The tibia is one of the long bones of the body most often subject to fractures. The long bones, among others, include the femur, the humerus, the tibia and the fibula. Fractures of the tibia are located below the knee joint and above the ankle. Since a lot of energy should be applied to fracture the tibial bone, this type of injury is usually part of multiple injuries.
ANATOMY
The lower extremity – from the knee joint and below – consists of two bones: the tibia and the fibula. The tibia is thicker than the fibula and bears greater loads, being an important part of the knee joint and the ankle.
Types of tibial fractures: The tibia – as well as the fibula – can be fractured in various ways and in various shapes. The severity of the fracture depends on the force exerted at the time of injury.
- Stable fractures: There is no displacement in this type of fractures. The two fractured ends of the bones are well aligned.
- Dislocated Fractures: In fractures of this type, the fractured ends of the bone are displaced and out of position. In these cases, surgical treatment is usually required.
- Transverse fractures: In this case there is a transverse (vertical) fracture line. When the fibula is fractured, then these fractures usually need surgery because they are unstable.
- Oblique fractures: These fractures have an oblique fracture line and are therefore generally unstable. Even though they are initially stable, they may lose their alignment over time and become unstable, especially if the fibula is broken.
- Spiral fractures: These fractures are caused by a rotational force. The result is a spiral fracture. These fractures can be unstable, depending on the force needed to cause them.
- Complicated-Comminuted Fractures: These fractures are very unstable with the bone broken into more than 3 pieces.
- Open fractures: When a bone is fractured and comes into contact with the environment, it is described as an open fracture. For example, when a car hits a passerby and the tibia is fractured, the bone can often protrude from the skin. Open fractures cause much more damage to surrounding tissues, ligaments and tendons. They are more likely to have complications and require more time to heal.
- Closed Fractures: The fractured bones do not penetrate the skin. Although the skin is intact, the soft tissues are still severely damaged. In extreme cases of serious injuries the edema can be so large that the blood flow to the tissues is interrupted resulting in necrosis and in even more severe cases the patient may need amputation.
ETIOLOGY
High-energy injuries, such as traffic accidents, are frequent causes of tibial fractures. In these cases the bone can break into several pieces (comminuted fracture). Sports injuries, such as a fall during running or skiing or even a serious collision with a football teammate, are lower-energy injuries that cause fractures of the tibia. These fractures are caused by a rotational force and lead to an oblique or spiral fracture.
SYMPTOMS
The most common symptoms are:
- Pain
- Inability to walk or charge leg
- Leg deformity or instability
- Applied pressure of the fractured bone under the skin or projection of the latter through an open wound in the skin.
- Transient loss of sensation of the foot
MEDICAL EXAMINATION
It is important for the treating physician to know the conditions of the injury. It is also important to know if there are concomitant health problems, such as diabetes mellitus or if medication is being taken systematically.
After completing the above, the physician will systematically examine the patient. The doctor will search for:
- Apparent distortion, such as angulation or shortening of the limb
- Skin breaks
- Bruises
- Edema
- Bone protrusions under the skin
- Instability (some patients may not be particularly unstable when the fibula is intact or the fracture is partial)
- After the examination, the treating physician will examine the sensitivity of the foot and whether blood flow is unhindered. Finally, the doctor will palpate the tibia to feel the exact topography of the fracture.
Examination:
The examinations required for further testing are:
X-rays: They will depict whether the foot has been fractured or not and will also indicate the type of fracture and whether or not the dislocation is present. They will also clarify how many bones are involved in the fracture and help the doctor assess the integrity or not of the ankle joint.
Computed tomography: After studying the simple radiographs, your doctor may recommend computed tomography. This is usually performed if there is a suspicion of a fracture extension in the ankle or knee joint
TREATMENT
In designing the therapeutic approach, the treating physician will consider many parameters, including:
- The cause of injury
- The overall picture of the patient’s health
- The severity of the injury
- The extent of the damage to the soft tissues
Conservative treatment:
Conservative treatment is recommended in patients who:
- They cannot undergo surgery because of their overall state of health
- They are less active, so they can accept some angulation or shortening of the bone
- They have a two-piece fracture with only a small gap between the bones
Initial treatment:
Most injuries cause swelling for the first few weeks. The orthopedist may recommend a splint to provide safety and support the injured leg. Contrary to plaster, the splint can be loosened or tightened further allowing the edema to recede securely. When the edema recedes, your doctor will consider a range of options for treatment.
Splint and functional immobilization:
Conservative treatment for such fractures involves immobilizing the fracture with a splint for initial healing. After a few weeks it can be replaced by a functional splint or plaster made of plastic and straps. This splint will provide protection until the healing process is complete, while it offers the patient the option to remove it for hygiene reasons and to wear it on again.
Surgical treatment
The treating physician may recommend surgery for a fracture of the tibia in the following cases:
- It is an open fracture with skin wounds that need monitoring
- It is an extremely unstable fracture with many bone fragments and significant dislocation
- It has not been healed with the classical method
Intramedullary nailing
The most modern way of dealing with these fractures is intramedullary nailing. During this procedure, a specially designed metallic nail enters the anterior surface of the knee into the medial canal. The nail passes through the fracture and thereby stabilizes it. These nails have different sizes and diameters to fit the patient’s tibia. The nail is fixed with screws at both ends, so that the fracture is fixed for healing purposes. Intramedullary nailing allows for the strong and stable immobilization required for healing.
Open Reduction Internal Fixation (ORIF):
Fractures of the tibia can be successfully treated by the use of plates and screws as osteosynthesis materials. Osteosynthesis is selected in fractures that cannot be treated with intramedullary nailing, such as those where the fracture extends to the knee joint. In this case the bones are first osteosynthesized and then fixed with special screws and plates on the outer surface of the bone.
External Osteosynthesis:
In this case, metal screws and pins are placed in the tibia and even above and below the fracture area. This structure is supported by rods in the correct position and thereby stabilizes the fracture so that it can be healed. Although with external osteosynthesis we get good results, having the patient with materials out of his body is not that popular anymore.
REHABILITATION
The time to return to daily activities varies, depending on the type of fracture. Some tibial fractures are healed within 4 months, while others take 6 months or more. This is most evident with open fractures or fractures of elderly patients.
- Fast mobilization. Many doctors encourage the initiation of early mobilization during the initial period of recovery. For example, if the soft tissue injury coincides with a fracture, then the knee, ankle and toes are quickly mobilized to prevent stiffness.
- As the patient wears the splint, he may lose some of his muscle strength and develop muscle atrophy in the injured area. Exercises during the injury period and after the splint removal are important. They will help restore normal muscle strength and range of motion.
- Weight-charging. During the initial period of mobilization, the patient will need crutches.
It is very important to follow the medical instructions when charging the affected leg with weight to avoid problems. The pain usually has disappeared long before the bone becomes able again to meet the daily challenges. Therefore, care should be taken not to overload it during the recovery period, which may lead to a new fracture and direct the patient back to the operating room.
Complications:
Sharp bones can cut or tear adjacent muscles, nerves, or vessels.
Excessive edema can lead to compartment syndrome, a condition where the edema cuts off the blood flow to the leg. This may have very unpleasant consequences and requires urgent surgical treatment when diagnosed.
Open fractures can lead to acute or chronic bone infection or osteomyelitis, although prevention of infection is well-advanced in modern times.
Surgical complications:
- Unacceptable (displaced) bone reduction
- Infection
- Nerve injury
- Vascular damage
- Blood clots
- Unable to heal (Pseudarthrosis)
- Αngulation
