With conservative treatment, skeletal traction is maintained for 4 weeks, achieving the correct standing of the fragments. After the appearance of radiological signs of a callus, the traction is removed, a plaster is applied to the leg for another 2.5 months. At the initial stage, the patient is prescribed analgesics. During the entire period of treatment, physical therapy and physiotherapy are indicated. After removing the plaster, rehabilitation measures are carried out.
Indications for surgical treatment are multi-fractured fractures, in which it is impossible to restore the normal position of the fragments using conservative methods. In addition, surgical treatment is used to activate patients early and prevent the development of post-traumatic contractures. In most cases, operations are performed a week or more after the patient is admitted to the hospital. By this time, the patient’s condition usually normalizes, the swelling of the limb decreases, and doctors have time to conduct a comprehensive examination in order to identify contraindications to surgery. In the preoperative period, the patient is on skeletal extension.
In the surgical treatment of tibial fracture, various metal structures are used, including intramedullary pins, plates and locking rods. The choice of the method of osteosynthesis is carried out taking into account the nature and level of the fracture. In most cases, intramedullary (intraosseous) osteosynthesis of the tibia is preferred. In addition, for such injuries, non–focal osteosynthesis by Ilizarov devices is widely used – this method allows restoring the normal interposition of fragments not only simultaneously (during surgery), but also in the postoperative period. It can be used to treat the most complex injuries, including fractured fractures with the formation of a bone defect. The disadvantage of the technique is the presence of a massive and inconvenient external metal structure.
Prognosis and prevention
The fusion period of an uncomplicated tibial fracture averages 4 months. In case of comminuted fractures, open injuries and severe combined injuries, this period may increase to six months or more. A prerequisite for the full restoration of limb function is the implementation of the doctor’s recommendations, including early resumption of movements, regular exercise therapy and limiting the load on the injured leg. Prevention includes measures to prevent injuries at home and at work.
Literature
- Busse J. W., Morton E., Lacchetti C. et al. Current management of tibial shaft fractures: a survey of 450 Canadian orthopedic trauma surgeons // Acta Orthop. — 2008. — № 5. — Р. 689–694. link
- Orthopaedic Trauma Association. Fracture and dislocation classification compendium — 2018 // Journal of orthopaedic trauma. — 2018. — № 1. — 173 р. link
