TIBIA AND FIBULA
The most common fracture below the knee is one of the
tibia (and fibula) that results from a direct blow, falls with the foot in a
flexed position, or a violent twisting motion. Fractures of the tibia and
fibula often occur in association with each other. The patient presents with
pain, deformity, obvious hematoma, and considerable edema. Frequently, these
fractures are open and in-volve severe soft tissue damage because there is
little subcutaneous tissue in the area.
Peroneal nerve damage is assessed. If nerve function is
impaired, the patient is unable to dorsiflex the great toe and has diminished
sensation in the first web space. Tibial artery damage is assessed by
evaluating pulses, skin temperature, and color and by testing the capillary
refill response. Hemiarthrosis or ligament damage may occur with fracture near
the joint.
The patient is monitored for an anterior compartment
syn-drome. Symptoms include pain unrelieved by medications and increasing with
plantar flexion, tense and tender muscle lateral to tibial crest, and
paresthesia.
Most closed tibial fractures
are treated with closed reduction and initial immobilization in a long leg
walking cast or a patellar tendon–bearing cast. Reduction must be relatively
accurate in re-lation to angulation and rotation. As with other lower extremity
fractures, the leg should be elevated to control edema. Partial weight bearing
is usually prescribed after 7 to 10 days. Activity decreases edema and
increases circulation. The cast is changed to a short leg cast or brace in 3 to
4 weeks, which allows for knee motion. Fracture healing takes 6 to 10 weeks. At
times it is diffi-cult to maintain reduction, and percutaneous pins may be
placed in the bone and held in position by an external fixator.
Comminuted fractures may
be treated with skeletal traction, internal fixation with intramedullary nails
or plates and screws,or external fixation. External support may be used with
internal fixation. Hip, foot, and knee exercises are encouraged within the
limits of the immobilizing device. Partial weight bearing is begun when prescribed
and is progressed as the fracture heals in 4 to 8 weeks.
Open fractures are treated with external fixation. Distal
frac-tures with extensive soft tissue damage heal slowly and may require bone
grafting.
Continued neurovascular evaluation is needed. The
develop-ment of compartment syndrome requires prompt recognition and resolution
to prevent permanent functional deficit. Other com-plications include delayed
union, infection, impaired wound edge healing due to limited soft tissue, and
loosening of the internal fix-ation hardware.
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