Tibial shaft fracture

AO/OTA 42A1

Spiral, distal third, with fibula

See it in 3D on the real bones, displace and reduce it, with simulated X-ray and CT — free, in your browser.

The commonest long-bone fracture. A third of the tibia lies directly under the skin, so open fractures and wound problems are frequent; the four tight compartments make compartment syndrome a constant threat.

Mechanism

Torsion (skiing, football: spiral, low energy) or direct high-energy blow (transverse or comminuted, often open).

Clinical findings

Deformity, swelling, inability to bear weight.
Compartment syndrome: pain out of proportion and pain on passive stretch of the toes. Measure pressures if in doubt (ΔP = diastolic − compartment pressure < 30 mmHg).
Document the skin (Gustilo–Anderson) and the distal neurovascular status.

Imaging

AP and lateral of the whole tibia, including knee and ankle joints.
CT if the fracture extends into the plafond or plateau.

Full-length AP and lateral including knee and ankle. Spiral distal-third fractures often have an occult posterior malleolus fracture: CT of the ankle.

Classification

42A: Simple: A1 spiral, A2 oblique, A3 transverse.
42B: Wedge.
42C: Multifragmentary.
Gustilo I–III: Open fractures: I < 1 cm clean wound; II 1–10 cm; IIIA adequate soft-tissue cover; IIIB needs a flap; IIIC needs vascular repair.

Types shown in 3D

42A1: Simple spiral, distal third (low-energy torsion). Look for an occult posterior malleolus fracture.
42A2: Simple oblique (30° or more).
42A3: Simple transverse: direct blow (bumper, kick). Often open.
42B2: Wedge (butterfly) fragment, intact.
42C2: Segmental: a whole intermediate segment. High energy; nail with care for the soft tissues.

Treatment

Non-operative: Closed, stable, acceptably aligned (< 5° varus/valgus, < 10° flexion/extension, < 1 cm shortening): long leg cast then functional (Sarmiento) brace.
Operative: Reamed locked intramedullary nail (suprapatellar or infrapatellar entry) for most displaced fractures. Very distal fractures: nail with blocking screws or a distal tibial plate. Open fractures: antibiotics within 1 hour, debridement, then fixation and soft-tissue cover within 72 hours.

Aftercare

Weight bearing as tolerated after a nail for stable patterns.

Complications

Compartment syndrome
Anterior knee pain after nailing
Malunion (valgus with proximal-third fractures)
Non-union and infection (open fractures)