The views and opinions expressed in this chapter are the those of the authors and are not necessarily representative of the official policy or views of the Department of the Navy, the Department of Defense, nor the U.S. Government.
Introduction
- Lance E. LeClere, MD, LCDR, MC, USN
- Robert M. Lucas, MD
Epidemiology
- •
Tibial shaft fractures are the most common long bone fracture treated by orthopedic surgeons.
- •
Tibial shaft fractures occur at a rate of 26 per 100,000 persons per year.
- •
The average age of patients that sustain a tibial shaft fracture is approximately 37 years.
- •
In general, there is a bimodal age distribution for tibial shaft fractures. Most commonly, tibial shaft fractures occur in adolescents and are the result of high energy trauma. A second peak in incidence may occur later in life owing to osteoporosis.
- •
Tibial shaft fractures are more common in men, at a ratio of approximately 2 : 1.
- •
In general, tibial shaft fractures are rarely the result of a sports injury. Most tibial shaft fractures are the result of high-energy mechanisms. High-impact sports and collision sports such as football, rugby, and martial arts are just a few examples. However, some low-energy sports injuries can also cause tibial shaft fractures. This is usually owing to torque and rotational forces on the leg, such as in downhill skiing or gymnastics.
- •
Tibial shaft fractures can occur via compression, tension, or rotational forces, direct impact, or combination of these forces. In general, tibial shaft fractures sustained during sport are from high-energy, direct impact mechanisms or from low-energy injuries that occur via rotational forces to the leg while the foot is planted on the ground. In the case of downhill skiing, often bindings do not release and a rotational force about the leg results in a spiral tibial fracture ( Figure 37-1 ). Soccer players commonly sustain tibial shaft fractures from direct impact and account for up to 80% of sports-related tibial shaft fractures. These fractures are usually transverse or short oblique in nature ( Figure 37-2 ).
FIGURE 37-1
An anteroposterior ( A ) and lateral ( B ) radiograph of a spiral tibial shaft fracture. These types of fractures are most typically seen as the result of a low-energy, rotational mechanism. One example is a skiing injury.
FIGURE 37-2
An anteroposterior ( A ) and lateral ( B ) radiograph of a transverse tibial shaft fracture. This transverse pattern is often seen in a low-energy direct-impact type of injury, such as in soccer.
Pathophysiology
Intrinsic Factors
- •
There are no specific anatomical, developmental, or neuromuscular factors that specifically predispose an athlete to tibial shaft fractures.
- •
Metabolic and pathological conditions of the bone such as osteopenia, osteoporosis, infection, and neoplasms may impair bone quality and predispose athletes to tibial shaft fractures.
Extrinsic Factors
- •
Extrinsic factors that may predispose athletes to tibial shaft fractures are footwear or equipment that prevents the foot from pivoting or rotating with the leg. For example, skiers who sustained tibial shaft fractures have been found to have binding release values that are higher than noninjured skiers, and improvements in the design of ski bindings that allow for release of skis more readily have decreased the incidence of ski-related tibial shaft fractures.
- •
Failure to wear proper equipment may leave the athlete more prone to fracture from direct impact. Lack of proper protective shin guards in soccer may predispose players to tibial shaft fractures.
Traumatic Factors
- •
High-energy trauma is the leading cause of tibial shaft fractures. Usually this is a result of direct impact, such as a tackle in football or getting kicked in soccer.
- •
Fractures that result from low-energy trauma are usually the result of rotational injuries, such as skiing.
Classic Pathological Findings
- •
Classic findings include pain, soft tissue swelling, gross deformity of the leg on visual inspection, palpable fracture, or even an open fracture.
- •
Plain radiographs of the tibia and fibula and anteroposterior and lateral planes will confirm diagnosis and allow for fracture classification.
Clinical Presentation
History
- •
Typically the patient will feel and/or hear a “pop” or “crack” and have the immediate onset of severe pain and inability to bear weight.
- •
It is important to establish the mechanism of injury because higher-energy injuries may lead to more significant soft tissue damage, swelling, and higher risk of developing compartment syndrome.
- •
Low-energy injuries or the presence of preceding pain may be related to underlying intrinsic disorders of the bone such as osteoporosis, osteopenia, infection or benign or malignant neoplasms.
Physical Examination
Abnormal Findings
- •
Tenderness to palpation at fracture site
- •
Gross deformity on visual inspection
- •
Significant soft tissue swelling
- •
Overlying skin or soft tissue damage may be present, such as blistering of the skin or open wounds
- •
Higher incidence of open fractures caused by limited soft tissue coverage
- •
Suspicion for possible compartment syndrome should arise when there is pain out of proportion to examination, firm swollen soft tissues, pain with passive stretch of ankle or toes and paresthesias, especially in the deep and superficial peroneal nerve distributions. Pallor, pulselessness, paralysis, and a cool extremity or late signs and concern for significant soft tissue necrosis.
Pertinent Normal Findings
- •
Nontender along tibial shaft
- •
No gross deformity of the leg
- •
No crepitus or motion over the area of maximal tenderness
Imaging
- •
Anteroposterior and lateral plain radiographs will confirm diagnosis and assist in fracture classification. It is important to include imaging of the knee and ankle.
- •
The quality of the bone should be taken into account when evaluating plain film x-rays to assess for metabolic, pathological, or infectious conditions and evidence of any previous fractures, which may indicate an underlying disorder.
- •
Rarely computed tomography (CT) or magnetic resonance imaging (MRI) is required for diagnosis. CT may be helpful in determining whether fracture lines extend into articular surfaces. Heightened concern for intra-articular fractures should arise with spiral fractures in the proximal and distal third of the tibia.
- •
MRI may be useful in further evaluation in bone and soft tissues if a pathological fracture is suspected.
Differential Diagnosis
- •
Contusion: No gross deformity will be present. Radiographs will be normal. The patient may or may not be able to bear weight on the affected extremity, although if the patient is able to bear weight the presence of a fracture is significantly less likely.
Treatment
Nonoperative Management
- •
Cast immobilization ( Figure 37-3 ) with long leg casting or patellar tendon bearing casting.
FIGURE 37-3
A, An example of a long leg cast used for treatment of a tibial shaft fracture. B, An example of a patellar tendon-bearing cast. Often a long leg cast is transitioned to a patellar tendon-bearing cast after initial healing. A patellar tendon cast allows for weight bearing by the patient.
- •
Early cast immobilization with transition to Sarmiento functional bracing ( Figure 37-4 )
FIGURE 37-4
A,B, A Sarmiento functional brace used for nonoperative treatment of a tibial shaft fracture.
Guidelines for Choosing Among Nonoperative Treatments
- •
Acceptable alignment for nonoperative treatment generally include :
- •
Less than 1 cm shortening
- •
5° valgus, 0° varus
- •
10° procurvatum or recurvatum
- •
10° external rotation, 0° internal rotation
- •
- •
Patellar tendon bearing casts and Sarmiento functional bracing are chosen based primarily on patient and treating physician preference. Large series of functional bracing show excellent healing rates and alignment in properly selected patients.
- •
Patients who are in poor general health, have significant co-morbidities, or a low preinjury motility status.
Surgical Indications
- •
Open fractures (strong relative)
- •
Neurovascular injury (strong relative)
- •
Failure to achieve acceptable alignment in cast/brace (relative)
- •
Patient preference (relative)
- •
Tibial fracture with intact fibula (relative)
- •
Extensive bone loss (relative)
- •
Failure to achieve acceptable closed reduction—see preceding criteria (strong relative)
- •
Polytrauma (relative)
- •
Desire for early weight bearing (relative)
Aspects of History, Demographics, or Exam Findings That Affect Choice of Treatment
- •
Patients who cannot tolerate prolonged cast immobilization or will be poorly compliant with bracing are more suitable candidates for surgical treatment.
- •
Patients with open fractures or neurovascular damage tend to be treated surgically, although open fracture is not necessarily an absolute indication.
- •
Surgical treatment has shown lower rates of nonunion, delayed union, and faster time to union.
- •
In general, patients can begin weight bearing earlier with surgical treatment if intramedullary nails are used. Therefore patients who wish to return to full weight bearing or prefer not to be casted are more suitable candidates for surgery.
- •
Surgeons in North America are more likely to used reamed intramedullary nails for both open and closed tibia shaft fractures.
Aspects of Clinical Decision Making When Surgery Is Indicated
- •
Most midshaft tibia fractures are treated with intramedullary nailing ( Figure 37-5 ). More proximal or distal fractures or those with severe comminution may be treated with open reduction and internal fixation with plates and screws.
FIGURE 37-5
An anteroposterior ( A ) and lateral ( B ) radiograph of a tibial shaft fracture treated with an intramedullary nail.
- •
For intramedullary nailing, a transpatellar or peri-patellar tendon approach should be considered. Although the incidence of anterior knee pain is high after intramedullary nailing (67%), there appears to be no advantage of one approach over the other in its prevention.
- •
Open fractures may be initially treated with external fixation, followed by conversion to intramedullary nailing within 2 weeks; however, they may also be initially treated with either reamed or undreamed intramedullary nailing.
- •
Patients who develop compartment syndrome require emergent fasciotomies.
Evidence
Multiple Choice Questions
- QUESTION 1.
Tibial fractures are most commonly seen in which age group?
- A.
5 to 10 years old
- B.
14 to 20 years old
- C.
30 to 40 years old
- D.
Over 80 years old
- A.
- QUESTION 2.
The appropriate treatment for tibial shaft fractures is:
- A.
Casting
- B.
Bracing
- C.
Intramedullary nails
- D.
All of the above
- A.
- QUESTION 3.
Which of the following tibial fracture patterns is most commonly seen in a downhill skier?
- A.
Transverse
- B.
Spiral
- C.
Comminuted
- D.
Open
- A.
Answer Key
- QUESTION 1.
Correct answer: B (see Epidemiology )
- QUESTION 2.
Correct answer: D (see Treatment )
- QUESTION 3.
Correct answer: B (see Epidemiology )
Nonoperative Rehabilitation of Tibial Shaft Fractures
- LT Katelyn H. McCormick, DPT, LT, MSC, USN
- Lance E. LeClere, MD
- •
Period of non/partial weight bearing for bone callus formation
- •
Restore full ankle/knee range of motion
- •
Once full range of motion is established progress to strength training (open kinetic chain)
- •
Progress weight bearing status, closed kinetic chain strengthening, balance training
- •
Plyometric training and sport-specific training
Phase I (weeks 1 to 4)
Protection
- •
If nonsurgical options are selected, the patient will be immobilized with the use of a cast or brace (American Academy of Orthopedic Surgeons guidelines), with possible use of crutches during this time of non–weight-bearing status.
| PHASE I (weeks 1 to 4) | PHASE II (weeks 4 to 12) | PHASE III (weeks 12 to 36) |
|---|---|---|
|
|
|
Management of Pain and Swelling
- •
Nonsteroidal antiinflammatory drugs (NSAIDs)
- •
Ice
- •
Compression
Techniques for Progressive Increase in Range of Motion
- •
Patient will be most likely in a hard cast for approximately 4 to 6 weeks for healing and hard callus bone formation.
- •
X-rays should be ordered every 1 to 2 weeks for first 4 weeks to ensure there is no displacement of fracture per AAOS guidelines.
Manual Therapy Techniques
- •
None at this time because the involved area is immobilized and to promote bone healing
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
If the patient has a below-knee cast or brace, hamstring stretching is important to facilitate normal gait once cast/brace is discharged/removed.
Other Therapeutic Exercises
- •
During the acute phase while the patient is immobilized, concentrate on upper extremity and hip strengthening while maintaining non–weight-bearing status, using core strength/stability training.
Activation of Primary Muscles Involved
- •
Activation of gastrocnemius, soleus, fibularis, and tibialis musculature may be limited due to immobilization during initial phase.
- •
Depending on the type of casting or bracing, during the initial phase gentle isometrics may be the only way to activate the musculature mentioned in the preceding.
Techniques to Increase Muscle Strength, Power, and Endurance
- •
While the patient is immobilized in either a cast or brace, lower extremity therapeutic exercises should focus on other lower extremity strengthening to include:
- •
Hip abduction
- •
Gluteal strengthening
- •
Straight leg raises
- •
Quadriceps and hamstring strengthening
- •
- •
The patient will most likely have to perform open kinetic chain exercises at this time secondary to the patient’s non–weight-bearing status.
Milestones for Progression to the Next Phase
- •
Radiographic confirmation of healed fracture site before removal of cast
- •
Decreased pain
Phase II (weeks 4 to 12)
According to Wolff’s law, increased weight-bearing activities can help to determine the formation of bone.
Protection
- •
If the patient demonstrates an antalgic gait, patient may be issued a CAM walking boot or crutches may be used to decrease forces through the injured area.
Management of Pain and Swelling
- •
Ice
- •
Interferential current using electrical stimulation to decrease any pain or swelling following treatment
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
Manual techniques will be determined following an assessment of the individual’s foot and ankle to include talocrural, subtalar, and first metatarsophalangeal joint mobility.
- •
Specific techniques will include anteroposterior, posteroanterior, and distraction mobilizations for improving ROM and mobility deficits.
- •
Mobilizations will start with Grade 1 to 2 and advance to Grades 3 to 4 as the patient tolerates.
Soft Tissue Techniques
- •
Soft tissue mobilization or massage to the gastrocnemius and soleus complex for increasing flexibility and ankle dorsiflexion range of motion, following a period of immobilization.
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Patient should be instructed in how to stretch the gastrocnemius and soleus muscle groups if he or she has limitations in dorsiflexion range of motion.
- •
Stretching should be continued until normal and symmetrical dorsiflexion ROM is achieved bilaterally. Low-load, long-duration stretching is stretching that takes place multiple times per day (two to three times), for longer hold periods (30 to 60 seconds), and increased repetitions per set (5 to 10 repetitions).
- •
Active stretching is to be continued once normal ROM is achieved (20- to 30-second hold, two to three sets, one to two times per day).
Other Therapeutic Exercises
- •
Total lower extremity strengthening should be included as a part of the patient’s program to include hip abduction, gluteals, quadriceps, and hamstring musculature.
- •
Core stability/strengthening exercises such as front and side planks should be incorporated into the strengthening program.
- •
Total lower extremity strengthening should include lower extremity strengthening to include the hip and thigh musculatures.
- •
Aquatic therapy/pool based exercise is a beneficial way for progressing weight bearing while performing gross lower extremity ROM and strengthening.
- •
Initially following removal of cast or brace, instruct the patient in AROM of the ankle to include ankle pumps for improving active dorsiflexion and plantarflexion ROM and pumping out swelling from the distal joints. The patient should also be instructed in ankle circles (clockwise and counterclockwise) for gross ankle range of motion and decreasing swelling of the distal joint segments.
- •
Ankle isometrics in all directions if initial AROM of the ankle is painful.
Activation of Primary Muscles Involved
- •
With a tibial shaft fracture and following a period of immobilization, strengthening to all compartments of the distal lower extremity will need to include:
- •
Anterior compartment: ankle dorsiflexors (tibialis anterior, extensor digitorum longus, extensor hallucis longus and fibularis tertius)
- •
Lateral compartment: ankle everters (fibularis longus, fibularis brevis)
- •
Posterior compartment: gastrocnemius and soleus, plantaris, popliteus, flexor hallucis longus, flexor digitorum longus, and tibialis posterior
- •
Open and Closed Kinetic Chain Exercises
- •
Open kinetic chain exercises: Intrinsic foot muscle strengthening exercises (towel/toe curls exercises and marble pickups) and ankle strengthening exercises (four-way resisted Thera-Band exercises [inversion, eversion, dorsiflexion, and plantarflexion])
- •
Closed kinetic chain exercises: Progression of weight bearing activities without an increase of pain to include: double leg bridging ( Figure 37-6 ), progressing to single leg bridging; squatting activities with multiple foot positions and bases of support, multi-directional lunges, deadlifts, progression of weight for both double and single leg shuttle/leg press
FIGURE 37-6
Double-leg bridging.
Sensorimotor Exercises
- •
Single-leg balance activities progressing from a firm surface to soft/unsteady surface ( Figure 37-7 )
FIGURE 37-7
Single-leg balance activities progressing from a firm surface to soft/unsteady surface. A, Ground, steady surface. B, Foam, uneven surface. C, BOSU balance trainer, uneven surface.
Functional Exercises
- •
Beginning of functional exercises as increased weight bearing is tolerated such as squats, lunges (anterior/posterior/lateral), step ups/downs ( Figure 37-8 )
FIGURE 37-8
A, Step up. B, Step down.
Milestones for Progression to the Next Phase
- •
Decreased pain with weight-bearing activities
- •
Symmetrical lower extremity ROM to include ankle dorsiflexion and knee flexion/extension as measured in open and closed kinetic chain positions
- •
Lower extremity strength 5/5
- •
Normal pain free gait
Phase III (weeks 12 to 36)
Management of Pain and Swelling
- •
As for Phase II
Techniques for Progressive Increase in Range of Motion
Soft Tissue Techniques
- •
As for Phase II
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Active stretching to the gastroc/soleus muscle complex along with the hamstring musculature as part of warmup activities before the advancement to higher demand exercises (20- to 30-second hold, two to three repetitions)
Activation of Primary Muscles Involved
- •
As for Phase III, gross lower extremity and core strengthening for return to athletics is continued
Sensorimotor Exercises
- •
Progression of single leg balance activities by adding dynamic upper extremity movements or opposite lower extremity movements ( Figure 37-9 ).
FIGURE 37-9
A,B, Progression of single-leg balance activities by adding dynamic upper extremity movements or opposite lower extremity movements
- •
Advance these exercises by increasing the amount of movement, speed of the movement, and the number of repetitions.
Techniques to Increase Muscle Strength, Power, and Endurance
- •
Progression of closed kinetic chain exercises for dynamic strengthening and endurance for return to sport-related activity
Plyometrics
- •
Progression to plyometrics begins with partial weight-bearing hops and jumps, starting on Shuttle Systems or in a pool.
- •
Once partial weight-bearing plyometrics are tolerated, the athlete can progress to full weight bearing activities, including double leg hops moving toward single leg hops and box jumps.
- •
Box jumps and bounding exercises may be performed to control impact and landing for proper shock absorption and explosive moments.
Sport-Specific/Functional Exercises
- •
Multidirectional movements to both stable and unstable surfaces such as lunges, squats (on BOSU [ Figure 37-10 ], foam rolls, stability ball)
FIGURE 37-10
Multidirectional movements on unstable surfaces: squats on BOSU balance trainer.
- •
Multidirectional plyometric drills to include forward-backward and side-to-side hopping (both with and without outside resistance)
- •
Walk-jog progression
- •
Resisted forward and backward running activities
Milestones for Progression to Advanced Sport-Specific Training and Conditioning
- •
Running without symptoms
- •
Jumping and multidirectional movements without symptoms
- •
No functional limitations
Criteria for Abandoning Nonoperative Treatment and Proceeding to Surgery or More Intensive Intervention
- •
Non-healing fracture with increased pain with weight-bearing activities
Performance Enhancement and Beyond Rehabilitation: Training/Trainer and Optimization of Athletic Performance
- •
Maintaining proper flexibility and strength of the lower extremities for symmetrical gait and performance of functional activities
- •
Integration of sport-specific training/activities into training program to move from the rehabilitation stage to returning to sport performance level
- •
Rehabilitation should also include practice/training on multiple surfaces most similar to the athlete’s specific practice and competition environment. For example, to return to athletic competition in a sport such as skiing, one should begin with training on flat to moderate terrain and progress to more demanding environments.
- •
Training should not only focus on strict return to athletic activity, but should also include days of sport-specific drills and rest/work training practice cycles to build up to competition demands.
Specific Criteria for Return to Sports Participation: Tests and Measurements
- •
Full lower extremity strength and flexibility
- •
Symptom free during ambulation, running and functional activities
Evidence
Multiple Choice Questions
- QUESTION 1.
What type of strengthening should first be introduced following the period of immobilization?
- A.
Isotonic
- B.
Isometric
- C.
Isokinetic
- D.
Plyometric
- A.
- QUESTION 2.
What criteria should be met for the athlete to return to sports?
- A.
Full Lower extremity range of motion
- B.
Full strength
- C.
Normalized gait
- D.
All of the above
- A.
- QUESTION 3.
What are some of the benefits of performing AROM of the ankle following a period of immobilization?
- A.
Improving ankle range of motion
- B.
Strengthening ankle musculature
- C.
Decreasing swelling
- D.
A and C
- E.
All of the above
- A.
- QUESTION 4.
What is one way to determine healing status without the use of an x-ray?
- A.
Evaluation of one’s gait pattern
- B.
Strength of involved musculature
- C.
Normal joint range of motion
- D.
None of the above
- A.
- QUESTION 5.
Ways to challenge one’s proprioceptive control during single leg stance activities would include which of the following?
- A.
Adding uneven/unsteady surfaces
- B.
Increasing the number of repetitions and sets
- C.
Increasing amount of movement and speed of opposite upper and lower extremity resisted movements
- D.
Having the individual close their eyes
- E.
All of the above
- A.
Answer Key
- QUESTION 1.
Correct answer: B (see Phase I )
- QUESTION 2.
Correct answer: D (see Phase III )
- QUESTION 3.
Correct answer: D (see Phase II )
- QUESTION 4.
Correct answer: A (see Phase II )
- QUESTION 5.
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