Tibia Shaft

Fracture and
Anterior Approach
BAGUS GEDE KRISNA ASTAYOGI
Mechanism of
Injury
 The most common
 Falls from a
standing height and
sporting injuries
 High-energy tibial
diaphyseal fractures
 vehicular trauma
 Subcutaneus
Location  Open
fractures are even
more common with Reference: Rockwood and Green’s
Fractures in Adult
high-energy
mechanisms
following
motorcycle crashes
 Reference: Rockwood and Green’s
Fractures in Adult
Associated Injury
 Compartment Syndrome
 Devastating consequences on limb function / cause renal failure
through rhabdomyolysis  clinicians should be aware

 Ankle Injuries
 Association with approximately 1/5 of tibial diaphyseal fractures

 Floating Knee Injuries

 Ipsilateral femoral and tibial fractures  floating knee injuries.
 Type I injuries : fractures of the femoral and tibial diaphyses
 Type IIA : fractures involve the knee joint
 Type IIB involve the hip and/or ankle.
Associated Injury
 Fractures extension to tibia plateau
 Proximal extension of tibial diaphyseal fractures
into the tibial plateau is rarer than the
extension into the tibial plafond or malleoli,
but is equally important.

 Proximal Tibofibular Joint Dislocation

 Dislocation of the proximal tibiofibular joint
can occur in isolation and is associated with
lateral ligamentous instability and peroneal
nerve injury
Reference: Rockwood and Green’s
Fractures in Adult
 Signs and Symptoms of Tibia
and Fibula Shaft Fractures
 History and Physical Examination
 focus on the timing and mechanism of injury, location and quality of
pain, and any additional presenting symptoms such as numbness or
tingling
 pre-existing conditions that may affect normal function of the limb 
diabetic neuropathy, spinal radiculopathy, or peripheral vascular disease.
 Compromised Skin
 Skin tenting and puckering
 Bone to perforate through threatened or necrotic skin  closed fracture
becoming an open fracture.
 Wounds
 A wound present on any fractured limb should be assumed open fracture
until proven otherwise (the thin anteromedial soft tissue envelope)
 Wound irrigation & Moist dressing cover
 Exposed bone and cartilage  soft tissue cover / moist dressing
 Photographic documentation Reference: Rockwood and Green’s
Fractures in Adult
Signs and Symptoms of Tibia
and Fibula Shaft Fractures
 Vascular
 Before and after alignment restoration 
examination
 If the pulses do not return to normal after bony
reduction  angiography, CT angiography, or
arterial Doppler studies should be performed
 Motor
 Strenght grading. Most case  pain and limb
instability  limit examination

Reference: Rockwood and Green’s

Fractures in Adult
 Sensory
Reference: Rockwood and Green’s
 distal sensory Fractures in Adult
examination performed
including the territories
Signs
of: and Symptoms
of Tibia andperoneal
the deep Fibula
Shaftnerve
Fractures
(first dorsal
interspace)
 the superficial
peroneal nerve (the
dorsum of the foot)
 the sural nerve
(lateral ankle and
heel)
 the saphenous nerve
(medial ankle and
heel)
 the tibial nerve
(plantar aspect of
foot)
Imaging and Other Diagnostic Studies for
Tibia and Fibula Shaft Fractures
 The initial
radiographic
evaluation 
anteroposteri
or (AP) and
lateral
orthogonal
radiographs
centered on
the midtibia
 Standard
views of the
ipsilateral
knee (AP and
lateral) and
ankle (AP,
lateral, and
mortise)
should also be
obtained.
Reference: Rockwood and Green’s
Fractures in Adult
Management – Main
Objectives

Reference: Apley & Solomon’s – System of

Orthopaedic Trauma
Non Operative Treatment

Reference: Rockwood and Green’s

Fractures in Adult
Low Energy Fractures
 If the fracture is undisplaced or minimally displaced, a
full-length cast from upper thigh to metatarsal necks is
applied with the knee slightly flexed and the ankle at a
right angle
 Displacement of the fibular fracture, unless it involves
the ankle joint, is unimportant and can be ignored
 Apposition need not be complete but alignment must
be near-perfect and rotation absolutely perfect
 After 2 weeks the position is checked by X-ray 
change from an above- to a below-the-knee cast is
possible around 4–6 weeks, when the fracture becomes
‘sticky’
 The cast is retained  until the fracture unites  8
weeks in children but seldom under 12 weeks in adults.
Reference: Apley & Solomon’s – System of
Orthopaedic Trauma
 Reference: Apley & Solomon’s – System of

Operative – Intramedulary Orthopaedic Trauma

Nailing
 Method of choice for internal fixation in most tibial
shaft fractures

 The proximal end of the tibia is exposed; a guide-

wire is passed down the medullary canal and the
canal is reamed. A nail of appropriate size and
shape is then introduced from the proximal end
across the fracture site. Transverse locking screws
are inserted at the proximal and distal ends

 Postoperatively, partial weight- bearing is started

as soon as possible, progressing to full weight-
bearing when this is comfortable.

 For diaphyseal fractures, union can be expected in

over 95% of cases.
Operative – Plating
 Plating can be used for metaphyseal fractures
deemed unsuitable for nailing.

 sometimes used for unstable tibial shaft

fractures in children as it avoids the potential
damage to the growth plate from passing an
intramedullary nail through an open physis.

 the disadvantages of plate fixation included

the need to expose the fracture site and, in
so doing, stripping the soft tissues around the
fracture, which could increase the risk of
introducing infection and delaying union.
Reference: Apley & Solomon’s – System of
Orthopaedic Trauma
Operative – External Fixation
 it avoids exposure of the fracture site and allows
further adjustments to be made if this should be
needed.

 It has a particular role in long, segmental,

multifragmentary fractures.

 Monolateral external fixation is most commonly

used as a tempo-rizing method of fixation in the
context of an open injury in adults but can be used
as a definitive method. It is more commonly used in
children.

 Disadvantages include the need to span joints for

sufficient stability, which can cause stiffness and
the potential for pin- site infection

Reference: Apley & Solomon’s – System of

Orthopaedic Trauma
Reference: Stanley Hoppenfeld – Surgical
Exposure in Orthopaedic
Reference: Stanley Hoppenfeld – Surgical
Exposure in Orthopaedic
Reference: Stanley Hoppenfeld – Surgical
Exposure in Orthopaedic
Reference: Stanley Hoppenfeld – Surgical
Exposure in Orthopaedic
Reference: Stanley Hoppenfeld – Surgical
Exposure in Orthopaedic