Tibial Fractures

Tibial fractures are cracks or breaks in the shin bone, the primary weight-bearing bone of your leg, most often caused by a major trauma or repetitive microtrauma. The major defining characteristics of tibial fractures include their location, whether they are open or closed, and whether they are displaced or non-displaced.

  • Displaced vs non-displaced - refers to whether the fragments of the bone have shifted significantly enough to jeopardize the structural integrity of the bone. If the fragments have shifted and no longer line up well, the fracture is likely to be unstable. Conversely, if the fragments did not displace completely, and still appear to be aligned well, the fracture may be stable.
  • Open vs. Closed - refers to whether there is significant damage to surrounding soft tissue (i.e. skin and muscle), such that the bone is now exposed to the outside environment.
  • Location
    1. Plateau- fractures at the top of the tibia, which makes up the knee joint
    2. Plafond (or Pilon)- fracture at the bottom of the tibia, which makes up the ankle joint
    3. Shaft- fractures along the long, narrow portion of the shin bone

The type, direction, and magnitude of force typically leads to variations in these defining characteristics. Depending on where the break is, tibial fractures are classified and managed differently.

Tibial Fractures Symptoms and Anatomy

The tibia, or shin bone, is located in the lower leg along with the fibula. The tibia is the larger of the two and bears the majority of weight transmitted through the lower leg. In addition to bearing weight, the tibia is important for proper knee and ankle biomechanics and function. The top of the tibia is called the tibial plateau, the bottom is called the tibial plafond, and the long, narrow portion in between is the shaft. Fractures of the tibial plateau and plafond affect knee and ankle function, respectively.

Symptoms of a tibia fracture include localized pain around the fracture site, bruising, swelling, and difficulty (or the complete inability) to bear weight or walk on the affected leg. In the case of tibial plateau or plafond fractures, there may be associated instability or inability to flex the knee or ankle, respectively. Depending on whether the fracture is displaced or open, there may be a visible deformity of the bone or laceration of the overlying skin. Finally, depending on the mechanism and location of injury, there may be symptoms such as numbness, tingling, burning sensations, and/or pain with minimal leg or foot movement. These symptoms are more worrisome and may indicate the presence of compartment syndrome or damage to neurovascular structures.

Of note, in the case of a stress fracture, the onset of pain may be more insidious. Initially, pain may only occur during periods of physical activity such as running; if left untreated, though, symptoms may progress and patients will experience more constant symptoms of pain.

Tibial Fractures Treatment Options

Typically, fractures can be managed operatively or non-operatively. As a general principle, stable fractures that are closed, minimally displaced, and extra-articular (meaning the fracture does extend into the joint surfaces), are good candidates for non-operative management.

Tibial Shaft: If the tibia remains within the limits of acceptable alignment (< 5 degrees varus-valgus angulation, < 10 degrees anterior/posterior angulation, > 50% cortical apposition, < 1 cm shortening, < 10 degrees rotational malalignment). Non-operative management consists of closed reduction and immobilization in a long-leg cast. After about 4 weeks, patients can be transitioned to a functional brace.

Tibial Plateau: Non-operative management includes use of a hinged knee brace and partial weight-bearing for a period of 8-12 weeks. While early ROM is encouraged, the exact time at which weightbearing and ROM are advanced depends on clinical and radiographic characteristics of the fracture.

Tibial Plafond: Patients with tibial plafond injuries are also at increased risk of wound healing complications due to the relatively thin skin around the ankle and the significant swelling that occurs after trauma. Patients with a medical history that predisposes them to skin healing problems (i.e. diabetes, vascular disease, smoking, etc.) should be managed non-operatively if possible. Such management includes closed reduction and immobilization in a long leg cast. At 6 weeks, patients may transition to a brace and begin working on ROM exercises. If non-operative management is not a valid option, an external fixator can be used as a temporizing measure until soft tissue swelling decreases and surgery can be performed (typically 1-2 weeks).

Tibial Stress fractures: the majority of stress fractures are managed non-operatively with activity restriction and protected weight bearing. Typically, 6-8 weeks is sufficient time for stress fractures to heal. Of note, patients should avoid NSAIDs for pain management as it is thought that the disruption of inflammation delays bone healing.

Tibial Fractures Surgery

Generally, if a fracture is open, significantly displaced, or intra-articular, surgery will be indicated for definitive management. Additionally, if the above non-operative interventions are not indicated or fail, operative management is indicated.

Tibial Shaft: May be treated with intramedullary nailing (IMN) or open reduction and internal fixation with a percutaneous locking plate. IMN involves placing a rod down the canal of the tibia. The rod crosses the fracture and is screwed in place at both ends. This method is avoided in children in order to spare the growth plate. Percutaneous locking plates involve a plate that is placed against the outer surface of the bone and screwed into place. This method is preferred over IMN when the fracture occurs at either end and of the tibia and cannot be adequately fixed with a rod. Tibial shaft fractures typically take about 4-6 months for full recovery.

Tibial Plateau & Plafond: typically treated with open reduction and internal fixation with plates and screws. Depending on the fracture pattern, some tibial plateau fractures can be treated with screws alone. It may take up to 3 months before patients are able to fully weight-bear.

Tibial Stress Fractures: In rare cases, surgery may be beneficial for tibial stress fractures. When there is a break in the anterior cortex of the tibia (seen as the "dreaded black line" on lateral plain films), an IMN may be indicated as these fractures have a higher likelihood of non-union.

Open fractures: all open fractures require immediate antibiotics and emergent irrigation and debridement (ideally within 6-8 hours). They can then be treated with external fixation or open reduction and internal fixation, depending on the fracture location and pattern.

External fixation: external fixators involve the use of pins or screws that are placed into the bone to create a stabilizing external frame around the fracture site. They are most useful in management of severely comminuted fractures or injuries associated with extensive soft tissue damage. In these cases, external fixation can be used for stabilization until healing is complete, or as a temporizing measure until definitive management can safely be performed.