Management of Tibial and Fibular Fractures
For hemodynamically stable patients without severe visceral injuries, perform early definitive osteosynthesis within 24 hours to reduce local and systemic complications; however, in unstable patients or those with shock, respiratory failure, or severe associated injuries, use temporary stabilization (external fixator or traction) followed by delayed definitive fixation once physiologically optimized. 1
Initial Assessment and Stabilization
Immediate Evaluation
- Assess for vascular injury using ankle-brachial index (ABI <0.9), presence of externalizing arterial bleeding, proximity to major vascular axes, non-expanding hematoma, or isolated neurological deficit 1
- Obtain CT angiography (sensitivity 96.2%, specificity 99.2%) as first-line imaging when vascular injury is suspected, rather than traditional arteriography 1
- Provide immediate analgesia with regular paracetamol as first-line, supplemented by carefully titrated opioids (cautiously in renal dysfunction present in ~40% of elderly fracture patients) 1
- Consider peripheral nerve blocks (femoral/fascia iliaca) for superior pain control, though effectiveness typically limited beyond first postoperative night 1
Risk Stratification for Surgical Timing
Stable patients (proceed to early definitive fixation within 24 hours): 1
- No circulatory shock
- No respiratory failure
- No severe visceral injuries (brain, thorax, abdomen, pelvis, spine)
- Normal coagulation parameters
- Stable anatomy
Unstable patients (require damage control approach): 1
- Circulatory shock or hemodynamic instability
- Respiratory failure or ARDS risk
- Severe associated visceral injuries
- Coagulopathy
- Hypothermia or lactic acidosis
Surgical Management Strategy
Early Definitive Osteosynthesis (Stable Patients)
Perform within 24 hours for tibial and fibular shaft fractures to reduce respiratory complications, ARDS, and fat embolism syndrome 1
Key considerations:
- Tibial and fibular shaft fractures carry particularly high risk of respiratory complications if surgery delayed 1
- Early fixation provides most effective analgesia 1
- Minimizes systemic inflammatory response and multiple organ failure risk 1
Damage Control Orthopaedics (Unstable Patients)
Initial temporary stabilization with external fixator or skeletal traction, followed by delayed definitive osteosynthesis once patient stabilized 1
Rationale: Avoids "second hit" phenomenon from massive operative blood loss, hypothermia, and inflammatory mediator release that can precipitate multiple organ failure 1
Fibular Fixation Decision
Do not routinely fix concomitant suprasyndesmotic fibular fractures when treating distal tibial fractures, as fixation increases infection risk (15%), revision surgery (40% vs 20%), and angular malalignment (10% vs 1.2%) without improving outcomes 2
Exception: Consider fibular fixation only for syndesmotic involvement 2
Perioperative Management
Preoperative Optimization
- Correct anemia if hemoglobin <9 g/dL, or <10 g/dL with ischemic heart disease; crossmatch 2 units if Hb 10-12 g/dL 1
- Review medications for polypharmacy issues (20% of patients >70 years take >5 medications) 1
- Assess renal function before opioid dosing (40% have GFR <60 mL/min) 1
- Maintain normothermia with theatre temperature 20-23°C 1
Postoperative Care
- Administer supplemental oxygen for at least 24 hours (elderly at high risk of hypoxia) 1
- Continue regular paracetamol with opioids as needed during remobilization 1
- Encourage early oral fluids rather than routine IV fluids; remove urinary catheters promptly 1
- Monitor for postoperative cognitive dysfunction (occurs in 25% of hip fracture patients) requiring multimodal optimization 1
Management of Osteoporosis and Secondary Prevention
Fracture Risk Assessment
Systematically evaluate all patients >50 years for osteoporosis, as 60% of osteoporotic fractures occur in patients with T-score >-2.5 1
Order DXA scan of lumbar spine and hip to quantify bone mineral density 3
Obtain laboratory workup to identify secondary osteoporosis causes 3
Pharmacological Treatment
First-line: Oral bisphosphonates (alendronate or risedronate) for 3-5 years, reducing vertebral fractures by 47-48%, non-vertebral by 26-53%, and hip fractures by 51% 1, 3
Alternatives for oral intolerance/non-compliance:
- Zoledronic acid (IV annually) - reduces hip fracture risk by 36% (RR 0.64) 1
- Denosumab (subcutaneous every 6 months) - reduces hip fracture risk by 39% (RR 0.61) 1
For very severe osteoporosis: Consider anabolic agents (teriparatide, romosozumab) 1
Adjunctive therapy:
- Calcium 1000-1200 mg daily 3
- Vitamin D 800 IU daily (reduces non-vertebral fractures by 15-20% and falls by 20%) 1, 3
Fall Prevention and Rehabilitation
- Conduct multidimensional fall risk assessment 3
- Implement supervised physical therapy with weight-bearing exercises to improve bone mineral density and muscle strength 3
- Allow weight-bearing as tolerated immediately for most fractures 3
- Provide nutritional supplementation (up to 60% of fracture patients malnourished on admission) 1
Special Considerations
Insufficiency Fractures
Recognize in elderly/osteoporotic patients presenting with spontaneous or minimal trauma fractures 4
Manage conservatively with osteoporosis treatment and clinical monitoring when radiographs conclusive and patient stable 3
Common pitfall: Frequently mistaken for other conditions with diagnostic delay averaging 76 days; maintain high index of suspicion in rheumatoid arthritis patients (particularly high risk) 4
Open Fractures
Administer early prophylactic antibiotics, perform aggressive debridement, wound irrigation, and appropriate fracture fixation to minimize infection and non-union 5
Consider orthoplastic collaborative approach for complex injuries 5
Long-term Regional Osteoporosis Risk
40% of tibial fracture patients develop significant regional BMD loss (T-score <-1) at 16 years follow-up 6
Risk factors include: smoking (OR 22), alcohol >20 units/week (OR 11), open fracture (OR 17), non-weight bearing >4 weeks (OR 15), delayed union >6 months (OR 15) 6