Tibial and fibular fractures

Tibial and fibular fractures are common types of long bone injuries and are usually caused by direct trauma. Fractures may occur proximally, at the shaft, or distally. Since only a small amount of soft tissue covers the tibia and fibula, there is a high risk of open fractures. X-rays are the initial diagnostic test of choice. Initial management varies by fracture location and commonly involves consulting orthopedic surgery, splinting, and weight-bearing restrictions. Complications include common peroneal nerve injury and compartment syndrome.

For distal tibial or fibular fractures, see “Ankle fractures.” See also “Tibial stress fractures.”

• Tibial fractures
  • Tibial plateau fracture: a break in the superior surface of the tibia which articulates with the femoral condyles
  • Isolated tibial shaft fracture
• Fibular fractures
  • Isolated proximal fibular fracture
  • Isolated fibular shaft fracture
• Combined tibial and fibular shaft fractures (managed similarly to tibial shaft fracture)
• Distal tibial or fibular fractures: See “Ankle fractures.”

• Local pain, tenderness, and/or deformity
• Swelling, bruising, and/or hematoma
• Skin abnormalities, e.g., lacerations, tenting
• Signs of neurovascular injury, e.g.:
  • Common peroneal nerve injury, e.g., foot drop, impaired foot eversion, sensory deficits
  • Posterior tibial nerve injury, e.g., impaired plantar flexion, sensory deficit over the sole of foot
  • Arterial injury, e.g., hard signs of extremity vascular injury, diminished distal pulses
• Signs of compartment syndrome
• See “Fracture signs.”

Tibial and fibular fractures are at high risk of open fractures due to minimal surrounding soft tissue. ^[1]

Clinical evaluation ^[1]

Urgent orthopedic consultation is indicated for any findings that suggest neurovascular injury or an open fracture.

• Neurovascular examination
  • Assess dorsalis pedis and posterior tibial pulses and capillary refill time.
  • Evaluate for peroneal nerve injury and posterior tibial nerve injury.
• Skin examination: Evaluate for laceration, tearing, and tenting.

X-ray ^[1][2]

Imaging for tibial and/or fibular fractures generally includes x-rays of the knee, tibia and fibula, and ankle.

• Views
  • Knee
    • Anterioposterior (AP) and lateral views
    • Intercondylar view for suspected tibial plateau fractures
  • Tibia and fibula: AP and lateral views
  • Ankle: AP, lateral, and mortise views
• Findings
  • Radiographic fracture signs, fracture fragments, displacement, angulation, and/or dislocation
  • In tibial plateau fractures, lipohemarthrosis may be visible as a fat-fluid level. ^[1]
  • See also “Ankle fracture diagnostics.”

Evaluate for a Maisonneuve fracture in patients with a proximal fibular fracture, as Maisonneuve fractures are often unstable and require urgent orthopedic evaluation. ^[1]

Advanced imaging ^[1][2]

• CT: may be indicated for preoperative planning, fractures with intraarticular extension, or inconclusive x-rays with high clinical suspicion
• MRI: may be indicated for diagnosis of associated tendon and/or ligament injuries, e.g., meniscal injury associated with tibial plateau fracture ^[3]

In patients with acute traumatic knee pain, tibial tenderness, inability to bear weight, and nondiagnostic x-rays, obtain a CT to rule out a tibial plateau fracture. ^[1]

Initial management by fracture type ^[1]

• All patients
  • Initiate general fracture care, including analgesia.
  • Place patients on non-weight-bearing status.
  • Identify fractures requiring urgent orthopedic consultation.
  • Consider VTE prophylaxis in consultation with orthopedics. ^[1]
• Tibial plateau fractures
  • Apply a knee immobilizer.
  • Arrange orthopedic follow-up within 1 week.
• Tibial shaft fractures (with or without fibular shaft fracture)
  • Perform closed reduction for displaced, deformed, or angulated fractures with neurovascular compromise.
  • Immobilize in a posterior long-leg splint; consider adding a stirrup splint for open fractures.
  • Consult orthopedics urgently.
• Isolated proximal or midshaft fibular fractures
  • Immobilize in a stirrup splint.
  • Arrange orthopedic follow-up within 1–2 weeks.
• Distal tibial or fibular fractures: See “Ankle fractures.”

For proximal fibular fractures, rule out associated Maisonneuve fracture and common peroneal nerve injury. ^[1]

Identify and treat acute compartment syndrome in high-energy tibial and fibular fractures if present. ^[4]

Nonoperative management ^[1]

• Indicated for most nondisplaced closed fractures, e.g.:
  • Tibial plateau fractures
  • Isolated proximal or midshaft fibular fractures
• Options include knee immobilizers and posterior long-leg splints.
• See “Conservative treatment of fractures.”

Surgical management ^[1]

• Fractures commonly requiring surgery include:
  • Open fractures
  • Displaced fractures
  • Fractures with neurovascular injury
  • Severe tibial plateau fractures (e.g., with comminution, significant articular step-off deformity, condylar widening, multiple condylar involvement) ^[4]
• Operative techniques include:
  • Open reduction and internal fixation
  • Closed reduction and internal fixation
  • Intramedullary nailing
  • External fixation

Toddler fracture ^[5][6]

• Definition: a nondisplaced fracture of the distal tibial shaft, usually following acute trauma (e.g., falling, tripping), causing rotation of the body around a fixed foot
• Epidemiology: : commonly seen in children between 9 months and 3 years of age ^[6]
• Etiology: trauma (e.g., low-energy fall from a chair or table, tripping while running)
• Clinical features
  • Irritability
  • Abnormal gait (limping or inability to bear weight)
  • Localized tenderness over the distal tibial shaft
• Diagnostics
  • Often goes undetected due to subtle clinical and radiographic findings
  • Imaging
    • AP, lateral, and oblique x-ray
    • MRI and/or CT: indicated in cases of prolonged symptoms and suspicion of infection (e.g., osteomyelitis)
• Treatment: immobilization with a long cast, controlled ankle movement walker boot, short cast, or splint ^[7]

• Patients with tibial fractures should be monitored for:
  • High risk of compartment syndrome in any of the compartments, given that the tibia is surrounded by the anterior, lateral, and deep posterior compartments of the lower leg
  • Fat embolism
  • Peroneal nerve injury (foot drop)
  • Deep vein thrombosis
  • Nonunion
  • Posttraumatic arthritis ^[8]
• See “Fracture complications.”

We list the most important complications. The selection is not exhaustive.