Tibia Fracture – Causes, Symptoms, Diagnosis, Treatment

Types of Tibia Fracture?

Classifications

Some classifications help with treatment decisions.

Western and Tscherne

This is a classification of closed fracture? soft tissue injury and is as follows:

• Grade 0: Injuries from indirect forces with minimal soft tissue damage
• Grade 1: Superficial contusion/ abrasion, simple fractures
• Grade II: Deep abrasions, muscle/skin contusion, direct trauma, impending compartment syndrome
• Grade III: Excessive skin contusion, crushed skin or muscle destruction, subcutaneous degloving, acute? compartment syndrome, and rupture of a major blood vessel or nerve

The Gustilo-Anderson

This classification is used to assess open tibia fractures.

• Type I is limited periosteal stripping, clean wound less than 1 cm
• Type II mild to moderate periosteal stripping; wound greater than 1 cm in length
• Type IIIA significant soft tissue injury, significant periosteal stripping with a wound that is usually greater than 1 cm in length with no flap required
• Type IIIB is significant periosteal stripping and soft tissue injury with a flap required due to inadequate soft tissue coverage
• Type IIIC these are significant soft tissue injury with a vascular injury requiring repair

Diagnosis?

Laboratory tests should be done as an adjunct in overall medical status for surgical treatment.

• CBC, ESR test
• Random blood sugar, glucose, and routine diabetes test if the patient has insulin? is low or not working well. সহজ বাংলা: রক্তে চিনি বেশি থাকার রোগ।" data-rx-term="diabetes" data-rx-definition="Diabetes is a condition where blood sugar stays too high because insulin is low or not working well. সহজ বাংলা: রক্তে চিনি বেশি থাকার রোগ।">diabetes? mellitus.
• Microscopic urine examination test, and stool test.
• ECG, EKG test for heart abnormality is present
• Ultrasonography test in some cases.
• Normalized hemoglobin, hematocrit test
• Coagulation profile with bleeding time and coagulation time test, prothrombin time (PT) test for surgery if needed,
• Partial thromboplastin time (PTT), and platelet counts will be needed for operative intervention.
• Serum creatinine test,
• Serum lipid profile
• Serum uric acid test

Treatment of Tibia Fracture?

Non-Operative Treatment

Closed-reduction and nonoperative treatment in a long leg cast is acceptable for fractures in less than 5 degrees of varus-valgus angulation, less than 10 degrees in anterior-posterior angulation, greater than 50% cortical apposition, less than 1-cm shortening and less than 10 to 20 degrees of flexion and less than 10 degrees of rotational malalignment after reduction.

Do no HARM for 72 hours after injury

• Heat—hot baths, electric heat, saunas, heat packs, etc has the opposite effect on the blood flow. Heat may cause more fluid accumulation in the fracture joints by encouraging blood flow. Heat should be avoided when inflammation? is developing in the acute stage. However, after about 72 hours, no further inflammation is likely to develop and heat can be soothing.
• Alcohol stimulates the central nervous system that can increase bleeding and swelling and decrease healing.
• Running, and walking may cause further damage, and causes healing delay.
• Massage also may increase bleeding and swelling. However, after 72 hours of your fracture, you can take a simple message, and applying heat may be soothing the pain.

Medication

The following medications may be considered by your doctor to relieve acute and immediate pain, long term treatment

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any other cephalosporin/quinolone, meropenem antibiotic must be used to prevent infection or clotted blood removal to prevent further swelling, inflammation, and edema.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include first choice NSAIDs is Ketorolac, then Etoricoxib, then Aceclofenac, naproxen.
• Muscle Relaxants –  These medications provide relief from spinal muscle spasms, spasticity.  Muscle relaxants, such as baclofen, tolperisone, eperisone, methocarbamol, carisoprodol, and cyclobenzaprine, may be prescribed to control postoperative muscle spasms, spasticity, stiffness, contracture.
• Calcium & vitamin D3 – To improve bone health, blood clotting, helping muscles to contract, regulating heart rhythms, nerve functions, and healing fractures. As a general rule, too absorbed more minerals for men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day to heal back pain, fractures, osteoarthritis.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, tingling sensation, and paresthesia.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tighten the loose tendon, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament. The dosage of glucosamine is 15oo mg per day in divided dosage and chondroitin sulfate approximately 500mg per day in different dosages, and diacerein minimum of 50 mg per day may be taken if the patient suffers from osteoarthritis, rheumatoid arthritis, and any degenerative joint disease.[rx]
• Topical Medications and essential oil – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation in acute trauma, pain, swelling, tenderness through the skin. If the fracture is closed and not open fracture then you can use this item.
•  Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins in your body’s natural painkillers. It also helps in neuropathic pain, anxiety, tension, and proper sleep.
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation. To heal the nerve inflammation and clotted blood in the joints.
• Dietary supplement – To eradicate the healing process from fracture your body needs a huge amount of vitamin C, and vitamin E. From your dietary supplement, you can get it, and also need to remove general weaknesses &  improved health.
• Cough Syrup – If your doctor finds any chest congestion or fracture-related injury in your chest, dyspnoea, post-surgical breathing problem, then advice you to take bronchodilator cough syrup.

What To Eat and What  to avoid

Eat Nutritiously During Your Recovery

All bones and tissues in the body need certain micronutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins is proven to help heal broken bones and all types of fractures. Therefore, focus on eating lots of fresh food produce (fruits and veggies), whole grains, cereal, beans, lean meats, seafood, and fish to give your body the building blocks needed to properly repair your fracture. In addition, drink plenty of purified mineral water, milk, and other dairy-based beverages to augment what you eat.

• Broken bones or fractures bones need ample minerals (calcium, phosphorus, magnesium, boron, selenium, omega-3) and protein to become strong and healthy again.
• Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines, sea fish, and salmon.
• Important vitamins that are needed for bone healing include vitamin C (needed to make collagen that your body essential element), vitamin D (crucial for mineral absorption, or machine for mineral absorber from your food), and vitamin K (binds calcium to bones and triggers more quickly collagen formation).
• Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, fried fast food, most fast food items, and foods made with lots of refined sugars and preservatives.

Operative Treatment

External Fixation

Treatment of choice when significant soft tissue compromise is present or in polytrauma cases where damage-control orthopedics is needed.

Intramedullary Nailing (IMN)

This is the treatment of choice for operative fixation.

When comparing outcomes of IMN with external fixation, IMN is associated with decreased malalignment and compared to closed treatment, IMN is associated with decreased union time and time to weight-bearing.

Percutaneous Plating-Shaft

This method is often used in the distal tibia or proximal-third fractures that are too proximal or distal for intramedullary nailing.

Amputation

This is another treatment method but can be difficult to get the patient to buy into this treatment. The mangled extremity severity score (MESS) can help predict when an amputation is necessary. A score of 7 or greater is highly predictive of amputation. MESS has a high specificity but low sensitivity in predicting amputations. Relative indications include significant soft tissue trauma, warm ischemia greater than 6 hours, and severe ipsilateral foot trauma. It is important to note that loss of plantar sensation is not an absolute indication for amputation.

Management of Tibial Fractures

Tibial plateau fracture: These fractures present with knee pain and effusion. They classically occur after a car hits a pedestrian’s fixed knee, which is known as a “bumper fracture.” They are classified using the Schatzker classification and managed by using nonsurgical or surgical methods to achieve stable alignment. Operative strategies include external fixation and open reduction internal fixation.[10]

• Schatzker Classification

  • Type 1: lateral split fracture
  • Type 2: lateral split-depressed fracture
  • Type 3: lateral pure depression fracture
  • Type 4: medial fracture
  • Type 5: bicondylar fracture
  • Type 6: metaphyseal-diaphyseal disassociation

Tibial shaft fracture: Compared to most long bone fractures, tibial shaft fractures are more likely to be open because the medial surface is adjacent to the subcutaneous tissue. The fracture can have a low or high energy pattern. The low energy patterns are a result of torsional injury resulting in a spiral fracture. The high energy pattern is from a direct force that causes a wedge or oblique fracture. Nonoperative treatment is chosen for low-energy fractures that are minimally displaced while operative treatment is indicated for high-energy fractures including external fixation, intramedullary nailing, and percutaneous locking plate. These fractures can lead to extensive soft tissue injury, compartment syndrome, malunion, and bone loss. [rx]

Ankle fractures involving the distal tibia: These injuries generally present with ankle pain and swelling and an inability to bear weight. They are usually the result of severe inversion or eversion of the ankle joint. The Lauge-Hansen and Danis-Weber classifications are commonly used to determine the type of fracture. There are also several specific distal tibial fractures that have their own name. The Pilon fracture involves the distal tibia and its articular surface with the ankle joint, and the Tillaux fracture involves the anterolateral distal tibial epiphysis. Distal tibial fractures are most commonly treated with open reduction and internal fixation.[rx],[rx]

• Lauge-Hansen Classification

  • Supination-adduction
  • Supination-external rotation
  • Pronation-abduction
  • Pronation-external rotation

• Danis-Weber classification

  • Type A: fracture of lateral malleolus distal to the syndesmosis
  • Type B: fracture of the fibula at the level of syndesmosis
  • Type C: fracture of the fibula proximal to syndesmosis