Tibial shaft fractures are relatively common and may generally be separated into two broad categories:
- “Low energy” tibial shaft fractures typically occur following a rotational injury. These are commonly sustained while participating in sports such as downhill skiing or ice hockey. The twisting mechanism usually causes fractures of both the tibia and fibula at different levels and it is uncommon for these fractures to be “open” (fracture ends protruding through open wound in skin).
- “High energy” tibial shaft fractures are usually caused by a direct blow to the leg. Common mechanisms for this injury include motor vehicle accidents and pedestrians being struck by cars. This typically results in tibial and fibular injuries at the same level and these injuries are more likely to result in “open” fractures.
Fractures of the tibial shaft are almost always diagnosed in the emergency department after an x-ray. Once the fracture has been accurately diagnosed, a “closed reduction” to align the tibia will be performed and a splint will be applied. If the fracture is “open” then you will be asked if your tetanus prophylaxis is up to date and a dose of IV antibiotics will be administered as soon as possible. Definitive treatment of your fracture will depend on several variables and can be divided into two broad categories:
- Conservative Treatment: It is uncommon for a tibial shaft fracture to be managed without an operation. Patients with a tibial shaft fracture that is well aligned can be treated in an above knee cast and a prolonged period of non-weight bearing on the injured leg. Most patients prefer an operation to allow a more prompt return to full activity. Some patients will have many other medical conditions that make them unfit for surgery and these patients will be treated in a cast. Other patients who are only minimally or non-ambulatory before their injury will be treated without an operation.
- Operative Treatment: The implant most commonly used to treat a tibial shaft fracture is a rod (intramedullary nail) that is inserted the full length of the bone. Occasionally, your surgeon may decide to treat your fracture with a plate and screws instead. The most common reason why this decision would be made is if your fracture is very close or even extending into the knee or ankle joint. Following surgery, you may require a short admission to hospital, especially if your fracture is complicated or you have other medical conditions. Your weight bearing instructions following surgery will be based on the implant used and the orientation of your fracture.
Follow-Up and Rehabilitation
- 0 – 2 Weeks: At this early point your rehabilitation will be focused on improving your mobility. Depending on how your fracture is being treated you may or may not be permitted to put weight on your injured leg. A follow-up appointment will be scheduled at approximately 2 weeks from your initial injury. At this time repeat x-rays will be done to ensure your fracture has not shifted, your skin staples or sutures will be removed and a repeat physical examination will be performed.
- 2 – 6 Weeks: Your pain and mobility should continue to improve at this interval. You may have been prescribed oral pain medication at the time of your injury and you should be weaning from this as soon as possible. A follow-up appointment will likely be scheduled at approximately six weeks from your injury for repeat x-rays and physical exam.
- 6 – 12 Weeks: After your six week examination, all but the most severe injuries will be permitted to put weight on the injured leg. You may initially be asked to wear a cast boot for additional protection while starting to walk on your injured leg. Referral to physiotherapy may be considered to help you regain the strength in your injured leg. A follow-up assessment will be scheduled at approximately three months from your initial injury. If you are doing well at this stage, this may be your final scheduled follow-up. Additional follow-up may be required for patients with more complex injuries.
If you have an operation to treat your tibial shaft fracture, there are standard surgical risks that apply to all patients undergoing surgery. There are some additional complications that are specific to tibial shaft fractures. These include the following:
- Compartment Syndrome: The muscles of your leg are separated into four separate compartments by a strong tissue called fascia. The swelling and bleeding caused by a tibial shaft fracture (especially from one sustained via a “high energy” mechanism) can cause the pressure in the compartments to increase. If this pressure becomes too high, the muscles in these compartments can start to die. For this reason, you will be monitored very carefully before and after your operation for any signs or symptoms of compartment syndrome. If you do develop compartment syndrome, you will require emergency surgery to release the fascia (“fasciotomy”) to decrease the pressure in the compartment and prevent the muscle from dying.
- Non-Union: In large studies of patients who are treated with a rod (“intra-medullary nail”) for their tibial shaft fracture, about 5% did not heal their fracture after one operation. This risk is increased in patients who have “open” fractures and “high energy” mechanisms of injury. If your fracture does not heal, you will likely require at least one additional procedure to address this “non-union”.
- Knee Pain: Patients that have tibial shaft fractures treated with a “rod” (intra-medullary nail) often have difficulty with pain in the front of their knee following surgery. Your surgeon will pay careful attention to ensuring that the rod is not left proud in your leg but even with perfect surgical technique patients often have some pain in the front of their knee. Once your fracture has healed you and your surgeon may consider removing the rod to address this pain, although the success of this operation is unpredictable.
- Infection: A relatively high number of patients with fractures of the tibial shaft will have “open fractures” (bone coming through skin). In this situation, the emergency room doctor will give IV antibiotics as soon as possible. You will also be asked if your Tetanus immunizations are up to date.
Patients with fractures of the tibial shaft generally do well post-operatively. It is important to participate fully with your rehabilitation following surgery and follow your weight bearing restrictions, if any. It is equally important to wean from your prescription pain medication as soon as possible as these medications are addictive.