HWN Suggests

No Leg to Stand On

Mid-shaft tibia/fibula fractures and trimalleolar fractures are rare but severe sports injuries. Acute mid-shaft tibial fractures with concomitant fibular fractures have the longest return-to-sports timing of all sports fractures (41-55 weeks), but with relatively good outcomes. Up to 92% of athletes can return to sports after surgical treatment such as intramedullary nailing, open reduction and internal fixation, and external fixation. However, complications can occur, including compartment syndrome, infection, nonunion, DVT, fat embolism and persistent knee pain.

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 It’s the way you (don’t) walk: Fractures of the tibia and fibula

Tibial shaft fractures are the third most common fracture in children—only fractures of the femur and forearm are more prevalent. , Approximately 30% of cases of tibial fracture have an associated fibula fracture. Adolescent patients are more likely to have combined fractures of the tibia and fibula than other pediatric age groups. ,

Articles of Interest

Ankle and Foot Fractures

Ankle fractures are most commonly diagnosed through clinical examination and x-ray. Ottawa rules provide clinicians with a tool to decide whether the joint should be imaged or not. Several classifications exist and are used to determine the severity of injury and management. Examples include the Danis-Weber classification which identifies the level of injury and; the Lauge-Hansen classification which is based on the mechanism of the injury which have predictable patterns and imaging findings.

Ankle Fractures

187 fractures per 100,000 people per year, no gender predominance. 60-70% are unimalleolar, 15-20% bimalleolar and 7-12% are trimalleolar.

Athletes, women and weekend warriors alike are prone to these problems

The tibia is the strongest weight-bearing bone in your body. It’s about four times as strong as concrete, and like the concrete in your driveway, constant stress and pressure can cause tiny cracks over time.

Commonly Missed Ankle Injuries

You probably can’t remember the last time you worked a shift in the ED and didn’t see at least one patient with an ankle injury. While almost all of these patients are relatively straightforward to diagnose and manage a small but significant minority of these patients will have a more elusive diagnosis, that if not identified early, could lead to significant morbidity. On the flip side, if we’re super conservative and defensive and we immobilize everyone with an ankle injury no matter how minor we’re not doing our patients or our consultants any favors either.

CORE EM: Tibial Plateau Fractures

Tibial plateau fractures can have subtle radiographic findings. Maintain a high clinical suspicion for obtaining additional imaging or CT for patients unable to bear weight in the ED following injury.

EM@3AM: Tibial Plateau Fracture

High clinical suspicion of acute compartment syndrome in high energy mechanisms, Schatzker VI fractures, and associated fibular fractures requiring frequent compartment checks.

Fibula Fractures

Isolated fibula shaft fractures are rare. More commonly, they are associated with tibia fractures, or with an ankle fracture affecting the distal fibula. As with any fracture, union issues (delayed, malunion and non-union) is a risk, made worse if there’s infection. Compartment syndrome is a risk, but is more relevant if there is an associated tibial fracture. Be suspicious of an isolated spiral fracture at the proximal fibula; it may be associated with a distal tibia fracture, called a Maisonneuve fracture.

Lower Leg Fractures in Children and Adolescents—Comparison of Conservative vs. ECMES Treatment

After forearm fractures in children isolated tibial fractures are most common and account for 15% of all pediatric fractures, whereas isolated fibula fractures are rare. Tibial shaft fractures most frequently occur during walking, indoor activity or sports. Low energy rotational lower leg injuries usually result in isolated spiral fractures of the tibia or both, tibia and fibula. The term “lower leg fracture” defines a fracture of the tibia- and/or fibula-shaft, corresponding region 42 with regard to the AO-PCCF classification. Isolated tibial fractures with intact fibula have a lower risk for shortening, but pose a risk for varus deformity. High energetic trauma results in fractures of both, tibia and fibula with risk for leg shortening and valgus deformity. Child abuse must always be considered if medical history and trauma do not match.

Maisonneuve Fracture

Maisonneuve fractures are a result of external rotation of a planted foot, most often with pronation of the foot. This extreme force places significant strain on the bones and ligaments that make up the ankle joint and often results in instability. The talus externally rotates and applies stress to the medial aspect of the ankle and may cause deltoid ligament rupture or medial malleolus fracture. Acting as a wedge, the talus places pressure on the lateral malleolus and causes syndesmotic disruption between the tibia and fibula. Lastly, as the force is traveling through the deltoid ligament and medial malleolus, up towards the syndesmotic ligaments and interosseous membrane, the force generated exits the proximal fibula via fracture.

Maisonneuve Fracture

Maisonneuve fracture results from an external rotation force applied to the foot. Force at the medial ankle --> force is directed laterally, tearing the interosseous membrane that tethers the distal tibia to the fibula --> force directed upwards fracturing fibula.

Ortho Pearls: Tibial Plafond Fracture

Plafond fractures are fractures of the distal tibial with intraarticular extension. They are often due to axial compression of the tibia, but can also be from rotational force, as in this patient. They are called plafond fractures, meaning ceiling in French, as this fracture is of the “ceiling” of the ankle joint. When the fracture is due to axial load on the tibia, they are referred to as a pilon fracture. Pilon is the French word for pestle, as in “mortar and pestle”, with the pestle being the distal tibia being compressed down against the mortar of the foot (i.e., talus).

Radiographic Pitfalls in Lower Extremity Trauma

In this article, we identify several common radiographic pitfalls in lower extremity trauma and describe strategies for dealing with them.

SplintER Series: Tibial Plateau Fractures | Leg Day #1

Tibial plateau injuries are serious injuries that require prompt attention and appropriate evaluation to avoid misdiagnosis or significant morbidity. The mechanism of injury should be considered and any injury that includes a direct blow to the knee, proximal leg, or distal thigh should raise suspicion. Fractures may be subtle on the initial plain radiographs, so patients with a concerning mechanism, significant effusion, severe tenderness, or inability to bear weight should have additional imaging with a non-contrast CT.

Tibial Shaft Fractures

Fractures of the tibia are common in children and adolescents with most breaks typically occurring in the middle of the bone (what orthopedic doctors call the “tibial shaft”).

Tibial Shaft Fractures in Children

3rd most common long bone injuries in children.

Tibio-Fibular Fractures - Classification and Treatment Modalities

It usually takes about 6 to 12 weeks for a tibia fibula fracture to heal, but it can take up to several months, depending on the severity of the injury.

Tiger Woods undergoes ankle surgery

Tiger Woods announced Wednesday that he has undergone another surgery on the right leg that was severely injured in his 2021 car accident. Woods’ latest procedure was a fusion of the subtalar joint “to address his post-traumatic arthritis from his previous talus fracture,” according to a statement released on Woods’ Twitter account. The subtalar joint is located just below the ankle joint, between the talus bone and heel bone, according to footcaremd.org.

Resources

Ottawa Ankle Rule

We found that emergency doctors were ordering many imaging studies for ankle injuries that were then found to be normal. I thought if there were a set a rules with criteria developed by emergency physicians, for emergency physicians, they would help this problem and shorten emergency department wait times and costs.