Tibial Shaft Fracture

A tibial shaft fracture involves the tibial diaphysis between the proximal and distal metaphyseal regions.

The tibia has limited anteromedial soft tissue coverage, making it particularly vulnerable to:

• Open fracture
• Soft tissue necrosis
• Infection
• Delayed union
• Nonunion
• Compartment syndrome

The associated fibula may be fractured or intact.

An intact fibula can sometimes contribute to varus malalignment during healing of a tibial fracture.

AO/OTA classification

Tibial shaft fractures are coded 42.

42A: Simple

• A1 spiral
• A2 oblique
• A3 transverse

42B: Wedge

• B1 spiral wedge
• B2 bending wedge
• B3 fragmented wedge

42C: Multifragmentary

• C1 complex spiral
• C2 segmental
• C3 irregular multifragmentary

Classification should be supplemented by description of:

• Open versus closed
• Proximal, middle or distal third
• Degree of displacement
• Soft tissue injury
• Associated fibular fracture
• Neurovascular status

Patients present with pain, deformity, swelling and inability to bear weight.

Inspect the entire tibia carefully because a small puncture wound converts the injury into an open fracture.

Assess skin viability, particularly over the anteromedial tibia.

Document:

• Dorsalis pedis pulse
• Posterior tibial pulse
• Capillary refill
• Tibial nerve function
• Deep and superficial peroneal nerve function

Compartment syndrome

Tibial shaft fracture is one of the commonest fractures associated with acute compartment syndrome.

The leg has four major compartments:

• Anterior
• Lateral
• Superficial posterior
• Deep posterior

Pain out of proportion and pain with passive stretch are early warning features.

Paraesthesia and weakness are later.

Pulselessness is a very late finding and should never be awaited.

In an awake patient with convincing clinical compartment syndrome, proceed to fasciotomy without delaying for compartment pressure measurements.

When diagnosis is uncertain or examination unreliable, measure compartment pressure.

A commonly used threshold is:

Delta pressure = diastolic blood pressure minus compartment pressure ≤30 mmHg

This strongly supports decompression when consistent with the clinical setting.

Obtain AP and lateral radiographs of the entire tibia and fibula, including both the knee and ankle.

CT is unnecessary for a routine midshaft fracture but useful when:

• Fracture extends into the plateau
• Fracture extends into the plafond
• Rotational or complex periarticular morphology is uncertain

Any open wound requires full open fracture management.

Initial management

Provide analgesia.

Restore gross length and alignment.

Apply a long leg posterior splint or appropriate temporary immobilisation.

Repeat neurovascular examination.

Open fractures receive immediate antibiotics, sterile dressing, tetanus assessment and operative debridement.

Nonoperative treatment

Closed treatment can be used for selected low energy fractures with acceptable alignment.

Commonly accepted initial parameters include approximately:

• Less than 5° varus or valgus
• Less than 10° anterior or posterior angulation
• Less than 1 cm shortening
• More than approximately 50% cortical apposition
• Less than approximately 10° rotational deformity

Apply a long leg cast initially, followed by functional bracing when early healing and stability permit.

Serial radiographs are essential.

Varus, valgus and rotational deformity should be identified before union becomes established.

Operative indications

Intramedullary fixation is appropriate for:

• Open fracture
• Unstable displaced fracture
• Segmental fracture
• Significant comminution
• Inability to maintain acceptable closed alignment
• Polytrauma
• Bilateral tibial fractures
• Associated ipsilateral femoral fracture
• Significant soft tissue injury requiring stable skeletal support

Intramedullary nail

A locked intramedullary nail is the standard fixation for most displaced adult tibial shaft fractures.

The nail provides load sharing fixation while preserving much of the fracture blood supply.

Correct alignment before nail insertion.

Particular attention is required for:

Proximal third fractures

Tendency toward:

• Valgus
• Apex anterior deformity

Use:

• Semiextended or suprapatellar positioning where appropriate
• Blocking screws
• Reduction clamps
• Provisional plate assistance

to maintain alignment.

Distal third fractures

The wide distal metaphyseal canal allows the nail to translate.

Use multiple distal locking screws and blocking screws where necessary to prevent coronal malalignment.

Confirm that there is no occult extension into the ankle joint.

Reamed versus unreamed nailing

Reamed nailing is generally preferred for most closed fractures because it permits a larger nail and strong fixation.

Open fracture management depends on contamination, soft tissue status and reconstructive plan rather than a simple rule that all open fractures must receive an unreamed nail.

Plate fixation

Plate fixation is useful for:

• Very proximal fractures
• Very distal fractures
• Fractures with articular extension
• Fractures where intramedullary access is unsuitable
• Some nonunions

Minimally invasive plate osteosynthesis preserves periosteal blood supply better than extensive stripping.

External fixation

Use for:

• Damage control in unstable polytrauma
• Severe open injury
• Major contamination
• Vascular repair
• Severe soft tissue compromise
• Temporary stabilisation during serial debridement

External fixation may be temporary or definitive depending on injury and resources.

Fibular fixation

Routine fixation of every fibular fracture is unnecessary.

Fixation can be useful when:

• Distal tibial fracture alignment is difficult to control
• Ankle mortise stability requires fibular restoration
• Fibular length assists distal tibial reduction

Overly rigid fibular fixation can theoretically reduce beneficial compression across selected tibial fracture patterns and should not be performed without a mechanical reason.

Compartment syndrome

Perform urgent four compartment fasciotomy.

The standard two incision technique decompresses all compartments.

Do not close fasciotomy skin under tension. Use delayed closure or skin grafting where required.

Postoperative care

Stable intramedullary constructs often permit early weight bearing, particularly simple midshaft fractures.

More distal, proximal or highly comminuted fractures may require initial protected weight bearing.

Encourage early knee and ankle movement.

Major complications include:

• Compartment syndrome
• Infection
• Nonunion
• Delayed union
• Malunion
• Anterior knee pain after intramedullary nailing
• Rotational deformity
• Hardware failure
• Chronic osteomyelitis after severe open injury

Persistent pain and lack of progressive radiographic healing should prompt assessment for mechanical instability, infection, smoking, metabolic factors and fracture gap rather than simply extending observation indefinitely.