Tibia and Fibula - Fracture

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.

Assessment and Diagnostic Findings

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.

Medical Management

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.