Fracture of the Lower Tibia
The tibia is one of the main supporting long bones in the lower extremity. It is part of the knee joint, the lower leg, and the ankle joint and can be fracture with a direct blow to the tibia, a fall that compresses the tibia, or a motor vehicle accident in which the tibia receives a high velocity force applied to it during the crash.
Because the tibia is a long bone, fractures can occur near the knee, along the shaft of the bone and at the far end of the bone, near the ankle. Each of these fractures are unique and require different sorts of treatment.
When caring for a tibia fracture, the orthopedic doctor needs to look into the following factors to know how to treat the break in the bone:
• Whether the nearby fibula is fractured
• Whether the fracture is in its proper place or has been displaced
• Where the fracture is located
• Soft tissue injuries near the fracture
• The overall patient health
• Whether the fracture is open (bone is exposed) or closed
Doctors classify tibia fractures into three separate categories. These are based on where on the tibia the bone has become broken. They can also divide tibial fractures into “open” or “closed” fractures. Some closed fractures can be treated with casting alone, while open fractures are at an extremely high risk of bony infection so that they almost always need to be surgically debrided and repaired in the operating room with antibiotics used to prevent infection.
Tibial Shaft Fractures
Most tibial fractures occur along the shaft or middle part of the bone. If the fracture is closed, it can be treated with a long leg cast and minimal weight bearing until the fracture fragments seal themselves together. Sometimes, closed reduction is necessary, in which the bones are placed in their proper alignment in the operating room, x-rayed to check for proper placement, and casted in place with a long leg cast.
Tibial Plateau Fractures
These are fractures to the most proximal part of the tibia, just beneath the knee. Because the knee joint itself can become part of this fracture, special care must be taken to repair the bone as knee arthritis is a common complication of these types of fractures.
Tibial Plafond Fractures
These are fractures of the far distal end of the tibia near the ankle joint. They can be associated with other fractures related to the ankle, including distal fibular fractures. Because the ankle joint may be involved, special care is necessary in order to reduce the risk of later developing arthritic changes in the ankle joint. There can be a great deal of soft tissue injury with these fractures so that ligaments and tendons can be injured along with the bone.
Treatment of Tibial Shaft Fractures
Tibial shaft fractures can happen following a fall from a great height, a sporting injury or a motor vehicle accident. Depending on the alignment of the broken bone and other nearby injuries, the fracture can be treated using a cast alone or surgery to repair the bone.
Casting is done whenever the bony fragments are aligned in their proper position. The cast used to treat this type of fracture must involve both the ankle and knee joints so that the cast extends from the toes up to the middle part of the femur in the upper leg. As long as the alignment is good, these fractures heal themselves quite well so that, after 6-12 weeks, the cast can be removed and the patient can begin the process of rehabilitation. The muscles tend to atrophy or weaken while the cast is in place so physical therapy is necessary to teach the patient ways to walk again without the cast.
If the bone is out of place or angulated, several surgical options exist. The first is called “intramedullary rod placement”, in which a rod is placed through the middle of the bone (where the bone marrow is) so that the tibia is straight and cannot angulate. The rods are held in place by screws that are located above and below the site of the fracture. The rod and screws can be permanently placed in the tibia or can be removed later. The major complication of rod placement is infection in the bone, although arthritis can be another complication.
Less commonly, the tibia can be held in place using plates and screws that align the fracture and keep it in place until it heals. This is especially the choice of surgery when the fracture is too near a joint. Another common surgery is called an “external fixator” placement. External fixators are used when the fracture is open or particularly comminuted (broken in several places). The fixator is attached to the bone from the outside and kept in place until the bone heals properly.
Treatment of Tibial Plateau Fractures
These fractures are treated as knee fractures because they often include part of the knee joint in the fracture. Knee arthritis is a common complication of these types of fractures so they are often treated surgically so as to align the joint surfaces as much as possible in their original position. Even with the best treatment, arthritis is still a possibility.
Tibial plateau fractures tend to take a long time to heal, especially without surgical intervention. The patient is casted for up to three months before they can remove the cast and begin walking again. These are injuries that bear close watching because they can become displaced during the healing process so that surgery is needed to put the bones back into position and keep them there with surgical hardware.
If the tibial plateau fracture is out of place, there are several kinds of surgery that can help this problem. Most involve the use of plates and screws to keep the bones aligned. Sometimes just a couple of screws can hold the fracture together, while at other times, a plate with screws to hold the plate against the fracture is necessary to achieve permanent alignment of the fracture.
It can take several months to heal from a tibial plateau fracture. Weight bearing is generally not allowed during healing because it can damage the joint during healing. The patient may need crutches with no weight bearing on the affected leg for around 3 months.
Treatment of a Tibial Plafond Fracture
This fracture involves damage to the ankle joint so that, even with great treatment, arthritis of the ankle is possible. There is often a great deal of swelling due to damage to the soft tissue structures around the ankle. Surgery may have to be delayed until the swelling goes down and the soft tissue injuries have healed themselves. Doctors usually keep the ankle immobilized using a splint, cast or external fixation device. The external fixator device is often preferred so that the doctor can continuously monitor the swelling and soft tissue injuries.
When the swelling has gone down and the soft tissue injuries have healed, the doctor may use casting to further keep the fracture pieces in place for several weeks until healing occurs. Surgery with external fixators is used in open fractures so they can be monitored for signs of infection. External and internal fixation devices can be used to keep the fracture fragments in place until healing occurs. If the ankle fracture is particularly severe, the doctor sometimes just fuses the ankle to avoid the arthritic complications that are likely following a severe tibial plafond fracture.
Like any leg fracture, it can take up to three months for enough healing to occur before the patient can bear weight on the ankle and begin the process of physical therapy and rehabilitation to gain a normal gait with a minimum amount of pain.
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