Diaphyseal Tibial Fractures: Diagnosis, Treatment, and Prognosis

TRAUMA 2023, Sep, 14 | 12:00 am

Diaphyseal Tibial Fractures: Diagnosis, Treatment, and Prognosis

Diaphyseal Tibial Fractures

Diaphyseal tibial fractures are the most common long bone fracture. Here's what you need to know about their diagnosis, treatment, and prognosis:

Summary

Diagnosis is confirmed by plain radiographs of the tibia and adjacent joints. Treatment is generally operative with intramedullary nailing. In rare cases, external fixation or ORIF is more appropriate depending on the location and orientation of the fracture.

Epidemiology

Incidence: Diaphyseal tibial fractures make up about 17% of all lower extremity fractures and account for 4% of all fractures seen in the Medicare population.

Demographics: Diaphyseal tibial fractures have a bimodal distribution, with high energy mechanisms in young patients and falls or lower energy mechanisms in older patients. They are more common in males than females.

Figure 1: Anatomical Location of Diaphyseal Tibial Fractures (Source: Hutaif Orthopedic Center)

Etiology

Pathophysiology: Diaphyseal tibial fractures can result from both low and high energy mechanisms. Spiral fracture patterns with fibula fractures at a different level are common in low energy injuries. High energy mechanisms can lead to wedge or short oblique fracture patterns with significant comminution and more severe soft tissue injury.

Associated conditions: Associated conditions may include soft tissue injury, compartment syndrome, bone loss, ipsilateral skeletal injury, and nerve injury.

Anatomy

Osteology	Tibial shaft: Triangular in cross-section Proximal medullary canal centered laterally, important for start point with IM nailing Anteromedial tibial crest is composed of dense, cortical bone and rests in a subcutaneous position, making it useful as a landmark Tibial tubercle sits anterolaterally, approximately 3 cm distal to joint line, attachment of patellar tendon Gerdy's tubercle lies laterally on proximal tibia, attachment of iliotibial band Pes anserinus lies medially on proximal tibia, attachment of sartorius, semitendinosus, and gracilis Muscles: Anterior compartment: Tibialis anterior, extensor digitorum longus (EDL), extensor hallicus longus (EHL) Lateral compartment: Peroneus longus, peroneus brevis Superficial posterior compartment: Gastrocnemius (medial/lateral heads), soleus, plantaris Deep posterior compartment: Popliteus, tibialis posterior, flexor digitorum longus (FDL), flexor hallicus longus (FHL) Ligaments: Superficial medial collateral ligament (MCL) attaches approximately 5-7 cm distal to joint line deep to the pes anserinus Adjacent fibula supports attachments for the lateral collateral ligament complex and long head of biceps femoris Blood Supply: Anterior tibial a. Peroneal a. Posterior tibial a. Medial sural a. Lateral sural a. Nervous System: Superficial peroneal n. Deep peroneal n. Tibial n. Sural n. Biomechanics: Proximal tibiofibular joint: Gliding synovial joint Tibia responsible for about 80-85% of lower extremity weight-bearing Interosseous membrane: Fibrous structure interconnecting tibia/fibula which provides axial stability Tibiofibular syndesmosis: Fibula rests in distal tibial incisura and is stabilized by syndesmotic ligaments (anterior inferior tibiofibular ligament, posterior inferior tibiofibular ligament, inferior transverse tibiofibular ligament, interosseous ligament)

Osteology

Tibial shaft:

Triangular in cross-section
Proximal medullary canal centered laterally, important for start point with IM nailing
Anteromedial tibial crest is composed of dense, cortical bone and rests in a subcutaneous position, making it useful as a landmark
Tibial tubercle sits anterolaterally, approximately 3 cm distal to joint line, attachment of patellar tendon
Gerdy's tubercle lies laterally on proximal tibia, attachment of iliotibial band
Pes anserinus lies medially on proximal tibia, attachment of sartorius, semitendinosus, and gracilis

Muscles:

Anterior compartment: Tibialis anterior, extensor digitorum longus (EDL), extensor hallicus longus (EHL)
Lateral compartment: Peroneus longus, peroneus brevis
Superficial posterior compartment: Gastrocnemius (medial/lateral heads), soleus, plantaris
Deep posterior compartment: Popliteus, tibialis posterior, flexor digitorum longus (FDL), flexor hallicus longus (FHL)

Ligaments:

Superficial medial collateral ligament (MCL) attaches approximately 5-7 cm distal to joint line deep to the pes anserinus
Adjacent fibula supports attachments for the lateral collateral ligament complex and long head of biceps femoris

Blood Supply:

Anterior tibial a.
Peroneal a.
Posterior tibial a.
Medial sural a.
Lateral sural a.

Nervous System:

Superficial peroneal n.
Deep peroneal n.
Tibial n.
Sural n.

Biomechanics:

Proximal tibiofibular joint: Gliding synovial joint
Tibia responsible for about 80-85% of lower extremity weight-bearing
Interosseous membrane: Fibrous structure interconnecting tibia/fibula which provides axial stability
Tibiofibular syndesmosis: Fibula rests in distal tibial incisura and is stabilized by syndesmotic ligaments (anterior inferior tibiofibular ligament, posterior inferior tibiofibular ligament, inferior transverse tibiofibular ligament, interosseous ligament)

Classification

Fracture classification is primarily descriptive based on pattern and location, with the OTA classification being the most commonly used system. Closed fracture soft tissue injury is classified according to Oestern and Tscherne, and open tibia fractures are classified using the Gustilo-Anderson system.

(View OTA Classification Image)

Presentation

Symptoms of diaphyseal tibial fractures include severe leg pain, inability to bear weight, and deformity. Physical examination may reveal deformity, contusions, blisters, open wounds, fracture crepitus, and neurovascular abnormalities.

Imaging

Radiographs, including full-length AP and lateral views of the affected tibia and AP, lateral, and oblique views of the ipsilateral knee and ankle, should be obtained to confirm the diagnosis. CT may be necessary in certain cases, such as for intra-articular fracture extension or suspicion of plateau/plafond involvement.

(View CT Classification Images)

Treatment

Treatment for diaphyseal tibial fractures is generally operative with intramedullary nailing, although external fixation or ORIF may be appropriate depending on the location and orientation of the fracture.

Techniques

The following techniques may be used to treat diaphyseal tibial fractures:

IM nailing (reamed or unreamed)
External fixation
ORIF
I&D + antibiotics
Fibular osteotomy for tibiofibular length discrepancy

Complications

Complications of diaphyseal tibial fractures may include anterior knee pain, malunion, nonunion, malrotation, compartment syndrome, nerve injury, and infection.

Prognosis

Prognosis for diaphyseal tibial fractures is generally good, although certain risk factors may impact outcomes. Early antibiotic administration is essential for reducing infection risk and thorough surgical debridement is an important factor in reducing infection. Adequate reduction, proper start point when nailing, and prevention of malalignment are the most important factors in reducing complications and optimizing outcomes.