Tibial shaft fractures in adults
- Karl B Fields, MD
Karl B Fields, MD
- Section Editor — Adult Orthopedics
- Section Editor — Primary Care Sports Medicine
- Professor of Family Medicine and Sports Medicine
- University of North Carolina at Chapel Hill
Tibial fractures are common long-bone injuries. National Center for Health Statistics cites 492,000 tibial fractures per year in the United States. Open fractures generally occur from high velocity trauma (eg, automobile collision). Closed injuries may occur from falls or sports-related trauma.
This topic will review issues related to tibial shaft fractures. Tibial shaft fractures in children and a general overview of tibial fractures in adults are presented separately. (See "Tibial and fibular shaft fractures in children" and "Overview of tibial fractures in adults".)
Greater than 70,000 hospitalizations, 800,000 office visits, and 500,000 hospital days have been attributed to tibial shaft fractures in the United States annually . The presence of significant osteoporosis increases the risk for compound or more complex fractures associated with higher morbidity and mortality [2,3]. More severe tibia fractures stem from high-energy trauma, most often motor vehicle collisions [2,4,5]. In Europe, closed tibial fractures are often associated with football (soccer) [6,7]. Shin guards may provide some protection, but many players who sustain tibial fractures are using shin guards at the time of injury . Skiing is another sport commonly associated with low-energy, often torsional, tibia fractures .
The tibia is the major weight-bearing bone of the lower leg (picture 1 and picture 2). The proximal portion of the bone, the tibial plateau, forms the lower surface of the knee joint (picture 3 and picture 4). The tibial shaft bridges the distance to the distal tibia which contributes the superior articular surface of the ankle joint at the tibiotalar articulation as well as the medial malleolus. Another key bony landmark is the tibial tuberosity which sits several centimeters below the joint line and the inferior patellar pole and serves as the attachment site for the patellar tendon .
A strong fibrous structure, the interosseous membrane, or syndesmosis, (figure 1) connects the tibia and fibula along the length of the two bones. Proximally, this structure, reinforced by strong anterior and posterior ligaments, forms a synovial joint, the proximal tibiofibular articulation. Distally, the interosseous membrane and three ligaments, the anterior, posterior, and transverse tibiofibular ligaments stabilize the superior ankle joint.
- Schmidt AH, Finkemeier CG, Tornetta P 3rd. Treatment of closed tibial fractures. Instr Course Lect 2003; 52:607.
- Grütter R, Cordey J, Bühler M, et al. The epidemiology of diaphyseal fractures of the tibia. Injury 2000; 31 Suppl 3:C64.
- Clement ND, Beauchamp NJ, Duckworth AD, et al. The outcome of tibial diaphyseal fractures in the elderly. Bone Joint J 2013; 95-B:1255.
- Chua W, Murphy D, Siow W, et al. Epidemiological analysis of outcomes in 323 open tibial diaphyseal fractures: a nine-year experience. Singapore Med J 2012; 53:385.
- Madadi F, Vahid Farahmandi M, Eajazi A, et al. Epidemiology of adult tibial shaft fractures: a 7-year study in a major referral orthopedic center in Iran. Med Sci Monit 2010; 16:CR217.
- Chang WR, Kapasi Z, Daisley S, Leach WJ. Tibial shaft fractures in football players. J Orthop Surg Res 2007; 2:11.
- Court-Brown CM, McBirnie J. The epidemiology of tibial fractures. J Bone Joint Surg Br 1995; 77:417.
- Boden BP, Lohnes JH, Nunley JA, Garrett WE Jr. Tibia and fibula fractures in soccer players. Knee Surg Sports Traumatol Arthrosc 1999; 7:262.
- Duke Orthopaedics. Wheeless' Textbook of Orthopedics. www.wheelessonline.com (Accessed on March 07, 2005).
- Petrisor, BA, Bhandari, M, Schemitsch, E. Tibia and Fibula Fractures. In: Rockwood and Green's Fractures in Adults, 2, Bucholz, RW, Court-Brown, CM, Heckman, JD, Tornetta, Paul III (Eds), Lippincott Williams & Wilkins, Philadelphia 2010. p.1867.
- Bisson LJ, Kluczynski MA, Hagstrom LS, Marzo JM. A prospective study of the association between bone contusion and intra-articular injuries associated with acute anterior cruciate ligament tear. Am J Sports Med 2013; 41:1801.
- Kim S, Endres NK, Johnson RJ, et al. Snowboarding injuries: trends over time and comparisons with alpine skiing injuries. Am J Sports Med 2012; 40:770.
- Ishimaru D, Ogawa H, Sumi H, et al. Lower extremity injuries in snowboarding. J Trauma 2011; 70:E48.
- Khatod M, Botte MJ, Hoyt DB, et al. Outcomes in open tibia fractures: relationship between delay in treatment and infection. J Trauma 2003; 55:949.
- Ettehad H, Mirbolook A, Mohammadi F, et al. Changes in the serum level of vitamin d during healing of tibial and femoral shaft fractures. Trauma Mon 2014; 19:e10946.
- Busse JW, Morton E, Lacchetti C, et al. Current management of tibial shaft fractures: a survey of 450 Canadian orthopedic trauma surgeons. Acta Orthop 2008; 79:689.
- Patellar, Tibial and Fibular Fractures. In: Fracture Management for Primary Care, Eiff, MP, Hatch, RL, Calmbach, WL (Eds), Saunders, Philadelphia 2003. p.263.
- Littenberg B, Weinstein LP, McCarren M, et al. Closed fractures of the tibial shaft. A meta-analysis of three methods of treatment. J Bone Joint Surg Am 1998; 80:174.
- Coles CP, Gross M. Closed tibial shaft fractures: management and treatment complications. A review of the prospective literature. Can J Surg 2000; 43:256.
- Sarmiento A, Latta LL. Fractures of the middle third of the tibia treated with a functional brace. Clin Orthop Relat Res 2008; 466:3108.
- Toivanen JA, Honkonen SE, Koivisto AM, Järvinen MJ. Treatment of low-energy tibial shaft fractures: plaster cast compared with intramedullary nailing. Int Orthop 2001; 25:110.
- Batta V, Dwyer AJ, Gulati A, et al. No difference in the long term final functional outcome after nailing or cast bracing of high energy displaced tibial shaft fractures. J Trauma Manag Outcomes 2012; 6:5.
- Cannada LK, Anglen JO, Archdeacon MT, et al. Avoiding complications in the care of fractures of the tibia. J Bone Joint Surg Am 2008; 90:1760.
- Ferguson M, Brand C, Lowe A, et al. Outcomes of isolated tibial shaft fractures treated at level 1 trauma centres. Injury 2008; 39:187.
- Lefaivre KA, Guy P, Chan H, Blachut PA. Long-term follow-up of tibial shaft fractures treated with intramedullary nailing. J Orthop Trauma 2008; 22:525.
- Khalid M, Brannigan A, Burke T. Calf muscle wasting after tibial shaft fracture. Br J Sports Med 2006; 40:552.
- Moghaddam A, Zimmermann G, Hammer K, et al. Cigarette smoking influences the clinical and occupational outcome of patients with tibial shaft fractures. Injury 2011; 42:1435.
- Adams CI, Keating JF, Court-Brown CM. Cigarette smoking and open tibial fractures. Injury 2001; 32:61.
- Castillo RC, Bosse MJ, MacKenzie EJ, et al. Impact of smoking on fracture healing and risk of complications in limb-threatening open tibia fractures. J Orthop Trauma 2005; 19:151.
- Harvey EJ, Agel J, Selznick HS, et al. Deleterious effect of smoking on healing of open tibia-shaft fractures. Am J Orthop (Belle Mead NJ) 2002; 31:518.
- Hoogendoorn JM, van der Werken C. [The adverse effects of smoking on healing of open tibial fractures]. Ned Tijdschr Geneeskd 2002; 146:1640.
- Lenehan B, Fleming P, Walsh S, Kaar K. Tibial shaft fractures in amateur footballers. Br J Sports Med 2003; 37:176.
- Vallier HA, Cureton BA, Patterson BM. Factors influencing functional outcomes after distal tibia shaft fractures. J Orthop Trauma 2012; 26:178.
- Larsen P, Lund H, Laessoe U, et al. Restrictions in quality of life after intramedullary nailing of tibial shaft fracture: a retrospective follow-up study of 223 cases. J Orthop Trauma 2014; 28:507.
- CLINICAL ANATOMY
- MECHANISM OF INJURY
- SYMPTOMS AND EXAMINATION FINDINGS
- RADIOGRAPHIC FINDINGS
- DIFFERENTIAL DIAGNOSIS
- INDICATIONS FOR ORTHOPEDIC REFERRAL
- INITIAL TREATMENT
- DEFINITIVE TREATMENT
- Long leg casting
- Operative interventions
- FOLLOW-UP CARE
- RETURN TO SPORT OR WORK
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS