Prehospital care

• Full assessment of associated injuries and immediate resuscitation if necessary.
• Careful neurovascular assessment in case of any compromise.
• Apply a sterile dressing to any open wounds.
• Splint the injury.
• Provide appropriate and adequate pain relief.

Assessment

• Diagnosis is usually obvious with deformity, localised swelling and tenderness. All wounds near to the fracture site suggest compound injuries.
• X-rays: must show the whole length of the tibia and fibula. Check for associated injuries to the knee and ankle.
• CT scans may be required if X-rays are inadequate to make a definitive assessment, and for proximal tibial fractures.^[1]
• Bone scanning and MRI scans are more sensitive in diagnosing stress fractures (X-ray findings are not usually seen until 2-8 weeks of symptoms and X-rays are often not very sensitive during the early stages of symptoms.^[1]

Complications

Displaced tibial shaft fractures may be complicated by injury to the popliteal artery and compartment syndromes. Fractures of the proximal fibula may be associated with injury to the common peroneal nerve (distal pulses and sensation should therefore be checked and monitored regularly). Potential complications include:^[1]

• Neurovascular compromise: popliteal artery injury is very serious and easily missed
• Compartment syndrome
• Peroneal nerve injury:
  • The common peroneal nerve crosses the fibular neck and is susceptible to injury from a fibular neck fracture, the pressure of a splint or during surgical repair.
  • Peroneal nerve injury may result in foot drop and sensation abnormalities.
• Infection
• Gangrene
• Skin loss
• Osteomyelitis
• Delayed union, nonunion, malunion
• Amputation
• Arthritis
• Fat embolism

See also the separate article Complications from Fractures.

Prognosis

• Prognosis is generally good but is dependent on the degree of soft-tissue injury and bony comminution.
• The prognosis is good for isolated fibular fractures.

Stress fractures of the tibia^[2]

• Those at risk include army recruits, runners and ballet dancers. There has often been an increase in intensity of training in the weeks or months leading up to the injury.
• Often they are not initially evident on X-ray but a bone scan will show increased bone activity at the site of the fracture. Later X-rays may show periosteal new bone, with a small transverse defect in the bone cortex.
• Tibial stress fracture presents with pain in the front of the leg. Pain is initially after exercise, then during and after exercise and then pain without exercise. Examination may reveal warmth, local tenderness and swelling.
• Management is to avoid the stressful physical activity for 8-10 weeks and then a gradual return to the activity.
• Persisting symptoms suggestive of stress fracture require orthopaedic follow-up.

Horse rider's knee

• Frontal impact at the level of the proximal tibiofibular joint may result in posterior dislocation of the fibular head.
• Reduction usually requires manipulation under anaesthesia.

Tibial shaft fractures

• Isolated fractures of the tibia are unusual except in children.
• There is a risk that the intact fibula will act to hold the fragments apart and so increase the likelihood of nonunion, in which case the fibula may need to be divided.

Management

• Undisplaced transverse tibial shaft fractures:
  • Analgesia and immobilisation in a long leg POP backslab.
  • Spiral and oblique fractures: immobilised in a long leg POP backslab. They are potentially unstable.
  • Refer to the orthopaedic team for admission.
• Displaced fractures:
  • Give IV analgesia, immobilise in a long leg POP backslab and refer to the orthopaedic team. May require manipulation under anaesthesia or closed intramedullary nailing.
  • Badly comminuted or segmental fractures may require open reduction and internal fixation.
  • Urgent orthopaedic referral is required for any case of suspected vascular injury, sensory deficit or gross swelling.
• Compound fractures:
  • Treatment includes irrigation of the wound with saline, covering the wound with a moist sterile dressing, and giving intravenous antibiotics (eg cefuroxime but this depends on local guidelines) and tetanus toxoid if indicated.
  • Refer to the orthopaedic team for urgent wound cleaning, debridement and fixation with closed intramedullary nailing or external fixation.

Toddler's fracture

• Undisplaced spiral fractures of the tibial shaft in children under 7 years old often follow minimal trauma and may not be visible on initial X-ray.^[3]
• Can be difficult to diagnose but should be suspected whenever a child presents with a limp or fails to bear weight on the leg.
• Treatment consists of immobilisation for a few weeks to protect the limb and to relieve pain.
• Subperiosteal bone formation is usually apparent on X-rays by two weeks.

Fibular shaft fractures

• These occur in combination with a tibial fracture or in isolation as a result of a direct blow or from twisting injuries.
• Proximal fibular injuries may cause damage to the common peroneal nerve, causing weakness of ankle dorsiflexion and reduced sensation of the lateral aspect of the forefoot.

Management

• Undisplaced proximal or fibular shaft fractures: analgesia and elevation. Support in a tubigrip or padded bandage.
• If unable to weight-bear, use a below-knee POP for comfort with crutches until weight-bearing is possible. Arrange orthopaedic follow-up.
• Comminuted or displaced fractures: refer to the orthopaedic team.

Stress fractures of the fibula

• Stress fractures of the fibula are relatively common, typically affecting the fibular neck of military recruits and athletes following vigorous training.
• Treat symptomatically with rest and analgesia.

Maisonneuve fracture^[4]

• Transmitted forces may fracture the proximal fibula following an ankle injury.
• This usually involves fracture of the medial malleolus and fracture of the proximal fibula or fibular shaft.
• It implies damage to the distal tibiofibular syndesmosis.
• Examine the proximal fibula in all ankle injuries and X-ray if locally tender.
• Management requires surgery followed by a short non-weight-bearing cast for 6 weeks.