Anatomy
1. Bones:
tibia fibula
omy of leg
2- Blood vessels :
POPLITEAL A. -tibial a.
ant.&post
-fibular a.
3- Nerves :
COMMON FIBULAR N.
3-Multifragment Fx
3- combined split Fx
Complications
1- Compartment syndrome With closed types 4 and 5 2- Joint stiffness 3- Deformity: Some residual valgus or varus deformity is
quite common
4- Osteoarthritis
Management
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.
After 2 weeks the position is checked by x-ray. A change from an above- to a below-theknee cast is possible around 46 weeks, when the fracture becomes sticky. The cast is retained (or renewed if it becomes loose) until the fracture unites, which is around 8 weeks in children but seldom under 12 weeks in adults.
Management: CONT.
Indications for skeletal fixation:many surgeons would hold that unstable fractures are better treated by skeletal fixation from the outset. Closed intramedullary nailing This is the method of choice for internal fixation. The fracture is reduced under x-ray control and image intensification. For diaphyseal fractures, union can be expected in over 95 per cent of cases. However, the method is less suitable for fractures near the bone ends. Plate fixation Plating is best for metaphyseal fractures that are unsuitable for nailing. It is also sometimes used for unstable tibial shaft fractures in children. External fixation This is an alternative to closed nailing; it avoids exposure of the fracture site and allows further adjustments to be made if this should be needed.
Management: CONT.
HIGH-ENERGY FRACTURES A suitable mantra for the treatment of open tibial fractures is: antibiotics debridement stabilization prompt soft-tissue cover rehabilitation. It is important to stabilize the fracture. For Gustilo I, II and IIIA injuries, locked intramedullary nailing is permissible as definitive wound cover is usually possible at the time of debridement. For more severe grades of open tibial fracture, internal fixation should be performed only at the time of definitive soft tissue cover. If this is not feasible at the time of primary debridement, the fracture should be stabilized temporarily with a spanning external fixator. Exchange of the fixator for an intramedullary nail can be done at the point when definitive soft tissue cover is carried out ideally within 5 days of the injury. Alternatively, definitive fracture management can be carried out using external fixation.
complications
1- VASCULAR INJURY 2-COMPARTMENT SYNDROME 3- INFECTION 4-Malunion 5- Delayed union 6- Non-union: Hypertrophic non-union can be treated by intra - medullary nailing (or exchange nailing) or compression plating. Atrophic non-union needs bone grafting in addition. If the fibula has united, a small segment should be excised so as to permit compression of the tibial fragments. Intractable cases will respond to nothing except radical Ilizarov techniques 7-Joint stiffness 8- Osteoporosis 9- Regional complex pain syndrome 10- Deep vein thrombosis
Pathological fractures sometimes occur in patients with osteomyelitis or bone tumours. Treatment is that of the underlying condition.
FATIGUE FRACTURES
Repetitive stress may cause a fatigue fracture of the tibia (usually in the upper half of the bone) or the fibula (most often in the lower third). This injury is seen in army recruits, mountaineers, runners and ballet dancers, who complain of pain in the leg. There is local tenderness and slight swelling. The condition may be mistaken for a chronic compartment syndrome. X-ray For the first 4 weeks there may be nothing abnormal about the x-ray, but a bone scan shows increased activity. After some weeks periosteal new bone may be seen, with a small transverse defect in the cortex. There is a danger that these appearances may be mistaken for those of an osteosarcoma, with tragic consequences. If the diagnosis of stress fracture is kept in mind, such mistakes are unlikely. Treatment The patient is told to avoid the stressful activity. Usually after 810 weeks the symptoms settle down.