Background

An understanding of the diagnosis and treatment of tibial shaft fractures is of importance to primary care physicians and orthopedic surgeons alike. Often, the primary care provider first comes into contact with tibial shaft fractures and must make the diagnosis and early treatment decisions.

High-speed lifestyles with motor vehicles, snowmobiles, and motorcycles, as well as the growing popularity of extreme sports, contribute to the increasing occurrence of tibial shaft fractures in today's society. In fact, the tibia is currently the most commonly fractured long bone in the body.

Although tibial shaft fractures are often the result of high-speed trauma, they can also be insidious in onset, such as stress fractures in active individuals. During the initial evaluation, the patient with a tibial shaft fracture should be evaluated carefully for open wounds at the fracture site, neurovascular sufficiency, and elevated compartment pressures. Abnormalities in any of these areas constitute a surgical emergency.

Several decades ago, plating was the treatment of choice for tibial shaft fractures. Since then however, intramedullary nailing and external fixation have replaced fracture plating because they are associated with decreased technical difficulty, lower infection rates, and less damage to local soft tissues (see Treatment).

For patient education resources, see the Breaks, Fractures, and Dislocations Center, as well as Broken Leg, Ankle Fracture, and Knee Dislocation.

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Anatomy

The leg is divided into four distinct fascial compartments. The compartmental anatomy can become extremely important during a traumatic situation in which internal bleeding in the leg can lead to a compartment syndrome.

The anterior compartment contains the dorsiflexors of the foot, including the tibialis anterior, the extensor digitorum longus, the extensor hallucis, and the peroneus tertius. Also housed in the anterior compartment is the deep peroneal nerve. The major blood supply to the anterior compartment is from the anterior tibial artery and its associated vessels.

The lateral compartment contains the peroneus longus and the peroneus brevis, which primarily serve in eversion of the foot. The superficial peroneal nerve is contained in this compartment and innervates these two muscles.

The posterior aspect of the leg is divided into two compartments, superficial and deep. The deep compartment contains the plantarflexing muscles, including the tibialis posterior, the flexor hallucis longus, and the flexor digitorum longus. The peroneal and posterior tibial arteries also course through this compartment with their corresponding veins. The superficial posterior compartment is the largest of the four compartments but contains only muscle. These plantarflexing muscles include the soleus, the gastrocnemius, and the plantaris.

Etiology

In the etiology of tibial fractures, high-speed trauma is paramount. In areas where people drive cars at high speeds and engage in activities with high potential for leg trauma (eg, skiing or soccer), the number of tibial fractures seen in the emergency department is high. Although a direct blow to the tibia is the most common cause, countless other etiologies for tibial shaft fractures are encountered. Two of the most prevalent are falls or jumps from significant height and gunshot wounds to the lower leg.

Epidemiology

The tibia is currently the most commonly fractured long bone in the body. Alho et al reported an annual incidence of two tibial shaft fractures per 1000 individuals.^[1] The average age of patients with tibial shaft fractures is approximately 37 years, and teenage males are reported to have the highest incidence.^[2]

Prognosis

The outcome of tibial shaft fractures can be less than ideal under many circumstances. These fractures almost always heal with some angulation, rotation, or shortening, which alters load transmission across the extremity.

Patients with tibial shaft fractures have been evaluated with respect to joint pain, disability, osteoarthritis, and joint stiffness. Studies have shown that long-term outcomes for tibial shaft fractures generally are good, but a small increase in osteoarthritis of unclear etiology in the knee and ankle has been observed.^{[3, 4]}  The cause of increased osteoarthritis appears to be multifactorial. Reamed intramedullary nails with interlocking screws provide an excellent means to control rotation and limb shortening (see Treatment, Intraoperative details, above).

Connelly et al carried out a prospective study to assess the clinical and functional outcome of tibial shaft fracture at 12-22 years, with the secondary aims of determining short- and long-term mortality and identifying any predictors of clinical or functional outcome or mortality.^[5]  Most of the fractures (90.7%) united without further intervention. Pain and function scores were good, but 26% of patients reported ongoing knee pain, 10% reported ankle pain, and 17% reported both, and this joint pain correlated with poorer functional outcome.

Clinical Presentation