Tibial Shaft Fractures - Types and Treatment

Introduction

The lower leg consists of two long bones: the tibia and the fibula. The tibia (shin bone) is the second largest bone in the body, and its main function is weight-bearing, especially the medial aspect of the tibial bone bears the majority weight of the body. It also serves as an insertion site for the muscles and allows flexion and extension at the knee joint, dorsiflexion, and plantar flexion at the ankle joint. The fibula supports the tibia and contributes to the stability of the knee and ankle joints. The tibia proximally forms the knee joint along with the femur bone, and distally it forms the ankle joint with the fibula and the talus bones.

The tibia and the fibula bones are connected by an interosseous membrane, and the tibia runs medially to the fibula from below the knee joint to the ankle joint. The tibial bone is divided into the proximal portion, the shaft, and the distal portion. The proximal portion consists of the medial and lateral condyles that constitute the inferior portion of the knee joint, and the space between the condyles is the intercondylar area. The shaft is triangular in cross-section and has three borders; the anterior, medial, and interosseous borders, and three surfaces; the anterior (medial), posterior and lateral surfaces. The distal portion of the tibial bone is made of five surfaces; the inferior, anterior, posterior, lateral, and medial, and it also has a distal medial protuberance.

What Are Tibial Shaft Fractures?

A break or discontinuity anywhere along the length of the tibia bone is called a tibial shaft fracture. It is the most common fracture of the long bone in the body. It mainly occurs in males rather than females and is primarily seen in young individuals or due to falls in children or elderly people with weak bones. A fracture of the distal portion of the tibia, with an intact fibula, is called a toddler’s fracture.

What Are the Types of Tibial Shaft Fractures?

Tibial shaft fractures can be classified based on the fracture pattern (OTA classification) as

• A - Simple fractures.

• B - Wedge pattern fractures.

• C - Complex or comminuted fractures.

Based on the wound size, level of contamination, and osseous injury, open tibial fractures can be classified (Gustilo - Anderson classification) as:

• Type I: An open fracture associated with a wound less than one centimeter long and clean.

• Type II: An open fracture with a laceration greater than one centimeter long and without extensive soft tissue damage.

• Type IIIA: An open fracture with adequate soft tissue coverage regardless of the wound size, despite extensive soft tissue laceration or high energy trauma.

• Type IIIB: An open fracture with extensive soft tissue injuries, presence of periosteal stripping, and bone exposure.

• Type IIIC: Open fractures associated with arterial injury requiring repair.

What Are the Causes of Tibial Shaft Fractures?

Some causes of tibial shaft fractures include

• High-energy injuries like motor vehicle accidents, crash injuries, and sports injuries, like skiing, football, etc.

• Low-energy injuries are mainly seen in children and elderly individuals due to falls, sudden twisting, turning, or rotation movements, resulting in spiral or oblique fractures.

What Are the Signs and Symptoms of Tibial Shaft Fractures?

Some signs and symptoms of tibial shaft fractures include:

• Severe pain and swelling at the site.

• Inability to walk or stand.

• Unable to bear the body weight.

• Bone tenting or protruding over the skin in case of open fracture.

• Significant deformity at the site of injury.

How Are Tibial Shaft Fractures Diagnosed?

A complete medical history is noted, followed by a thorough physical examination. Inspection of the fracture site is done to check the extent of soft tissue injuries, bruises, and lacerations. An obvious swelling or a deformity with tenderness may be present. Range of motion and touch sensation is also assessed. Radiological investigations include:

• X-rays are recommended to determine the location, type, pattern, and extent of the fracture. A full-length anteroposterior (AP) and lateral view of the affected area is required, along with an AP and oblique view of the knee and ankle. It also helps to rule out fractures of the fibula and involvement of the knee and ankle joints.

• Computed Tomography (CT Scan) is advised in some cases, as it provides a cross-sectional view of the fracture and a clear image compared to radiographs. It is advised in cases of multiple injuries as it helps in surgical planning.

How Are Tibial Shaft Fractures Managed?

Tibial shaft fractures can be managed by conservative and surgical treatments, depending on the type, cause, and severity of the fracture, along with the patient's general health. Non-surgical treatment is recommended in case of closed fractures or in patients who cannot undergo surgery due to poor health conditions. Conservative management includes:

• Casting and Bracing: It is recommended in closed, nondisplaced, or minimally displaced fractures. A plaster cast or a long leg cast is the most preferred casting method and is applied as early as possible after the injury. The reduction is first achieved by the gravity-assisted method, wherein the patient is asked to lie in a lateral or prone position, which permits gravity to aid in the reduction and hold the fracture in place during plaster application. The duration of casting is around four to eight weeks, with regular monitoring, followed by bracing by functional braces made of plastic and fasteners for around two to four weeks.

• Closed Reduction and Immobilization: It is advised for fractures of less than ten degrees in anterior-posterior angulation or less than one-centimeter shortening. The patient is instructed to lie down in a supine position, and longitudinal traction is applied through a plaster boot, with a gauze sling placed behind the calf region of the fracture site to prevent displacement. After a significant reduction is achieved, a long leg cast is applied to immobilize the bone and promote healing.

Surgical treatment is necessary in cases of open or displaced fractures and in cases of fractures not healed by nonsurgical treatments. Surgical management includes:

• External Fixation: It is recommended in cases of multiple trauma, open fractures, nonunion, or delayed union of fractures or fractures with joint involvement. During this procedure, metal pins and screws are placed above and below the fracture site. These pins and screws are attached to a bar outside the skin which is called the stabilizing frame; it stabilizes the fragments and maintains the alignment during healing.

• Intermedullary Nailing: It is considered the gold standard treatment for the management of tibial shaft fractures. It is indicated in cases of severe soft tissue injuries associated with fractures, highly unstable fractures, or in case of fractures of both the tibia and fibula. The procedure is done under general anesthesia; the patient is asked to lie in a supine position, an incision is done near the hip joint, and an intramedullary nail is inserted through the femur bone and fixed at both the ends with the help of metal screws, which stabilizes the fragments to achieve healing. The advantages of this procedure are it involves minimal surgical intervention, preserves blood supply, and does not disrupt soft tissues.

• Open Reduction and Internal Fixation (ORIF): It is usually indicated in rare cases of tibial shaft fractures such as multiple injuries, fractures that extend into the joint (proximal or distal fractures), etc. It is a procedure during which an incision is made at the fracture site, and the area is exposed. The surgical site is irrigated and debrided to remove the loose bony fragments, and the bones are aligned in their anatomical position. Internal fixation is done using metal rods, screws, or pins, which will remain under the skin. The surgical site is then closed with sutures, followed by antibiotic medications to prevent infections and analgesics to relieve pain.

• Percutaneous Pinning: It is a surgical procedure during which metal wires or pins are inserted across the fracture fragments to hold them in place during the healing process and removed once the fracture has completely healed.

What Are the Complications of Tibial Shaft Fractures?

Some of the complications include:

• Delayed union or mal union (abnormal union) following treatment.

• Damage to the blood vessels and nerves, and ligaments.

• Open fractures may lead to bone infections, which may delay the healing process and require surgical intervention and long-term antibiotics.

• Severe fractures may cause pressure build-up within the muscles, which reduces the blood flow and oxygen to the tissues resulting in severe pain; it is called acute compartment syndrome.

Conclusion

A break or discontinuity anywhere along the length of the tibia bone is called a tibial shaft fracture. It is commonly seen in children and adolescents and occurs in young adults due to high-energy trauma like motor accidents, falls from heights, or falls in elderly people with osteoporosis. It is associated with pain, swelling, loss of function, and a significant deformity. It is usually managed by conservative treatment such as closed reduction and long leg cast, surgical treatment through an intramedullary nailing procedure, or open reduction and internal fixation followed by medications and physical therapy.