Fractures and dislocations of the tibia and ankle joint
Fractures of the Tibia can be divided up as follows:
- Proximal ‘Plateau’ fractures
- Shaft fractures
- Distal ‘Pilon’ fractures
Below we conser each type.
Proximal ‘Plateau’ fractures
So called because they affect the Tibial plateau, the articular surface of the proximal tibia that articulates with the femoral condyles. These are caused in cases of axial load + varus/valgus stress. Commonly associated with meniscal (50%) and medial collateral ligament tears. Patients present with history of trauma, pain, swelling and inability to bear weight, if there is decrease in pulses it is vital to do an angiogram and confirm patency of the popliteal artery which runs posteriorly.
There are six types of plateau fracture:
- Lateral plateau split fracture
- Lateral split/depression fracture
- Lateral plateau depression
- Medial plateau split fracture
- Bicondylar plateau fracture
- Fracture with metaphyseal-diaphyseal separation
Types IV-VI are usually from a high energy trauma of some sort.
Treatment should in nondisplaced cases should consider knee brace/cast for 6-8 weeks, where displaced, use ORIF with or without bone graft, early ROM is advisable. Both medial and lateral periosteal stripping can occur and should be avoided, ensure repair of soft tissue around the knee.
Complications include compartment syndrome, posttraumatic osteoarthritis, persistent knee pain and popliteal artery injury.
Fracture of Tibial shaft
This is a common long bone fracture, commonly a high energy trauma with the biggest risk being to the surrounding soft tissues, the condition of these is critical to the success of outcome. Compartment syndrome is the biggest risk in such cases. Patients will present with a history of trauma, pain, swelling and inability to bear weight often with swelling and deformity. Compartments may appear firm and tense, an indication for compartment syndrome. Again, if there are decreased pulses, do angiograms.
Types of tibial fracture include:
- Transverse fracture with fibula intact
- Spiral fracture with shortening
- Comminuted fracture with marked shortening
- Segmental fracture with marked shortening
Treatment for nondisplaced fractures is a cast for 8 weeks, in displaced/unstable cases, a locked intramedullary nail is often indicated. In open fractures external fixation is useful, fasciotomies for compartment syndrome are also a good idea.
Complications include compartment syndrome, nonunion + malunion, knee pain (from IM nail), ankle and/or knee stiffness.
Remember that the leg has four compartments with muscles, these are:
- Anterior compartment
- Extensor muscles
- Tibialis anterior
- Extensor digitorum longus
- Extensor hallucis longus
- Anterior tibial artery and vein
- Deep peroneal nerve
- Lateral compartment
- Peroneal muscles
- Peroneus longus