Tibia Fracture - Types and Management

Introduction:

The most common fracture of the lower extremity is the tibial bone fracture. The tibia is also called the shin bone. The lower leg consists of two main bones; the tibia and the fibula. The tibia is the larger one, which supports the body weight and is an important component of the knee and ankle joints. The fibula is a smaller and thin bone than the tibia, located behind the tibial head at the knee joint. The tibial bone articulates with the talus, fibula, and distal femur bones.

The upper end of the tibia bone is wider, which narrows below, and the medial surface is broad and smooth, remaining subcutaneously (under the skin) throughout and thus prone to fractures.

What Is a Tibia Fracture?

A fracture of the tibia or the shin bone is called a tibia fracture. It may also be associated with soft tissue injuries or nerve involvement and requires immediate care and attention to restore normal function, strength, and stability. Tibial fractures result from trauma or fall in children, adolescents, or elderly people with weakened bones. Males, especially the youth, are more prone to these fractures than females. Low-impact fractures have a spiral pattern and have a low degree of association with soft tissues. In contrast, high-energy fractures are short oblique or wedge fractures with severe soft tissue injuries.

What Are the Types of Tibia Fractures?

Tibial fractures can be classified based on the location:

• Proximal Tibia Fractures: Proximal tibia fractures occur at the knee end, affecting the stability and the growth plates. They are also called tibial plateau fractures and are further classified into

• Proximal Tibial Epiphyseal Fractures: These fractures occur at the bone epiphysis (top portion) due to direct force to the knee, resulting in the separation of the growth plates. It needs immediate treatment or can hamper the growth leading to permanent deformity.

• Proximal Tibial Metaphyseal Fractures: These fractures occur at the metaphysis (neck of the bone), where the tibial bone starts to narrow down. It usually occurs due to force applied at the side of the knee when the leg is extended and is commonly seen in children around two to eight years.

• Tibial Shaft Fractures: Fractures that take place in the shaft (diaphysis) or the middle portion of the tibia are tibial shaft fractures; they are further classified into

• Nondisplaced Fractures: A fracture where the segments remain aligned, are non-displaced fractures, usually seen in children around four years of age, following a mild injury or twisting of the leg.

• Displaced Non-Comminuted Fractures: It is the most common fracture of the tibial shaft, wherein the broken fragments are not more than two fragments (non-comminuted) but are not aligned. An isolated tibia fracture with an intact fibula bone is caused by rotational or twisting forces such as sports injuries or falls.

• Displaced Comminuted Fractures: Fractures caused due to high energy trauma result in several fragments of broken bones which are not aligned, and require surgical management.

• Distal Tibial Fractures: These fractures are commonly seen in children at the ankle end of the tibia bone. These are usually transverse or oblique fractures and can be healed by closed reduction, but an early closure of the growth plate can lead to a permanent deformity or leg length discrepancy.

What Are the Causes of Tibia Fractures?

Some of the causes of tibia fractures are

• Fractures caused due to high impact trauma like vehicle accidents, direct hit or fall from long distances in the case of athletes, or low-impact trauma such as twisting or falls from standing heights in the case of elderly individuals.

• Sports injuries include long-distance running, football, skiing, snowboarding, etc.

• Persons with osteoporosis or low bone density are highly susceptible to tibial fractures.

What Are the Signs and Symptoms of Tibia Fractures?

Some of the signs and symptoms include:

• Severe pain and swelling in the lower leg area.

• Severe bruises and abrasions in the shin bone area in case of accidents.

• Difficulty in standing or walking, or bending down.

• Unable to bear the weight on legs.

• Deformity or uneven length of the leg.

• Skin being pushed up by the bone results in a tent-like appearance.

• Loss of sensation or numbness in the affected area.

• Protrusion of bone through a break in the skin.

How Is a Tibia Fracture Diagnosed?

Tibial fractures require immediate care and management or can lead to permanent deformity. The doctor takes a complete medical history, followed by a physical examination of the lower leg to assess the range of motion and associated injuries. Soft tissues are evaluated for abrasions, fracture blisters, bruises, signs of compartment syndrome, etc. Radiological investigations include

• X-rays: Anteroposterior (AP) and lateral views of the affected area and the AP, lateral, and oblique views of the ipsilateral (same side) knee and ankle are preferred. X-rays to help determine the fracture's type and location, associated fractures, and joint extensions.

• Computed Tomography (CT Scan): It is recommended to obtain a better view of the fracture and rule out other fractures in cases of intra-articular involvement.

• Magnetic Resonance Imaging (MRI): It gives a clear and better view of the bones and surrounding soft tissues but is recommended only in cases where the other scans are not helpful in the diagnosis.

How Is a Tibia Fracture Managed?

The management of tibial fractures mainly depends on the cause, location, and severity of the fracture, the involvement of soft tissues, and the general health of the patient. Non-surgical methods are employed in cases of non-displaced fractures, in cases of less active individuals, or in patients with poor health. Closed reduction and immobilization are followed, during which the doctor aligns the bones to their normal positions and immobilizes them with a long leg cast or a short leg cast for four to six weeks, followed by analgesic medications like non-steroidal anti-inflammatory drugs to relieve pain. Surgical treatment includes

• Open Reduction and Internal Fixation: It is a surgical procedure during which an incision is given at the affected area, the underlying tissues are exposed, irrigated to remove any debris or bony fragments, and the bones are aligned and fixed with metal screws or plates. It is usually followed in cases of intra-articular fractures and in cases where intramedullary nailing is not possible. Percutaneous pinning with metal wires is used in some cases to fix and stabilize the fracture fragments.

• External Fixation: It is followed in cases of extensive soft tissue damage, wherein the metal pins and screws are fixed from the outside to stabilize the fracture and promote healing. Intermedullary rods or pins are used in closed or low-grade open fracture cases.

• Medications: Oral antibiotics are prescribed to prevent infections and analgesics for relieving pain; a tetanus shot may also be given in case of injuries.

What Are the Complications of a Tibia Fracture?

• Compartment syndrome can occur due to swelling, which causes a reduction in blood supply leading to severe pain and numbness.

• Anterior knee pain is the most common complication in intramedullary rod or nail fixation cases.

• Failure to heal (non-union) or malalignment can occur in some cases, leading to deformity.

• Damage to the nerves and blood vessels following surgery.

Conclusion:

Fractures involving the tibia or the shin bone are tibial fractures; caused due to high-velocity injuries like vehicle accidents or sports injuries or low-velocity trauma like twisting or falls in children or elderly individuals. It is associated with severe pain, swelling, numbness, and difficulty standing or walking. Tibial fractures are usually managed successfully by non-operative methods, but severe displaced or comminuted fractures require surgical treatment and take about four to six months for complete recovery.