a.. Introduction

Most common long bone fractures. Most commonly seen open fracture.  The incidence of these fractures is approximately 26 per 100,000 people.  Men are more commonly affected than women.  Compared with other fractures these have a high incidence of infection, delayed union, nonunion, and malunion due to the relatively poor blood supply.

b.. Anatomy (bone, joint, soft tissues etc. neurovascular considerations blood supply etc)

The tibia is triangular is cross section.  Four tight fascial compartments - the anterior, lateral, superficial posterior and deep posterior compartments, bound this bone.  The tibia articulates with the femur and patella superiorly, the fibula laterally and the talus inferiorly to make part of the ankle joint.  The two main arteries that supply the tibia with blood are the nutrient artery (main supply) and the anterior tibial artery.  Coursing through the anterior compartment is the deep peroneal nerve. The lateral compartment contains the superficial peroneal nerve.  The tibial nerve runs through the deep posterior compartment.

c.. Classification
          The Gustilo and Anderson Classification system is used to describe open fractures:
Grade I - clean skin opening of <1 cm, usually from inside to outside; minimal muscle contusion; simple transverse or short oblique fractures.

Grade II - Laceration >1 cm long, with extensive soft tissue damage; minimal to moderate crushing component ' simple transverse or short oblique fractures with minimal comminution.

Grade III - Extensive soft tissue damage, including muscles, skin, and neurovascular structures; often a high-energy injury with severe crushing component.

IIIA - Extensive soft tissue laceration, adequate bone coverage; segmental fractures, gunshot injuries, minimal periosteal stripping.

IIIB - Extensive soft tissue injuries with periosteal stripping and bone exposure requiring soft tissue flap closure; usually associated with massive contamination.

IIIC - Vascular injury requiring repair. 
The Tscherne Classification system describes closed fractures:

Grade 0 - Injury from indirect forces with negligible soft tissue damage

Grade I - Closed fracture caused by low-moderate energy mechanisms, with superficial abrasions or contusions of soft tissues overlying the fracture.

Grade II - Closed fracture with significant muscle contusion, with possible deep, contaminated skin abrasions associated with moderate to sever energy mechanisms and skeletal injury; high risk for compartment syndrome.

Grade III - Extensive crushing of soft tissues, with subcutaneous degloving or avulsion, with arterial disruption or established compartment syndrome

d.. Presentation Classic history Physical Examination Radiographic studies Lab studies

Often the patient will present in significant pain, with inability to bear weight on the affected limb.  The patient will often give a history of recent trauma as well.

            Physical exam must include neurovascular status with dorsalis pedis and posterior tibial artery pulses, common peroneal and tibial nerve integrity and compartment syndrome should also be ruled out. 

            Radiographs of the entire tibia with visualization of the knee and ankle joint should be obtained in the anteroposterior and lateral possition.  Oblique views may also be helpful.  Computed tomography (CT) and magnetic resonance imaging (MRI) are usually not necessary, but MRI, along with technetium bone scans may be useful in diagnosing occult stress fractures.  Angiography is indicated if arterial injury is suspected.

            If the patient is a healthy individual and surgery is not needed, laboratory studies are not needed.  In surgical candidate a complete blood count (CBC), chemistry panel, and cross-match should be preformed.  In the incidence that the tibia was fractured with minimal trauma serum calcium and phosphorus levels, along with endocrine and other metabolic indices should be evaluated for possible causes of low bone density associated with the fracture. e.. Diagnosis (What else to think about)? Associated injuries? Underlying conditions?

Diagnosis is usually made based on clinical examination and radiographic findings.  During the initial evaluation the patient should be assessed for open wounds at the fracture site, neurovascular sufficiency, and elevated compartment pressures.  The fibula, along with the ligamentous structures of the knee and ankle should also be evaluated for disruption.  Any condition that can lead to demineralization of bone should be ruled out in any elderly patient who presents with minimal trauma to the lower leg, leading to a diagnosis of a tibial shaft fracture.
f.. Treatment (Include consideration of: Benign neglect Immobilization Pinning ORIF Other)

Acceptable fracture reduction aims for <5^o of varus/valgus angulation, <10 ^o of anterior/posterior angulation, and <10 ^o of rotational deformity.  <1 cm of shortening and <5 mm of distraction are acceptable.  >50% of cortical contact is recommended.  As a general rule, the anterior superior iliac spine (ASIS), center of the patella, and base of the second proximal phalanx should be colinear.

Nonoperative treatment is usually initiated in isolated, closed, low-energy fractures with minimal displacement and comminution.  Fracture reduction is followed by application of a long leg cast with the knee in 0-5 degrees of flexion.  Weight bearing as tolerated is initiated with advancement to full weight bearing by the second to fourth week.  Following 4-6 weeks the cast may be exchanged for a patella-bearing cast or a fracture brace.

In a tibial stress fracture, cessation of the offending activity is the usual treatment.  A short leg cast may be applied in some situations, with partial-weight-bearing ambulation.

Operative fixation is needed for unstable tibial fractures.  Intramedullary (IM) nailing offers preservation of periosteal blood supply and limited soft tissue damage along with the ability to control alignment, translation, and rotation and is therefore recommended in most fractures.  Nail type may be locked/nonlocked, reamed/unreamed, or flexible/rigid.  Other operative choices are external fixation or plates and screws.

Four compartment fasciotomy is need in compartment syndrome.
g.. Complications (Include complications of injury complications of treatment)

Malunion, nonunion, infection, soft tissue loss, stiffness at knee/ankle joint, knee pain, hardware breakage, thermal necrosis, reflex sympathetic dystrophy, compartment syndrome, neurovascular injury, fat embolism, and claw toe deformity are among the most common and serious complications.
h.. Red Flags and controversies

The general consensus is that IM nail is the standard of care for most tibial shaft fractures.  However, some controversy exists on weather the tibia should be reamed before the IM nail is placed and the type of nail used.

i.. Outcomes

The average time to union is 16 ±4 weeks, with variability owing to fracture pattern and soft tissue injury. Tibial shaft fractures almost always heal with some rotation, angulation or shortening, which alters load transmission across the extremity. 

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