Tibial shaft fracture

Tibial shaft fractures are the most common long bone fractures and the second most common type of open fractures (second only to open phalanx fractures) ¹. Up to 1 in 4 tibial shaft fractures are open injuries ¹.

Pathology

Mechanism 

Typically involve high-energy mechanisms such as road traffic accidents (incidence 43%) or sports ¹. These are usually the result of direct force to the tibia. Higher energy injuries are more likely to have a severe soft tissue injury.

Falls are the second most common cause with an incidence of 25% of all tibial shaft fractures ¹. This typically occurs as a result of a torsional force and as an indirect injury.

Associated injuries include:

• soft tissue or open injuries
• compartment syndrome
• bone loss
• ipsilateral skeletal fractures such as, e.g. tibial plateau, tibial plafond, femoral shaft, or posterior malleolar
• neurovascular injuries

Radiographic features

Although transverse fractures are usually trivially easy to identify, oblique or spiral fractures can be very difficult to identify inon a single view. The radiographic series comprisecomprises of AP and a lateral projections to allow adequate assessment of angulation, displacement and shortening. It is essential both the knee and the ankle joints are included to assess for proximal or distal extension of the fracture.  Associated Associated ankle injuries occur more frequently with spiral fractures involving the distal third of the tibia. Similarly, radiographs of the knee are necessary to exclude proximal extension into the tibial plateau. 

Report checklist

In addition to reporting on the presence of a fracture, a number of features should be assessed and commented on:

• fracture
• location and extension to metaphysis/epiphysis/articular surface
• type of fracture (transverse, spiral, oblique)
• comminution/segmental
• angulation, displacement and shortening
• open vs. closed; gas in soft tissues or foreign bodies
• underlying bony lesions (i.e. pathological fractures)
• carefully assess the elbow and shoulder for secondary injuries (be careful, as these will be sub-optimally imaged unless dedicated views are obtained)

InOn post-operative imaging, comment should be made on the type of fixation, whether there is anatomic reduction or angulation, presence of soft tissue surgical changes, and amount of union depending on the time since surgical fixation.

Treatment and prognosis 

Management is dependent on the pattern of the fracture, degree of comminution, extension into a joint (either proximally or distally), and whether the injury is open or closed.

Surgical fixation may be internal, such as plating or intramedullary nailing, or external, such as an external fixator ¹.

Internal fixation is favoured over external fixation in that external fixation can be cumbersome and inconvenient for the patient. External fixation may, in some cases, be used as a temporising measure when waiting for definitive fixation but very rarely is it used as definitive fixation.

There are advantages and disadvantages of both internal plating and intra-medullaryintramedullary fixation which include absolute versus relative fracture stabilisation, compromise intra-osseous and periosteal blood supply, and risks of further soft tissue injury due to surgical technique.

For open fractures, surgical washout and prophylactic antibiotics are suggested in addition to any surgical intervention.