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Orthopaedics
Trauma
Emergency Medicine
EMERGENCY

Tibia Shaft Fracture

High EvidenceUpdated: 2025-12-26

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Red Flags

  • Compartment Syndrome -> Pain on Passive Stretch (Emergency Fasciotomy)
  • Open Fracture -> IV Antibiotics <1 hour (Gustilo-Anderson)
  • Vascular Compromise -> Absent Distal Pulses (CTA required)
  • Skin Tenting -> Impending Open Fracture (Reduce immediately)
  • Polytrauma -> Look for Floating Knee
Overview

Tibia Shaft Fracture

1. Clinical Overview

Summary

The Tibial Shaft is the most commonly fractured long bone. Due to its subcutaneous anteromedial surface (1/3 of the circumference is skin-on-bone), it is also the most common site for Open Fractures. The management is dictated by soft tissue condition. High-energy injuries carry a significant risk of Compartment Syndrome (the "Silent Killer" of limbs). The gold standard for definitive management is Reamed Intramedullary Nailing, supported by the SPRINT Trial. For open fractures, adherence to BOAST 4 Guidelines (IV Antibiotics <1h, Debridement <24h, Soft Tissue Cover <72h) is mandatory to prevent deep infection. [1,2,3]

Key Facts

  • Most Common Long Bone Fracture: 26 per 100,000.
  • Compartment Syndrome: The Tibia has 4 tight fascial compartments (Anterior, Lateral, Superficial Posterior, Deep Posterior). The Anterior compartment is most commonly affected.
  • Open Fractures: 25% of tibia fractures are open. The infection rate rises from 2% (closed) to >10% (open).
  • Healing Potential: The distal third of the tibia has poor periosteal blood supply, leading to delayed union.

Clinical Pearls

"Pain Out of Proportion": The hallmark of Compartment Syndrome. If a patient with a splinted leg has escalating pain despite opiates, or pain on passive stretch of the toes, you must measure compartment pressures or release the dressings immediately.

"Antibiotics ASAP": In open fractures, the clock starts at the time of injury. For every hour delay in antibiotic administration, the infection risk rises. Co-Amoxiclav + Gentamicin (or local protocol) must be given within 1 hour of ED arrival.

"To Ream or Not to Ream?": The SPRINT Trial settled this debate. ALWAYS Ream (drill out the canal). It provides biological bone graft (the reamings) and allows a larger (stiffer) nail, reducing non-union rates.

"The Backslab Check": Never trust a plaster applied by someone else. If the patient has pain, split the cast down to skin. Casts can act as a tourniquet.

2. Epidemiology

Demographics

  • Bimodal Distribution:
    • Young Males (15-40): High energy (Motorcycle, Sports - Football/Skiing).
    • Elderly Females (>70): Low energy (Falls).
  • Mechanism:
    • Twisting: Spiral fracture (Low energy). Usually Fibula intact or fractured at different level.
    • Direct Blow: Transverse/Comminuted (High energy/Bumper injury). Usually Tibia and Fibula fractured at same level.
    • Axial Load: Pilon fracture extension.

Risk Factors for Non-Union

  1. Smoking: The bone vasconstricts. Nicotine inhibits osteoblasts.
  2. NSAIDs: Avoid in first 2 weeks.
  3. Open Fracture: Biological environment compromised.
  4. Infection: Biofilm prevents union.
3. Pathophysiology

Anatomy

  • Blood Supply:
    • Nutrient Artery: Enters posterior cortex at proximal 1/3. Descends.
    • Periosteal Vessels: Supply outer 1/3 of cortex. (Disrupted by stripping muscles).
    • Significance: Reaming destroys the nutrient artery, making the bone reliant on periosteal supply. If the periosteum is stripped (open fracture), the bone is ischaemic.
  • Soft Tissue Envelope: The anteromedial face is subcutaneous. This area has poor blood supply and is prone to breakdown.
  • The Fibula: Acts as a strut. If the fibula is intact ("Strutting Fibula"), it prevents compression of the tibia, leading to varus collapse.

Compartment Syndrome

  • Delta Pressure: The difference between Diastolic BP and Compartment Pressure.
  • Formula: Delta P = Diastolic BP - Compartment Pressure.
  • Threshold: Delta P < 30 mmHg = Fasciotomy Indicated.
  • Note: Hypotension makes compartment syndrome more likely (lower threshold).
4. Classification

Gustilo-Anderson (Open Fractures)

Predicts infection risk and amputation risk.

  • Type I: Wound <1cm. Clean. Minimal muscle injury.
  • Type II: Wound 1-10cm. Moderate muscle injury.
  • Type IIIA: Wound >10cm. Severe crushing. Bone CAN be covered by local soft tissue.
  • Type IIIB: Wound >10cm. Severe loss of coverage. Requires Flap Reconstruction (Plastic Surgery).
  • Type IIIC: Arterial injury requiring repair.

Oestern-Tscherne (Closed Fractures)

Predicts soft tissue risk in closed injuries.

  • Grade 0: Minimal injury.
  • Grade 1: Abrasion / Contusion.
  • Grade 2: Deep abrasion / Blistering / Severe swelling.
  • Grade 3: Extensive skin degloving / Compartment syndrome / Vascular injury. "Closed degloving".
5. Clinical Presentation

Symptoms

Signs

Severe pain.
Common presentation.
Inability to weight bear.
Common presentation.
Deformity.
Common presentation.
6. Investigations

Imaging

  • X-Ray Tib/Fib (Full length): Include Knee and Ankle joints ("Joint Above and Below").
    • Look for syndesmosis injury if fibula fracture is high (Maisonneuve).
  • CT Scan:
    • If intra-articular extension suspected (Pilon/Plateau).
    • If assessing rotation/comminution for nail planning.

Other

  • Doppler / CTA: If pulses asymmetry or Ankle-Brachial Index (ABI) <0.9.
  • Lactate: Marker of shock in polytrauma.
7. Management Algorithm
                 TIBIA SHAFT FRACTURE
                          ↓
             OPEN? VASCULAR? COMPARTMENT?
             ┌────────────┴─────────────┐
            YES                         NO
             ↓                          ↓
         EMERGENCY              SOFT TISSUES OK?
      (Debride/Fix)             ┌───────┴───────┐
                               YES               NO
                                ↓                ↓
                             IM NAIL         DAMAGE CONTROL
                          (Gold Standard)    (Ex-Fix / Slab)
                                                 ↓
                                           WAIT 7-14 DAYS
                                          (Swelling Check)
                                                 ↓
                                          CONVERT TO NAIL
8. Management: Initial (ED)

BOAST 4 Guidelines (Open Fractures)

  1. Antibiotics: IV Co-Amoxiclav (1.2g) + Gentamicin (1.5mg/kg) within 1 hour of injury.
  2. Immobilisation: Backslab (Above Knee).
  3. Photograph: Take ONE photo of the wound (to prevent multiple people taking dressings down).
  4. Cover: Saline-soaked gauze and occlusive dressing. Do NOT look again until theatre.
  5. Tetanus: Booster if status unknown.
  6. Transfer: To Major Trauma Centre (MTC) for Ortho-Plastic joint care.
9. Management: Definitive

1. Intramedullary (IM) Nail - Gold Standard

  • Rationale: Load sharing device. Allows early weight bearing.
  • Technique:
    • Reamed: Drill the canal tostimulate biology. Insert a thicker, stronger nail.
    • Interlocking Screws: Proximal and distal screws prevent rotation and shortening.
    • Approaches: Infra-patellar (Standard) or Supra-patellar (Newer, allows semi-extended leg, better for proximal fractures).
  • Evidence: SPRINT Trial showed Reamed nails have lower non-union rates than Unreamed nails in closed fractures.

2. External Fixation

  • Indication:
    • Severe soft tissue injury (Tscherne 3 / Open IIIB).
    • Damage Control ("Span, Scan, Plan") in polytrauma.
    • Children (Flexible nails preferred).
  • Cons: Pin site infection. Non-union high. Awkward for patient.
  • Circular Frame (Ilizarov): Gold standard for infected non-unions or bone loss (Bone Transport).

3. Plaster Cast (Sarmiento)

  • Indication: Low energy, stable, minimally displaced fractures in compliant patients.
  • Technique: Above knee cast (4 weeks) -> Patella Tendon Bearing (PTB) cast (4-6 weeks).
  • Functional Bracing: Allows movement of knee/ankle to pump muscles.
  • Cons: High rate of stiffness. Malunion common. Rarely used in adults now except for very simple fractures.
10. Complications

Compartment Syndrome

  • Incidence: 5-10%.
  • Pathology: Swelling within a closed fascia raises pressure > capillary perfusion pressure -> Ischaemia -> Necrosis.
  • Treatment: 4-Compartment Fasciotomy.
    • Lateral Incision: Releases Anterior and Lateral compartments.
    • Medial Incision: Releases Superficial Posterior and Deep Posterior compartments.
    • Pearl: Do NOT perform a single incision fasciotomy (misses Deep Posterior).

Infection

  • Osteomyelitis: Deep infection in the presence of metalwork is a disaster. Biofilm forms on the nail.
  • Management: Remove nail, ream canal (RIA), insert Antibiotic-Loaded Cement Nail, prolonged IV antibiotics.

Anterior Knee Pain

  • Incidence: 30-50% after Nailing.
  • Cause: Scar tissue in Patellar Tendon (Infra-patellar approach) or Nail prominence.
  • Management: Supra-patellar approach reduces this risk.

Non-Union

  • Definition: Not healed at 6 months.
  • Treatment: Dynamization (remove locking screws) -> Exchange Nailing (Ream bigger, bigger nail).
11. Evidence & Guidelines

The SPRINT Trial (2008) - JBJS

  • Study of Prospective Randomized Reamed Intramedullary Nails in Tibial Fractures.
  • Question: Reamed vs Unreamed?
  • Result: Reamed nails had significantly lower rate of re-operation (fixation exchange/grafting) for closed fractures. No difference in open fractures.
  • Conclusion: Always ream closed fractures.

BOAST 4 (Open Fractures)

  1. Debridement: Immediately for localized contamination. Within 12 hours for high energy. Within 24 hours for all others.
  2. Plastic Surgery: Must be involved early. Fixation and Flap coverage should ideally happen in the same sitting (<72 hours).
12. Patient Explanation

The Injury

You have broken your shin bone. It is the main weight-bearing bone.

The Operation (Nail)

We put a titanium rod down the hollow center of the bone. It acts like an internal splint. We lock it with screws at the top and bottom.

Can I walk?

Usually, yes. The rod is very strong. You can put as much weight on it as pain allows. This actually helps the bone heal by "waking up" the bone cells.

The Risks

  • Knee Pain: Common (kneeling pain).
  • Compartment Syndrome: If your pain gets uncontrollable tonight, tell the nurse immediately. We need to catch it early.
  • Smoking: If you smoke, the bone will not heal. You must stop.
13. References
  1. Bhandari M, et al. (SPRINT Investigators). Randomized trial of reamed and unreamed intramedullary nailing of tibial shaft fractures. J Bone Joint Surg Am. 2008.
  2. British Orthopaedic Association (BOAST). Open Fractures. 2017.
  3. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones. J Bone Joint Surg Am. 1976.
14. Examination Focus (Viva Vault)

Q1: Define Compartment Syndrome. A: A surgical emergency where the osteofascial compartment pressure exceeds the capillary perfusion pressure, leading to tissue ischaemia and necrosis. Diagnosis is clinical (Pain out of proportion, Pain on passive stretch). Delta Pressure <30mmHg is confirmatory.

Q2: Describe the Gustilo-Anderson Classification for Open Fractures. A:

  • I: Wound <1cm, clean.
  • II: Wound 1-10cm, moderate contamination.
  • IIIA: Wound >10cm, Adequate soft tissue coverage derived from local tissue.
  • IIIB: Wound >10cm, Inadequate coverage. Requires Flap (Free/Rotational).
  • IIIC: Arterial injury requiring repair.

Q3: What did the SPRINT Trial show? A: Reamed intramedullary nailing resulted in fewer implant failures and re-operations compared to unreamed nailing for closed tibial shaft fractures. It established Reamed Nailing as the Gold Standard.

Q4: Name the 4 compartments of the leg. A: Anterior, Lateral, Superficial Posterior, Deep Posterior.

  • Anterior: Deep Peroneal Nerve, Anterior Tibial Artery.
  • Lateral: Superficial Peroneal Nerve.
  • Deep Posterior: Tibial Nerve, Posterior Tibial Artery.

(End of Topic)

Last updated: 2025-12-26

At a Glance

EvidenceHigh
Last Updated2025-12-26
Emergency Protocol

Red Flags

  • Compartment Syndrome -> Pain on Passive Stretch (Emergency Fasciotomy)
  • Open Fracture -> IV Antibiotics &lt;1 hour (Gustilo-Anderson)
  • Vascular Compromise -> Absent Distal Pulses (CTA required)
  • Skin Tenting -> Impending Open Fracture (Reduce immediately)
  • Polytrauma -> Look for Floating Knee

Clinical Pearls

  • **"The Backslab Check"**: Never trust a plaster applied by someone else. If the patient has pain, split the cast down to skin. Casts can act as a tourniquet.
  • Patella Tendon Bearing (PTB) cast (4-6 weeks).
  • capillary perfusion pressure -
  • Exchange Nailing (Ream bigger, bigger nail).

Guidelines

  • NICE Guidelines
  • BTS Guidelines
  • RCUK Guidelines