Fractures of Leg

By: Mustafa Al-Obaidy

Anatomy
1. Bones:
tibia fibula

omy of leg

2- Blood vessels :
POPLITEAL A. -tibial a.
ant.&post

-fibular a.

3- Nerves :
COMMON FIBULAR N.

deep fibular n. superficial fibular n.

TIBIAL N. (posteriorly)

4- Muscles: for ankle action;

Dorsflexion -tibialis ant. -tibialis post. -extensor hallucis longus -extensor digitorum longus Planter flexion -gastocnemius -plantaris -soleus

TIBIAL PLATEAU FRACTURES

Mechanism of injury Fractures of the tibial plateau are caused by a varus or valgus force combined with axial loading (a pure valgus force is more likely to rupture the ligaments). This is sometimes the result of a car striking a pedestrian (hence the term bumper fracture); more often it is due to a fall from a height in which the knee is forced into valgus or varus. The tibial condyle is crushed or split by the opposing femoral condyle, which remains intact.

TIBIAL PLATEAU FRACTURES: Classification

Type A: Extra-articular 1- Avulsion Fx 2- simple Fx Type B: partial articular 1- split Fx 2- depressed Fx Type C: Complete articular 1- Articular simple Fx 2- Articular intercondylar Fx 3- Multi fragment

3-Multifragment Fx

3- combined split Fx

TIBIAL PLATEAU FRACTURES

Pathological anatomy A useful classification is that of Schatzker :

TIBIAL PLATEAU FRACTURES

Clinical features The knee is swollen and may be deformed. Bruising is usually extensive and the tissues feel doughy because of haemarthrosis. Examining the knee may suggest medial or lateral instability but this is usually painful and adds little to the x-ray diagnosis. More importantly, the leg and foot should be carefully examined for signs of vascular or neurological injury. Traction injury of the peroneal or tibial nerves is not uncommon and it is important to establish whether this is present at the time of admission and before operation.

TIBIAL PLATEAU FRACTURES

Imaging Anteroposterior, lateral and oblique x-rays will usually show the fracture, but the amount of comminution or plateau depression may not be appreciated without computer tomography (CT).

TIBIAL PLATEAU FRACTURES : Treatment

Type 1 fractures Undisplaced type 1 fractures can be treated conservatively. The haemarthrosis is aspirated and a compression bandage is applied. The limb is rested on a continuous passive motion (CPM) machine and knee movements are begun. As soon as the acute pain and swelling have subsided (usually within 1 week), a hinged castbrace is fitted and the patient is allowed up; however, weightbearing is not allowed for another 3 weeks. Thereafter, partial weightbearing is permitted but full weightbearing is delayed until the fracture has healed (usually around 8 weeks). Displaced fractures should be treated by open reduction and internal fixation. The condylar surface is examined and trapped fragments are released or removed. The aim is for an accurate reduction; two lag screws or a buttress plate are usually sufficient for fixation.

TIBIAL PLATEAU FRACTURES : Treatment

Type 2 fractures If depression is slight (less than 5 mm) and the knee is not unstable, or if the patient is old and frail or osteoporotic, the fracture is treated closed. After aspiration and compression bandaging, skeletal traction is applied; the knee is then flexed and extended several times to mould the upper tibia on the opposing femoral condyle. As soon as the fracture is sticky (usually at 34 weeks), the traction pin is removed, a hinged cast-brace is applied and the patient is allowed up on crutches. Full weightbearing is deferred for another 6 weeks.

TIBIAL PLATEAU FRACTURES : Treatment

In younger patients, and more so in those with a central depression of more than 5 mm, open reduction with elevation of the plateau and internal fixation is often preferred. Bone graft or a similar substitute is needed to support the elevated fragments. Small 3.5 mm screws placed in parallel just beneath the subchondral bone hold up the elevated fragments well (raft screws).

TIBIAL PLATEAU FRACTURES : Treatment

Type 3 fractures The principles of treatment are similar to those applying to type 2 fractures. Type 4 fracture of the medial condyle:The principles of treatment are the same as for type 2 fractures of the lateral plateau. Types 5 and 6 fractures: A simple bicondylar fracture, in an elderly patient, can often be reduced by traction and the patient then treated as for a type 2 injury some residual angulation may follow

Types 5 and 6 fractures: CONT.

New strategies involve spanning the knee joint with an external fixator, thereby providing provisional stability, and waiting for the soft-tissue conditions to improve sometimes as long as 23 weeks.Then buttress plates placed in a submuscular fashion are used .

Complications
1- Compartment syndrome With closed types 4 and 5 2- Joint stiffness 3- Deformity: Some residual valgus or varus deformity is
quite common

4- Osteoarthritis

FRACTURE OF PROXIMAL END OF FIBULA

Fracture of the proximal end of the fibula may be caused by either direct injury or an indirect twisting injury of the lower limb. Beware: an isolated fracture of the proximal fibula is rare; it may be merely the most visible part of a more extensive rotational injury of the leg involving a serious fracture or ligament injury of the ankle or a major disruption of the posterolateral corner of the knee. Always x-ray the ankle and check for knee stability! The fracture itself is of little consequence and it requires no treatment. However, associated injuries are frequent and they may result in prolonged disability Associated injuries 1) the ankle injury (2) peroneal nerve injury; (3) Lateral collateral ligament injury

FRACTURES OF TIBIA AND FIBULA

Because of its subcutaneous position, the tibia is more commonly fractured, and more often sustains an open fracture, than any other long bone. Mechanism of injury Indirect injury is usually low energy; with a spiral or long oblique fracture one of the bone fragments may pierce the skin from within. Direct injury crushes or splits the skin over the fracture; this is usually a high-energy injury and the most common cause is a motorcycle accident. Pathological anatomy The behaviour of these injuries and therefore the choice of treatment depends on the following factors: 1. The state of the soft tissues 2. The severity of the bone injury 3. Stability of the fracture 4. Degree of contamination

FRACTURES OF TIBIA AND FIBULA

Clinical features The limb should be carefully examined for signs of soft-tissue damage: bruising, severe swelling, crushing or tenting of the skin, an open wound, circulatorychanges, weak or absent pulses, diminution or loss of sensation and inability to move the toes. Any deformity should be noted before splinting the limb. Always be on the alert for signs of an impending compartment syndrome. X-ray The entire length of the tibia and fibula, as well as the knee and ankle joints, must be seen. The type of fracture, its level and the degree of angulation and displacement are recorded. Rotational deformity can be gauged by comparing the width of the tibio-fibular interspace above and below the fracture.

Management
LOW-ENERGY FRACTURES If the fracture is undisplaced or minimally displaced, a full-length cast from upper thigh to metatarsal necks is applied with the knee slightly flexed and the ankle at a right angle. Displacement of the fibular fracture, unless it involves the ankle joint, is unimportant and can be ignored.

After 2 weeks the position is checked by x-ray. A change from an above- to a below-theknee cast is possible around 46 weeks, when the fracture becomes sticky. The cast is retained (or renewed if it becomes loose) until the fracture unites, which is around 8 weeks in children but seldom under 12 weeks in adults.

Management: CONT.
Indications for skeletal fixation:many surgeons would hold that unstable fractures are better treated by skeletal fixation from the outset. Closed intramedullary nailing This is the method of choice for internal fixation. The fracture is reduced under x-ray control and image intensification. For diaphyseal fractures, union can be expected in over 95 per cent of cases. However, the method is less suitable for fractures near the bone ends. Plate fixation Plating is best for metaphyseal fractures that are unsuitable for nailing. It is also sometimes used for unstable tibial shaft fractures in children. External fixation This is an alternative to closed nailing; it avoids exposure of the fracture site and allows further adjustments to be made if this should be needed.

Management: CONT.
HIGH-ENERGY FRACTURES A suitable mantra for the treatment of open tibial fractures is: antibiotics debridement stabilization prompt soft-tissue cover rehabilitation. It is important to stabilize the fracture. For Gustilo I, II and IIIA injuries, locked intramedullary nailing is permissible as definitive wound cover is usually possible at the time of debridement. For more severe grades of open tibial fracture, internal fixation should be performed only at the time of definitive soft tissue cover. If this is not feasible at the time of primary debridement, the fracture should be stabilized temporarily with a spanning external fixator. Exchange of the fixator for an intramedullary nail can be done at the point when definitive soft tissue cover is carried out ideally within 5 days of the injury. Alternatively, definitive fracture management can be carried out using external fixation.

complications
1- VASCULAR INJURY 2-COMPARTMENT SYNDROME 3- INFECTION 4-Malunion 5- Delayed union 6- Non-union: Hypertrophic non-union can be treated by intra - medullary nailing (or exchange nailing) or compression plating. Atrophic non-union needs bone grafting in addition. If the fibula has united, a small segment should be excised so as to permit compression of the tibial fragments. Intractable cases will respond to nothing except radical Ilizarov techniques 7-Joint stiffness 8- Osteoporosis 9- Regional complex pain syndrome 10- Deep vein thrombosis

FRACTURE OF TIBIA ALONE

A direct injury, such as a kick or blow with a club, may cause a transverse or slightly oblique fracture of the tibia alone at the site of impact. In children, the fracture is usually caused by an indirect injury; the fibula is intact or may show plastic deformation. Local bruising and swelling are usually evident, but knee and ankle movements are possible. Transverse or slightly oblique fractures are easy to spot on x-ray even if displacement is slight. The child with a spiral fracture may be able to stand on the leg, and as the fracture may be almost invisible in an anteroposterior film, the injury can be missed unless two views are obtained Treatment If the fracture is displaced, reduction should be attempted. An above-knee plaster is applied. A fracture of the tibia alone takes just as long to unite as if both bones were broken, so at least 12 weeks is needed for consolidation and sometimes much longer. Complications Delayed union

FRACTURE OF FIBULA ALONE

Isolated spiral fractures should be regarded with suspicion: they are often associated with other injuries and it is wise to obtain x-rays of the ankle and knee. A transverse or short oblique fracture may be due to a direct blow. There is local tenderness, but the patient is able to stand and to move the knee and ankle. Pain can usually be controlled by analgesic medication and the patient will need no more than an elastic bandage, from knee to toes, for 2 or 3 weeks. In the occasional case where pain is more severe, a below-knee walking cast may be necessary.

Pathological fractures sometimes occur in patients with osteomyelitis or bone tumours. Treatment is that of the underlying condition.

FATIGUE FRACTURES
Repetitive stress may cause a fatigue fracture of the tibia (usually in the upper half of the bone) or the fibula (most often in the lower third). This injury is seen in army recruits, mountaineers, runners and ballet dancers, who complain of pain in the leg. There is local tenderness and slight swelling. The condition may be mistaken for a chronic compartment syndrome. X-ray For the first 4 weeks there may be nothing abnormal about the x-ray, but a bone scan shows increased activity. After some weeks periosteal new bone may be seen, with a small transverse defect in the cortex. There is a danger that these appearances may be mistaken for those of an osteosarcoma, with tragic consequences. If the diagnosis of stress fracture is kept in mind, such mistakes are unlikely. Treatment The patient is told to avoid the stressful activity. Usually after 810 weeks the symptoms settle down.