Tibial Shaft Fracture

Question 1

Where might the tibia be fractured?

Answer 1

One of the most common long bones to be fractured

Proximmaly, distally or along its shaft.

Question 2

What is the tibial shaft vulnerable to?

Answer 2

Direct injuries from a fall or from a direct blow

Indirect injuries from twisting or bending forces

Question 3

Why is there an increased risk of open fractures and compartment syndrome in tibial fractures?

Answer 3

There is a lack of significant soft tissue to envelop the bone and the fascial compartments

Question 4

Clincal features

Answer 4

Hx of trauma
Soft tissue injuries

Severe pain in lower leg

Inability weight bear

Question 5

Examination findings

Answer 5

Clear deformity like angulation or malrotation

Significant swelling and bruising

Question 6

Special examinations of TSF

Answer 6

Careful inspection of skin for the possibility of an open fracture.

Full neurovascular examination

Question 7

Dx

Answer 7

TPF

Ankle fractures

Fibular fractures

Soft tissue injury

Question 8

Ix

Answer 8

Investigated and managed as per ATLS protocol
Urgent bloods + coagulation + G&S

Full length AP x-ray + lateral X-ray
Both tibia and fibula should be visible.

CT imaging might be indicated.

Question 9

Indications of CT scanning

Answer 9

Potential intra-articular extension

Spiral fracture of distal tibia to assess fracture of posterior malleolus

Question 10

Explain associated fibula fractures

Answer 10

Location of fibular fracture correlate to degree of energy of injury.

High energy -> fibula fracture at same level

Low energy -> fibula fracture at different level

Question 11

Initial management

Answer 11

Realignment ASAP ideally in A&E under analgesia/conscious sedation.
Tibia should be brought approximately to length and rotation.

If there is an open fracture it should be managed accordingly.

Question 12

Following reduction what should be done?

Answer 12

Above knee backslab in slight flexion to control rotation.

The limb should be elevated immediately and closely monitored for signs of compartment syndrome.

Also post-manipulation X-ray + neurovascular status reassessment

Question 13

Indications for conservative management

Answer 13

Put in a Sarmiento cast in closed stable tibial fracture.

Question 14

Most TSF are done surgically.

When is urgent operative intervention indicated?

Answer 14

Acute compartment syndrome

Ischaemic limb

Open fracture

Question 15

Types of surgical intervention of TSF

Answer 15

Intramedullary nailing

ORIF with locking plates

Temporary external fixation

Question 16

When is intramedullar nailing done?

Answer 16

Most commonly used and used if they aren’t massively complicated.

It provides a stable construct and is minimally invasive with a high success rate.

Post-op patients should be able to fully weight bear immediately.

Question 17

When is ORIF with locking plates used?

Answer 17

Proximal or distal fractures that extend into the joint.

Question 18

When might temporary external fixation be done?

Answer 18

If they are not stable enough to undergo definitive surgery.

Question 19

What should be done to associated fibular fractures?

Answer 19

Can usually be left alone as they heal very well once the tibial fracture has been stabilised.

Question 20

Complications

Answer 20

Compartment syndrome

Ischaemic limb

Open fractures

Malunion

Non-union