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Overview of tibial fractures in adults

Overview of tibial fractures in adults
Literature review current through: Jan 2024.
This topic last updated: Aug 12, 2022.

INTRODUCTION — Fractures of the tibia may result from significant trauma or be the consequence of repeated overuse. The latter mechanism leads to stress fractures.

An overview of traumatic tibial fractures in adults with a focus on epidemiology and complications is presented here. The evaluation and management of particular types of tibia fractures, including proximal and shaft fractures, stress fractures, and fractures in children, are discussed separately:

Fractures in adults (see "Proximal tibial fractures in adults" and "Tibial shaft fractures in adults")

Fractures in children (see "Proximal tibial fractures in children" and "Tibial and fibular shaft fractures in children")

Stress fractures (see "Stress fractures of the tibia and fibula" and "Overview of stress fractures")

EPIDEMIOLOGY — Tibial fractures occur in both high energy trauma, such as motor vehicle, winter sports (eg, skiing), and cycling accidents, and low energy trauma, such as falls, contact sports, distance running, and other endurance or repetitive impact activities. Injuries caused by high energy trauma are more likely to involve complex and open tibia fractures and fractures in certain locations, such as the tibial plateau [1]; injuries caused by low energy trauma more often result in simple transverse or linear tibia fractures. Open fractures of the tibia have high complication rates and are often associated with long-term limitations in function and chronic pain [2].

In adults and children, closed tibial shaft fractures are the most common long-bone fractures. With greater than 70,000 hospitalizations, 800,000 office visits, and 500,000 hospital days per year in the United States alone, they have major economic consequences [3]. According to retrospective series of pediatric tibial fractures over 18 years at one institution, the cause of such fractures may be shifting towards organized sport rather than bicycling injury or other trauma [4]. Older adults suffer many of these fractures from simple falls, and those with significant osteoporosis incur open or more complex fractures, often with high morbidity [3].

In developing countries, tibial fractures often occur from motor vehicle collisions. These fractures frequently lead to quality-of-life, employment, and financial difficulties for patients. A study from Uganda showed that only 12 percent of patients had recovered physically and financially at two years post-injury [5].

Tibial fractures occur during contact and noncontact sporting events. Several studies demonstrate that a direct, low velocity blow (eg, tackling, kicking) causes approximately 95 percent of sports-related tibial fractures [4,6-8]. In a five-year retrospective study of 244 tibial fractures seen at a major trauma center, 24 (9.8 percent) occurred during football (soccer) games [7]. A similar review reported that football (soccer) and rugby accounted for the largest number of sports-related open tibial fractures [8]. Even when low energy trauma is the cause, concomitant fibular fractures occur in approximately 60 percent of cases. Nevertheless, significant complications develop in fewer than five percent of sports-related tibial fractures and the prognosis is generally good.

The incidence of tibia fractures among football (soccer) players appears to be declining, although the reasons for this remain unclear [6,7,9]. Some claim that increased use of shin guards accounts for the decline. However, studies of other contact sports and a case series in which 85 of 100 football-related tibia fractures were sustained by athletes wearing shin guards argue against this claim. Case reports suggest that tibial fractures occur in snowboarding, mixed martial arts, and "X-game"-type sports (eg, skateboarding), although demographic data are scant.

Avulsion fractures of the lateral and medial tibia may have diagnostic significance in looking for anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL) ligament injuries. The Segond fracture occurs just below the iliotibial band attached to the fibers of the lateral capsule and is associated with ACL tear. Proximal tibial avulsion fractures at the medial aspect of the bone may be a marker of PCL injury [10-13].

Long term bisphosphonate use, particularly in older adult patients, may contribute to tibial fractures. Case reports document insufficiency type fractures of the tibia without known trauma [14]. (See "Risks of bisphosphonate therapy in patients with osteoporosis", section on 'Atypical femur fracture'.)

As the number of total knee replacements has increased, so has the incidence of peri-prosthetic tibial fractures [15]. These fractures fall into two categories, intraoperative and postoperative, and involve four general locations:

Tibial plateau near tibial components

Adjacent to the stem in the metaphysis-diaphysis junction

Tibial shaft distal to implant

Tibial tubercle

Peri-operative infection, osteopenia, and osteoporosis all increase the risk for such fractures. Trauma contributes to such injuries, particularly among younger recipients of knee replacements who resume sport and other physical activities.

CLASSIFICATION — Fractures of the tibia in adults are classified clinically based upon their location. Fractures of the proximal tibia are subclassified into those affecting the tibial plateau or the intercondylar notch and avulsion fractures of the tibial tubercle. Researchers use a more complex classification system known as the Arbeitsgemeinschaft Osteosynthesefragen/Association for the Study of Internal Fixation (AO/ASIF) [16].

Locations of fractures — Issues related to the different locations of tibial fractures are discussed separately in the appropriate topic reviews:

Proximal tibial fractures (see "Proximal tibial fractures in adults" and "Proximal tibial fractures in children")

Tibial shaft fractures (see "Tibial shaft fractures in adults" and "Tibial and fibular shaft fractures in children")

Distal tibial and medial malleolus fractures (see "Ankle fractures in adults" and "Ankle fractures in children")

ANATOMY — The tibia is the major weight-bearing bone of the lower leg (figure 1 and figure 2). The proximal portion of the bone, the tibial plateau, forms the lower surface of the knee joint. The tibial plateau consists of the medial tibial condyle, the thicker of the two articular surfaces, and the lateral tibial condyle, a relatively thinner and weaker portion of the joint. Separating the medial from the lateral condyle is the intercondylar eminence, an important bony prominence that anchors the attachment of the anterior cruciate ligament. The tibial shaft bridges the distance to the distal tibia which contributes the superior articular surface of the ankle joint at the tibiotalar articulation as well as the medial malleolus. Another key bony landmark is the tibial tuberosity, which sits several centimeters below the joint line and the inferior patellar pole, and serves as the attachment site for the patellar tendon [17].

A strong fibrous structure, the interosseous membrane (figure 3), connects the tibia and fibula along the length of the two bones. Proximally, this structure is reinforced by strong anterior and posterior ligaments and forms a synovial joint known as the proximal tibiofibular articulation. Distally, the interosseous membrane and three ligaments, the anterior, posterior, and transverse tibiofibular ligaments, stabilize the superior ankle joint. Another fibrous structure, the crural fascia, surrounds the bones and muscles of the lower leg. Fascial extensions and the interosseous membrane separate the muscles, nerves, and vessels of the lower leg into four distinct compartments (figure 4). Three of these, the anterior, posterior, and deep posterior compartments, all border the tibia and can be compromised by tibial injury.

Nerves and vessels lie within the anterior and the deep posterior compartments, and trauma that causes significant swelling in these compartments can result in neurovascular compromise (figure 5). The key blood supply of the tibia arises from periosteal vessels and the nutrient artery. The nutrient artery originates from the posterior tibial artery and enters the posterolateral cortex at the middle third of the tibial shaft near the origin of the soleus muscle. Fractures in this region potentially compromise this blood supply. The periosteal vessels provide a less vulnerable circulation as they derive an abundant blood supply from the anterior tibial artery which travels down along the interosseous membrane. Vascular compromise can arise more proximally from marked effusion of the knee joint, from trauma that affects the popliteal artery before it branches into the anterior and posterior tibial arteries, or at the level of the anterior tibial artery as it branches off the popliteal artery and passes through a gap in the interosseous membrane [17].

The tibial nerve and several branches provide the key innervation to the muscles of the lower leg and foot. Nerve roots arise from L4 through S3. The posterior tibial nerve parallels the course of the posterior tibial artery and courses through the deep posterior compartment. In the popliteal space (picture 1), branches of the tibial nerve provide innervation to the posterior compartment and to the popliteus muscle. The deep peroneal nerve branches and follows the course of the anterior tibial artery providing innervation to muscles in the anterior lower leg.

EXAMINATION

Deformity — The injured leg is examined for localized swelling, discoloration, tenderness, shortening, rotation and angulation.

Skin integrity — The skin is inspected for evidence of one or more of the following:

Contusions and/or ecchymosis

Lacerations

Puncture wounds or evidence of secondary infection

Protrusion of bone fragments indicative of a compound fracture

If medicolegal considerations warrant, photographs of the injury may be taken with the patient's permission. Wound and blood cultures should be obtained prior to initiating antibiotic therapy if there are signs of soft tissue infection.

Ligamentous and meniscal integrity — Ligamentous and meniscal injuries frequently occur in conjunction with proximal tibial fractures. Instillation of local anesthetic into the knee joint is sometimes necessary to allow testing (eg, McMurray, Lachman, collateral ligament stressing). Varus or valgus stress that leads to more than 10 degrees of opening is abnormal and, if inferior to the joint line, suggests a displaced fracture. (See "Approach to the adult with unspecified knee pain".)

Neurovascular integrity — Direct damage to neurovascular structures may occur with tibial fractures. It is appropriate to test skin sensation, muscle function, distal pulses, and capillary refill to determine the integrity of the nerves and arterial supply to the lower limb.

COMPLICATIONS

Overview — Tibial fractures, particularly open or complex injuries, often involve complications, which may include acute compartment syndrome, neurovascular injuries, and infection. Fat emboli may complicate any type of tibial fracture, ranging from complex fractures treated surgically to simple fractures treated nonoperatively. Although tibial fractures due to low energy mechanisms, such as those sustained during sports, have lower complication rates, even these are susceptible. (See "General principles of fracture management: Early and late complications".)

Spiral and distal shaft fractures of the tibia are associated with occult posterior malleoli ankle fractures. In one series, such occult fractures were noted in approximately 13 percent of patients (25 of 186) [18].

Complications from tibial fractures, whether managed surgically or nonoperatively, adversely affect patient quality of life, even after the fracture and complications have healed clinically, for 12 months or longer [19].

Open fractures — Open tibial fractures are associated with higher rates of infection, soft tissue damage, and death. According to a national Swedish registry study of 3777 open tibial fractures, 425 patients died, a rate of 11.3 percent [20]. Among older patients, the risk of death was comparable to that seen with hip fractures. Cardiovascular and pulmonary complications accounted for most of the increase in mortality.

Post-surgical pain and hypersensitivity — Particularly for patients treated with intramedullary nailing of a shaft fracture, long-term knee pain and hyperalgesia are common complications following surgical treatment of a tibial fracture. This is discussed separately. (See "Tibial shaft fractures in adults", section on 'Complications'.)

Acute compartment syndrome — Elevated pressure due to increased volume within a constricting fascia can cause an acute compartment syndrome, which can threaten the limb and constitutes a surgical emergency. Bleeding from a tibial fracture can extravasate into the posterior, deep posterior, or anterior compartment (figure 5) and elevate the intracompartmental pressure. More complicated and larger fractures pose a greater risk [21]. Involvement of the lateral compartment usually implies that a fibular injury is also present. Acute compartment syndrome is discussed in detail separately. (See "Acute compartment syndrome of the extremities".)

Tense swelling of the affected muscles, decreased distal pulses, muscle weakness, increased pain elicited by passive stretch of involved muscles, and impaired sensation due to nerve compression or ischemia may be noted on examination. This may progress to pulselessness, paralysis, and anesthesia. Permanent neuromuscular damage may ensue if the compartment pressure is not decreased promptly by fasciotomy.

Runners can present with both lower leg pain and injuries that cause a compartment syndrome in the absence of a fracture. Similar symptoms may also accompany or be confused with the shin splint syndrome. (See "Running injuries of the lower extremities: Patient evaluation and common conditions", section on 'Chronic exertional compartment syndrome'.)

Long-term calf atrophy and sport limitation — Tibial shaft fractures treated with casting may lead to long term muscle atrophy of the posterior compartments of the calf. One observational study reevaluated 23 patients who at an average age of 18 sustained a tibial shaft fracture treated with cast immobilization for an average of 10 weeks [22]. Sixteen years after the initial injury, CT examination revealed significant calf muscle atrophy. Only 3 of the 23 returned to their previous level of competitive sport, while 10 of 23 returned to recreational sport at a lower level.

Long-term function and arthritis risk — Several observational studies have examined the development of significant osteoarthritis and overall function following treatment of tibial fractures. As expected, more severe injuries are associated with a higher risk of osteoarthritis and disability.

An observational study of 44 patients with tibial spine fractures that were diagnosed at a mean age of 24 and required internal fixation reported minimal arthritis and good function at a mean follow-up of 16 years (range 5 to 27) [23]. According to several observational studies, younger patients with tibial plateau fractures managed surgically appear to retain good knee and leg function at five-year follow-up [24,25]. One study with a mean follow-up of 14 years (range 5 to 27) reported mild to moderate arthritis in 31 percent of patients with single condyle injuries, but more severe arthritis in patients who had 5 or more degrees of malalignment [25].  

Tibial plateau fractures are more problematic. In a matched cohort study involving all tibial plateau fractures managed in Denmark between 1996 and 2000 (n = 7950) with a mean follow-up of 13.9 years, patients with such fractures had a 3.5 times greater risk (95% CI 3.1-3.9) of requiring delayed total knee replacement compared with a reference group of age- and sex-matched individuals [26].

A retrospective study with a mean followup of 27 years (range 23 to 32) of 45 patients who sustained tibial fractures in childhood reported that ten had leg length discrepancies, four had rotational deformity of at least 20 degrees, and 2 had developed osteoarthritis [27]. The authors concluded that long-term function was generally good.

Nonunion — A small percentage of tibial fractures develop a nonunion. A study of 237 consecutive patients who experienced this complication reported a dramatic impact on quality of life, including effects on mental health and physical activity worse than those reported by patients with decompensated heart failure and as bad as those reported by patients with end-stage osteoarthrosis of the hip [28].

According to data from a national data bank in Scotland, the risk of nonunion appears highest in younger men and older women, and fractures in the region of the tibia and fibula pose the highest risk of all anatomic sites [29]. Adults from 30 to 44 years are affected most often. The overall nonunion rate for tibial fractures is 5.4 to 7.5 percent. Open tibia fractures have a 26 percent risk of nonunion versus one percent for closed fractures. High-energy fractures from sport, direct blows, and motor vehicle collisions are more common among the young, and this may affect the age distribution noted. While older adult women patients have a higher risk of nonunion, the older age group does not have a higher overall risk of fracture compared to younger adults.

DIAGNOSTIC IMAGING — Plain film radiographs are the basic means to assess tibial shaft fractures. Initial studies include anteroposterior (AP) and lateral views. These should incorporate the entire length of the lower leg from knee to ankle. Radiolucent splinting during the procedure reduces the risk of additional injury and allows proper positioning to best visualize fractures.

Important features that can be assessed from the plain radiographs are the following:

Fracture location and type (eg, transverse, oblique, comminuted)

Displacement

Angulation

Nondisplaced fractures of the tibia have ≤5 mm of displacement and <10 degrees of angulation or rotation.

Computed tomography (CT) scans and magnetic resonance imaging (MRI) are reserved for more complex injuries. MRI has particular value in higher tibial fractures that may extend into the knee joint or are suspected of involving the tibial plateau. MRI also helps delineate associated meniscal or ligamentous injuries.

Routine use of musculoskeletal ultrasound for the diagnosis of tibial fractures in adults cannot be endorsed, but as more physicians become adept at ultrasound, and the technology continues to evolve, we anticipate that diagnostic ultrasound will likely play a greater role in diagnosing these injuries at the bedside. Preliminary studies of diaphyseal tibial fractures in children are promising [30], but results in adults have been mixed, possibly due to the variable experience and skill of the clinicians performing the examination [31,32]. While ultrasound has limitations, its sensitivity and specificity for detecting fractures of the metaphyseal and diaphyseal regions of long bones when clinicians experienced with ultrasound perform the study have been reported to be as high as 90 and 96 percent, respectively [32].This has led to wider use in the emergency department and sports medicine settings as an initial test to help determine the need for additional imaging or the possibility of return to play [33].

MANAGEMENT — The general principles of fracture management apply to tibial fractures. Management of specific tibial fractures varies with the anatomic location of the fracture and is discussed separately. (See "Proximal tibial fractures in adults" and "Tibial shaft fractures in adults".)

The following steps should be performed:

Minimize further tissue injury, particularly of neural and vascular structures, by immobilizing the fracture. Because substantial soft tissue swelling can occur, initial immobilization is generally achieved by applying a removable plaster or fiberglass splint. The splint will later be removed to allow reduction, fixation, or replacement with a better fitting cast.

Apply ice to minimize swelling and inflammation.

Elevate the injured extremity above the level of the heart.

Give analgesics.

Most patients achieve adequate pain relief from immobilization, ice, and over-the-counter analgesics such as acetaminophen or ibuprofen. Opioid analgesics are occasionally needed to control pain during the first three to five days. Patients requesting opioids beyond this time should be reevaluated for irritation from a poorly fitting splint, a missed secondary injury, or a fracture complication.

Patients with tibial fractures awaiting urgent surgical intervention should be managed with splinting, ice, and non-opioid analgesics (only if possible) until they have made a decision about surgery. With open tibial fractures, surgical delays of up to 96 hours to manage associated trauma or arrange transfer to a better surgical setting do not appear to worsen outcomes [34].

Evidence to guide definitive treatment of tibial fractures continues to evolve. Depending upon the location and severity of the fracture and available resources, treatment options may include non-weight-bearing with long leg casting or cast bracing, intramedullary nailing, open reduction and internal fixation, and circumferential external fixation. The choice of treatment affects the return to activity, and so complication and infection rates should be discussed with patients as part of the decision-making process [35,36]. Both surgical and nonsurgical approaches are used in peri-prosthetic tibial fractures depending on the pattern of injury [15].

As the risk of knee osteoarthritis and long-term disability following tibial fracture is relatively high, appropriate physical therapy and home exercise programs are advisable. Physical therapy may be underutilized following tibial fracture: in a study of insurance claims in the United States, one-third of patients did not attend outpatient physical therapy [37].

ADDITIONAL INFORMATION — Several UpToDate topics provide additional information about fractures, including the physiology of fracture healing, how to describe radiographs of fractures to consultants, acute and definitive fracture care (including how to make a cast), and the complications associated with fractures. These topics can be accessed using the links below:

(See "General principles of fracture management: Bone healing and fracture description".)

(See "General principles of fracture management: Fracture patterns and description in children".)

(See "General principles of definitive fracture management".)

(See "General principles of acute fracture management".)

(See "General principles of fracture management: Early and late complications".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Lower extremity (excluding hip) fractures in adults" and "Society guideline links: Acute pain management".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)

Basics topics (see "Patient education: Lower leg fracture (The Basics)" and "Patient education: Fractures (The Basics)" and "Patient education: How to care for your cast (The Basics)")

Beyond the Basics topic (see "Patient education: Cast and splint care (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Epidemiology – Closed tibial shaft fractures are the most common long-bone fractures. Tibial fractures occur in both high energy trauma, such as motor vehicle, downhill skiing, and cycling accidents, and low energy trauma, such as falls, contact sports, distance running, and other endurance or repetitive impact activities. Injuries caused by high energy trauma are more likely to involve complex fractures and complications. (See 'Epidemiology' above.)

Classification with links to related topics – Fractures of the tibia in adults are classified clinically based upon their location and type (see 'Classification' above). Each type is discussed in detail separately:

Proximal tibial fractures (see "Proximal tibial fractures in adults" and "Proximal tibial fractures in children")

Tibial shaft fractures (see "Tibial shaft fractures in adults" and "Tibial and fibular shaft fractures in children")

Distal tibial and medial malleolus fractures (see "Ankle fractures in adults" and "Ankle fractures in children")

Stress fractures (see "Stress fractures of the tibia and fibula" and "Overview of stress fractures")

Physical examination – A careful examination of the injured extremity includes an assessment of neurovascular function, leg deformity, skin integrity, and joint stability (if possible). (See 'Examination' above.)

Complications – Tibial fractures, particularly open or complex injuries, often develop complications, which may include chronic pain, acute compartment syndrome, neurovascular injuries, infection, nonunion, and fat emboli. Tibial plateau fractures may lead to knee osteoarthritis and ultimately the need for total knee replacement. (See 'Complications' above.)

Diagnostic imaging – Plain film radiographs are the basic means to assess tibial shaft fractures. Initial studies include anteroposterior (AP) and lateral views. Ultrasound may be used as an initial screening diagnostic evaluation by experienced clinicians. (See 'Diagnostic imaging' above.)

Initial management – Initial management of tibial fractures includes immobilization, analgesics, elevation, and ice. (See 'Management' above.)

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References

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