tibia

CHAPTER 11 The tibia

Common Causes of Pain in the Anterior Aspect of the Lower Leg

Note: Knock-knee and bow-leg deformities are included with the knee joint.

Osteitis of the Tibia

Osteitis of the tibia occurs predominantly in children, with or without a history of previous trauma or sore throat. Pain is intense, tenderness is acute and initially well localised over the metaphyseal area, and there is inability to weightbear. There is systemic upset with fever and tachycardia, and often (but not always) a polymorph leukocytosis. Admission and investigation with repeated blood cultures is essential. Radiographs of the tibia are initially normal, often with a lag of 2 weeks or more before any abnormality is detectable (although MRI and CT scans may be affected somewhat earlier). The ESR and C-reactive protein are usually elevated at an early date. When this condition is suspected, it is customary to administer a broad-spectrum antibiotic effective against the penicillin-resistant Staphylococcus, and in large doses to achieve adequate bone levels, prior to the results of blood culture. Splintage of the affected area is often helpful, and in proven cases antibiotics are administered for 4 weeks. Surgical drainage is seldom necessary and is avoided unless failure of response to antibiotics, profound toxicity and spread of the infection make it essential.

Cellulitis from insect stings, small wounds and abrasions and hair follicle infections may sometimes cause difficulty in diagnosis.

Low-grade osteitis of the tibia (Brodie’s abscess) may give rise to chronic upper tibial pain.

Bone Tumours

The tibia is a common site for many primary bone tumours, so that radiographic examination of the tibia is essential in any case of undiagnosed leg pain.

Anterior Tibial Compartment Syndrome

This is a common complication of fractures of the tibial shaft, but may follow a period of intense lower limb activity: hence it is common in athletes. It gives rise to pain in the front of the leg. This is due to oedema and swelling within the confines of the anterior compartment, which lead in turn to ischaemia in the anterior tibial muscles. In severe cases where swelling is progressive there may eventually be muscle necrosis. The leg is diffusely swollen and tender, and the skin has a glossy appearance. Tibialis anterior and extensor hallucis longus are first affected, with weakness and later inability to extend the ankle and great toe. The dorsalis pedis pulse may be absent, and there may be sensory loss in the first web space due to ischaemic changes in the deep peroneal nerve. In high-risk and suspect cases compartment pressure monitoring is advisable. In severe cases immediate surgical decompression of the anterior tibial compartment is essential if muscle necrosis is to be avoided.

Stress Fracture of the Tibia

In this condition the onset of leg pain may be sudden or less acute. There is sharply localised bone tenderness and overlying oedema. Radiographic demonstration of the hairline fracture may be difficult, and with persistent pain repeated examination is essential. A radioisotope bone scan may be helpful in diagnosing a local ‘hot spot’. In many cases the diagnosis may not be firmly established until a small area of tell-tale callus is showing. The condition is also common in Paget’s disease where, of course, there is an easily identifiable radiological abnormality.

Medial Tibial Syndrome/Shin Splints

In this condition pain on the medial side of the shin in sportsmen may be severe, and there is usually tenderness along the posteromedial border of the lower part of the tibia. In a number of cases the symptoms may arise from stress fractures of the tibia, but in others the pathology is less clear. (Other causes include compartment syndromes, fascial hernias, interosseous membrane tears, periosteal avulsions, tendinitis, muscle sprains and periostitis.) Where symptoms are of a chronic nature, and fracture has been excluded, division of the attachments of the crural fascia may give relief.

Tabes Dorsalis

Severe pain in the shins (lightning pains) is common in tabes dorsalis. Usually other criteria are present (e.g. Argyll–Robertson pupils) and serological tests will confirm the diagnosis.

Common Causes of Pain in the Posterior Aspect of the Lower Leg

1. ‘Ruptured plantaris tendon’. Sudden pain in the calf during activity with diffuse tenderness in the upper and outer part of the calf is now regarded as being due to tearing of muscle fibres of soleus or gastrocnemius, rather than injury to the plantaris muscle whose name is attached to the condition. Pain often persists for several months and a period of plaster immobilisation is often helpful in giving relief in the acute initial stages.

2. Thrombophlebitis. Thrombosis in the superficial veins of the calf with local inflammatory changes is a common cause of recurrent calf pain, and the presence of tenderness and other inflammatory signs along the course of a calf vein make diagnosis easy. Thrombosis in the deep veins is often silent, and its importance in the postoperative situation is well known.

3. Other causes of posterior leg pain. Pain in the calf is common in patients suffering from prolapsed intervertebral discs. Claudication pain is a feature of vascular insufficiency and spinal stenosis. Lesions of the foot and ankle that lead to protective muscle spasm on standing and walking frequently give rise to marked calf and leg pain.

Deformities of the Tibia

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Tags: Clinical Orthopaedic Examination

Jun 5, 2016 | Posted by admin in ORTHOPEDIC | Comments Off

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