What are the treatment options for suspected fractures and bruising after falling and hitting my shins on a hard surface, resulting in two lumps that feel like bone?

Immediate Imaging and Evaluation for Suspected Tibial Fracture

You need plain radiographs of your shin (tibia/fibula) immediately—anteroposterior, lateral, and oblique views—to confirm or exclude fracture, as palpable bony lumps after direct trauma strongly suggest either displaced fracture fragments or significant periosteal hematoma. 1

Initial Diagnostic Approach

Radiographic Imaging (First-Line)

• Standard three-view radiographs of the lower leg are mandatory as the initial imaging study for any suspected tibial fracture following direct trauma 1
• The "lumps that feel like bone" you describe could represent:
  • Displaced fracture fragments breaking through soft tissue
  • Significant subperiosteal hematoma creating a firm mass
  • Periosteal elevation from underlying fracture 1

When to Obtain Advanced Imaging

• If radiographs are negative but clinical suspicion remains high (persistent focal tenderness, inability to bear weight, significant swelling), CT scan should be obtained to detect occult fractures 1
• CT is particularly useful for detecting tibial plateau or shaft fractures that may be radiographically occult initially 1
• MRI is generally reserved for suspected soft tissue injuries or bone marrow edema, not as first-line for acute fracture evaluation 1

Treatment Algorithm Based on Findings

If Fracture is Confirmed

Non-displaced or minimally displaced tibial shaft fractures:

• Short leg cast or walking boot for 6-8 weeks 2
• Non-weight bearing initially, progressing to weight-bearing as tolerated based on pain and radiographic healing 2

Displaced or unstable fractures:

• Early definitive surgical fixation within 24 hours is recommended if you are hemodynamically stable without severe associated injuries 1
• This approach reduces risk of complications including malunion, nonunion, and compartment syndrome 1, 3
• Intramedullary nailing is typically preferred for tibial shaft fractures 1

If No Fracture is Found

Severe soft tissue contusion/hematoma:

• Hard-soled shoe or walking boot for comfort 4
• Ice, elevation, and NSAIDs for pain management
• Weight-bearing as tolerated
• The palpable "lumps" likely represent organized hematoma that will resorb over 4-8 weeks

Critical Red Flags Requiring Immediate Emergency Evaluation

• Inability to bear any weight suggests possible fracture even with negative initial radiographs 1
• Increasing pain, tightness, or numbness may indicate compartment syndrome—a surgical emergency 4
• Skin tenting or open wounds require urgent orthopedic consultation 1
• Neurovascular compromise (absent pulses, severe numbness, pale/cold foot) demands immediate vascular assessment 1

Common Pitfalls to Avoid

• Do not assume palpable bony irregularity is "just bruising"—this physical finding has high specificity for underlying fracture and warrants imaging 1
• Avoid delaying imaging because you can walk—some tibial fractures remain stable enough for partial weight-bearing initially but can displace without proper immobilization 4
• Do not accept reassurance without radiographs when there is focal bony tenderness and palpable deformity after direct trauma 1
• Inadequate immobilization of confirmed fractures leads to malunion, delayed union, or nonunion 3

Follow-Up Considerations

• If fractures are treated non-operatively, repeat radiographs at 1-2 weeks are essential to ensure no displacement has occurred 2, 4
• Weight-bearing radiographs during follow-up provide important information about fracture stability 2
• Most tibial shaft fractures require 6-12 weeks for clinical union, with return to full activity at 3-4 months 4