What is the evaluation and management of a tibia and fibula fracture?

Evaluation and Management of Tibia and Fibula Fractures

Early definitive osteosynthesis is strongly recommended within the first 24 hours for stable patients with tibia and fibula fractures, while temporary stabilization followed by delayed definitive fixation is recommended for patients with severe associated injuries or hemodynamic instability. 1

Initial Evaluation

Clinical Assessment

• Assess for:
  • Pain, swelling, deformity, and inability to bear weight
  • Open vs. closed fracture
  • Neurovascular status (pulses, sensation, motor function)
  • Associated injuries
  • Hemodynamic stability
  • Compartment syndrome signs (pain out of proportion, pain with passive stretch, paresthesia, pallor, paralysis)

Imaging

1. Plain Radiographs: Three standard views are essential 2:

   • Anteroposterior view
   • Lateral view
   • Mortise view (for ankle involvement)
   • Include views of joints above and below the fracture

2. CT Scan: Indicated for:

   • Complex fracture patterns
   • Intra-articular extension
   • Preoperative planning

3. CT Angiography: Recommended if vascular injury is suspected 1

4. MRI: Not routinely indicated for acute fractures but useful for:

   • Suspected stress fractures with normal radiographs
   • Soft tissue injuries
   • Ligamentous injuries

Management

Initial Management

1. Immobilization:

   • Long leg splint for initial stabilization
   • Pain control with multimodal analgesia (paracetamol, NSAIDs, opioids) 1
   • Elevation to reduce swelling
   • Ice application

2. Open Fractures:

   • Immediate IV antibiotics
   • Tetanus prophylaxis
   • Urgent surgical debridement
   • Temporary external fixation

Definitive Treatment Options

Non-operative Management

• Indicated for:
  • Stable, non-displaced fractures
  • Patients with contraindications to surgery
• Methods:
  • Long leg cast for 6-8 weeks followed by functional bracing
  • Regular radiographic follow-up to assess alignment and healing

Operative Management

1. Intramedullary Nailing:

   • Gold standard for most diaphyseal tibia-fibula fractures 3
   • Advantages: preserves blood supply, allows early weight-bearing, lower infection rates
   • Considerations: may be extended to treat proximal or distal metaphyseal fractures with newer nail designs

2. Plate Fixation:

   • Indicated for:
     • Metaphyseal fractures
     • Intra-articular fractures
     • Fractures with small intramedullary canals
   • Techniques: ORIF, MIPO (minimally invasive plate osteosynthesis)

3. External Fixation:

   • Indicated for:
     • Open fractures with significant soft tissue injury
     • Polytrauma patients requiring damage control
     • Skeletally immature patients with unstable fracture patterns 3
   • Types: uniplanar, circular (Ilizarov), hybrid

4. Fibula Fixation:

   • Not routinely required in all cases 4
   • Consider in:
     • Ankle syndesmotic injuries
     • When fibula fixation aids tibial reduction
     • Unstable fracture patterns
   • Note: Recent meta-analysis shows no significant differences in nonunion or malunion rates when comparing tibial fixation alone versus additional fibular fixation 4

Special Considerations

Distal Tibia-Fibula Fractures

• Circular external fixators show good outcomes for spiral and oblique fractures of the distal third of the tibia-fibula 5
• Benefits include:
  • Fewer complications like shortening and angulation
  • Early mobilization
  • Shorter treatment time

Spiral Fractures with Intact Fibula

• May require special attention due to potential interference with healing by the intact fibula 6
• Consider fibular osteotomy in cases of delayed union

Postoperative Care and Rehabilitation

1. Immediate Postoperative Period:

   • Antibiotic prophylaxis
   • Regular assessment of neurovascular status
   • Wound healing monitoring
   • Pain management

2. Early Rehabilitation:

   • Early mobilization as tolerated
   • Non-weight bearing or partial weight bearing based on fracture stability and fixation method
   • Range of motion exercises for adjacent joints

3. Progressive Rehabilitation:

   • Progressive weight bearing as healing progresses
   • Muscle strengthening
   • Balance training
   • Return to activities based on radiographic and clinical healing

Complications and Their Management

1. Nonunion/Delayed Union:

   • Consider bone grafting, exchange nailing, or adjunctive treatments (ultrasound, bone stimulators)
   • For spiral fractures with intact fibula, fibular osteotomy may be considered 6

2. Malunion:

   • May require corrective osteotomy if functionally significant

3. Infection:

   • Aggressive debridement, culture-specific antibiotics, possible implant exchange

4. Compartment Syndrome:

   • Emergent fasciotomy if diagnosed

5. Hardware Issues:

   • Higher rate of hardware removal with fibular fixation 4

Long-term Follow-up

• Regular radiographic assessment until union
• Functional assessment
• Consideration for osteoporosis evaluation in appropriate patients
• Fall prevention strategies

By following this structured approach to the evaluation and management of tibia and fibula fractures, optimal functional outcomes can be achieved while minimizing complications.