A fracture just below the knee is called a fracture of the proximal end of the tibia. The proximal part of the tibia is that segment of the tibia bone, which extends to the knee to form the knee joint.
In addition to the fractured bone, soft tissues (skin, muscles, nerves, vessels and ligaments) can be injured at the time of the fracture. The fractured bone and the injured soft tissues should be treated at the same time. In most cases, surgery is needed to restore movement, muscle strength and leg stability and to reduce the chance of post-traumatic arthritis.
Three bones form the knee joint: The femur, the tibia and the patella. The last one lies in front of the joint and provides, among other things, protection.
The bones are joined together by ligaments. There are 4 main knee joints. They act like strong straps (bands) that hold the bones together and stabilize the knee.
There are several types of fractures of the proximal end of the tibia. The fracture may be a single transverse fracture or a comminuted one (into several pieces).
Many times, the fractures extend to the knee joint and divide the bone surface into fewer or more bone pieces. Such fractures are called tibial plateau intra-articular fractures. The upper surface of the tibia is made of spongy bone, which is softer than the compact bone of the lower tibia. Fractures of the tibial plateau occur when the tougher and stiffer lower part of the tibia is inserted to the spongy upper part, causing the latter to recede and break. This often results to the submersion of the spongy bone. The damage to the bone surface results in deformity of the knee joint, which, in turn, can lead to arthritis development, instability and loss of range of motion.
The fractures of the proximal part of the tibia may be closed (meaning that the bone does not come into contact with the environment) or open. An open fracture occurs when the bone breaks in such a way that the bones penetrate the skin or when the wound reaches such a depth that it contacts the bone. Open fractures usually involve greater damage to adjacent soft molecules such as tendons, muscles and ligaments.
They have a longer healing period and are usually accompanied by more complications.
A fracture of the proximal tibia can occur due to stress (minor cracks caused by abnormally high activity) or due to bone pathology, such as infection or cancer. But it is mostly the result of injury.
In younger people this type of fracture is the result of high energy impacts, such as falling from a significant height, injury during sports activities or car accidents.
Older people require much less energy for such fractures to occur.
- Pain that gets worse when the patient tries to charge the lower extremity with weight
- Swelling around the knee and reduced joint flexion
- The knee may appear out of place
- Pale-cold foot. This may mean that the blood flow is disturbed
- Paresthesia-numbness in the foot. This may imply nerve damage or increased leg edema
If the patient is presented with these symptoms, he or she should be referred to the Orthopedic Center immediately for an assessment of their condition.
Medical history and physical examination:
The doctor will ask how the injury happened. He will also ask about concomitant problems that the patient may have, such as diabetes mellitus. He will examine the soft tissues around the injured site and check for redness, edema and trauma. Finally he will assess the nerve function and blood flow to the injured leg.
Radiographs: The simplest and most common way to diagnose a fracture is to perform an X-ray. An X-ray will also depict the morphology of the fracture and its complexity. To clarify that there are no other fractures, radiographs will be performed on both the hip and the ankle joint.
Computed tomography: It will depict the transverse image of the bone and provide important information on the severity of the fracture. It will clarify whether the fracture extends into the joint and if so, how many bone fragments there are. This examination greatly helps the Orthopedist to plan the most appropriate treatment method.
Magnetic resonance imaging: It will depict with increased resolution soft tissues, such as tendons and ligaments. Although not a screening test for fractures of the upper tibia, the doctor may order this test to assess the condition of the surrounding tissues. It may also, in cases of doubt of a fractured bone, highlight an inflammatory reaction in bone marrow, and, thus, a fracture may be diagnosed.
Various other tests to rule out concomitant injury to other parts of the body (head, abdomen, chest, spine or even the other lower extremity) may be performed.
Upper leg fractures can be treated conservatively or surgically. Both methods have advantages and disadvantages.
Whether or not a fracture of the proximal end of the tibia will be treated surgically is a complex decision that will be made jointly by the physician and the patient, taking into account all the facts and circumstances. The most appropriate treatment is based on the type of injury and the general needs of the patient.
For a young patient, surgical treatment is most appropriate because it will restore the anatomical integrity of the joint, provide stability and minimize the risk of developing post-traumatic arthritis in the future. For patients with concomitant health problems and reduced requirements due to old age, surgical treatment is not indicated because it increases the risks excessively.
Open fractures: If there is an open fracture, the underlying bone may be exposed to bacteria and infections, so emergency surgical washout and cleaning is required.
External Osteosynthesis: In cases where the soft tissues (muscles, skin) around the fracture are severely injured, or if further time is required for surgery due to other concomitant problems, then the Orthopedic surgeon may place an external osteosynthesis device. In this case, metal pins and screws are placed in the femur and tibia and attached to a frame (bar) outside the skin. This device is bone-stabilizing in an appropriate position until the surgery.
Compartment Syndrome: In a small group of patients, the injury to the soft tissues can be so severe that it can compromise the blood flow and nerve function of the leg, so that emergency surgery is needed. During surgery (compartment release), vertical incisions are made to release the skin and muscles. These incisions are left open and after a few days, when the edema has subsided and the risk is minimal, they are sutured.
It includes a splint and immobilization, as well as avoidance of charging the affected leg. The examination is performed with a series of radiographs at regular intervals to be chosen by the treating physician to control the course of healing. Movements and charging will be performed according to the instructions of the treating physician.
In this case, the fractured bone pieces are anchored and stabilized by means of plates and screws in the correct bone-healing position. When the upper 1/3 of the tibia is fractured, but the fracture is not extended to the articular surface, an intramedullary nail or osteosynthesis plate is used for stabilization purposes. If the fracture is comminuted, bone grafts may be used, always according to the physician’s judgment and the intraoperative medical assessment. Biological growth factors can also be used to accelerate the healing process.
As mentioned above, this method of treating and repairing fractures can also be used successfully. In this case, external osteosynthesis can be used not only temporarily, but also definitively.
TREATMENT – RESTORATION
The doctor will decide when it is best to start moving and charging the injured leg to prevent stiffness. It depends on how well the soft tissues heal, how fast the bone healing process progresses and, finally, how stable the fracture bone is. Rapid mobilization is most often initiated with passive mobilization performed by the physiotherapist to obtain full range of motion, always in line with the pre-operative bone injury.
In order to avoid problems it is necessary to comply with the medical instructions on charging the injured leg.
Whether the fracture is treated conservatively or surgically, it is a fact that weight-charging should be avoided until some degree of healing is achieved. This means that it may take up to 3 months for the physician to allow the leg to be fully charged. Walking aids will be required during this time. The use of a splint may also be required for protection. Your doctor will schedule X-rays to assess bone healing at regular intervals. Once it is verified that there is no real risk for the fracture, the physician will permit gradual loading of the leg.
When the knee is allowed to be charged with weight, it is natural that the foot will be weak, unstable and stiff. Although this is to some extent expected it should be assessed by your physician or physiotherapist. A rehabilitation program specifically designed for muscular strength, flexibility and range of motion of the joint will be designed.
Compliance with the physiotherapy-rehabilitation process plays a major role in the final result. For example, if the patient is a smoker, the physician will ask him/her to quit, because smoking impedes the healing process.
Because fractures of the proximal end of the tibia include a loaded joint, there are some medium and long-term parameters to consider. These include loss of movement and stability and chronic post-traumatic arthritis. All this will be discussed in detail with the treating physician.
For example, questions to be discussed are:
- What are the pros and cons of conservative and surgical treatment?
- How will this injury affect later life in the performance of daily activities, work and leisure activities?
- What impact do habits (alcohol, smoking) have on this particular injury?
- What can a patient expect from post-traumatic arthritis and what are their options?
- After treatment (conservative or surgical), when will weight-bearing and load-charging begin?
- How will rehabilitation affect the patient’s work and family responsibilities?
- What kind of help will be needed for recovery?
- If bone grafting is required, what are the available options? What are the risks and benefits?
- Will there be a need for anticoagulants administration? If so, for how long?