Tibia Fracture

Introduction

The tibia (or shin bone) is the larger of the two lower leg bones and its function is to support the weight of the body. A broken bone or fracture may be full, partial or hairline, but all of them are referred to as a fracture. The size and shape of tibia fractures are wide-ranging and so each fracture needs to be treated with individual factors taken into account.

Causes

Sometimes, the stress placed on the tibia is too much, for example when landing from a significant height, and this is when the tibia can break.

Tibia fractures can also follow a direct blow to the front or inner aspect of the lower leg or ankle and can result from what seem like fairly low-energy injuries such as household falls. Occasionally these breaks happen as a result of running and jumping sports involving change of direction such as football, soccer, rugby, basketball and netball. They can also happen gradually over time due to overuse, a classic example of this is with runners due to repetitive stress on the tibia.

Because of the large forces required to break the tibia bone, a tibia fracture often occurs in combination with other injuries such as a sprained ankle or other fractures of the foot, ankle or lower leg.

Fracture locations

The most common location for a tibia fracture is between the knee and ankle joints. Usually these fractures can be treated in a long leg cast although sometimes there is too much displacement or angulation and surgery may be needed to realign and secure the bones.

Tibia fractures can also occur just below the knee joint and are called tibial plateau fractures. These fractures can also affect the knee joint and its cartilage surface. If the fracture occurs at the bottom of the shin bone around the ankle joint, it is referred to as a tibial plafond fracture. These fractures also require special consideration because of potential damage to the ankle cartilage and surrounding soft-tissues.

Sometimes the break causes the bone to push through the skin. This is referred to as an open or compound fracture which needs special treatment due to high-risk of infection and generally requires surgical treatment.

Diagnosis and treatment

In most cases, the lower leg will be X-rayed to confirm the diagnosis. Sometimes Mr Hull may use a computer tomography (CT) scan to achieve a cross-sectional image of your leg.

For uncomplicated breaks, the fractured leg is placed in a lower leg and ankle cast for 6-8 weeks to immobilise the bone. Injuries usually cause some swelling for the first few weeks so Mr Hull may initially apply a splint to provide comfort and support. Unlike a full cast, a splint can be tightened or loosened, and allows swelling to occur safely. Once the swelling goes down, MR Hull will consider a range of treatment options.

After some weeks in the cast, Mr Hull may replace it with a functional brace made of plastic and fasteners. This will enable you to take it off for hygiene issues and physical therapy.

Surgery

In severe or complicated fractures, internal fixation with screws and plates or rods may be necessary. The most common procedure is to place a metal rod down the center of the tibia to hold the alignment of the bone which is called intrameduallary rodding (IM).

The operation lasts for about one hour and is done under under general anesthesia. Mr Hull will first make an incision over the knee joint, and small incisions below the knee and above the ankle. Some fractures may also require an incision near the fracture to realign the bones. IM rods are secured within the bone by screws both above and below the fracture. The metal screws and the rod can be removed if they cause problems, but can also be left in place for life.

Sometimes Mr Hull may use plates and screws. Whilst less commonly used, they can be helpful in some fracture types, especially those closer to the knee or ankle joints.

In more severe fractures, expecially open fractures, Mr Hull may choose an external fixator. This is often because the soft tissue damage prevents the placement of rods or plates. In this type of operation, metal pins or screws are placed into the bone above and below the fracture site. The pins and screws are attached to a bar outside the skin which forms a stabilizing frame that holds the bones in the proper position so they can heal.

Risks and complications

If your fractured tibia requires surgery, as with all operations, there is a possibility of a reaction to the anaesthetic, excessive bleeding, developing a blood clot and wound infection. A general anaesthetic may also make you feel temporarily sick after the operation.

There are also a few other complications specifically related to fractured tibias. The healing process may be poor or delayed, for example. This is particularly common in an open fracture of the tibia because of lower blood flow to this bone. You may also experience pain in the knee or ankle.

Another possibility is bone infection (osteomyelitis). If you have an open fracture, your bone may be exposed to fungi and bacteria that can cause infection. Infection can also occur around the rods placed during surgery, in which case MR Hull may need to replace it.

Nerve or blood vessel damage may also occur if adjacent nerves are injured which can cause numbness.

Arthritis is also quite common some years later particularly with fractures that extend into the joint and where there is poor bone alignment. You may also find that your legs are slightly noticeable different in length.

Preparing for surgery

Mr Hull will talk to you about how best to prepare for surgery which may include stopping taking any anti-inflammatory medications such as aspirin to reduce the risk of blood clots and stopping smoking if you are a smoker to minimize the risk of infection.

If you're having a general anaesthetic, you will be asked to follow fasting instructions. This means not eating or drinking, typically for about six hours beforehand.

Mr Hull may also ask you to wear compression stockings to help prevent blood clots forming in the veins in your legs or may give you an injection of an anti-clotting medicine called heparin to help prevent blood clots forming in the veins in your legs. You will usually be put on an antibiotic drip before surgery. This is to reduce your risk of getting an infection during surgery.

Recovery

If you had an operation, you will need to rest until the effects of the anaesthetic have worn off and will be given painkillers to help with any discomfort.

You may need to keep your leg elevated at first and will be given crutches to use so that you don't put any weight on your leg. If you have metal pins inserted, you will be told how to keep the insertion points clean.

You can usually go home after one to two days, as long as there are no complications and will be given some exercises by our physiotherapist to start getting the movement back in your leg. It’s possible to start putting some weight back on your leg within a few weeks of your operation, and you may be able to return to work within two weeks if your occupation doesn't involve any physical work.

Sometimes splints and casts are appllied following surgery, as well as for use on broken legs which don’t need an operation. Exercises during the healing process and after your cast is removed are important. They will help you restore normal muscle strength, joint motion, and flexibility.

Once the cast or splint is removed, physical therapy will reduce stiffness and restore movement in the injured leg. Because you haven't moved your leg for a while, you may even have stiffness and weakened muscles in uninjured areas.

How long it takes to make a full recovery varies on a number of factors including age, type of surgery and severity of the break. Some tibial shaft fractures heal within 4 months, yet many may take 6 months or longer to heal. This is particularly true with open fractures and fractures in patients who are less healthy.

Accelerated recovery: Exogen

To help accelerate recovery time, Mr Hull may recommend a bone healing system called Exogen. This is used to treat fractures, especially those which are not healing naturally, and uses ultrasound waves to stimulate bone healing. Exogen can be used with casts and is effective even where metal fixations are present. It’s a very user-friendly device and only needs to be used for 20 minutes each day. How long you will need to take it can depend on a number of factors such as age and lifestyle but Mr Hull will be able to advise you about this.

Further information

For further information please contact Mr Peter Hull FRCS, Consultant Trauma & Orthopaedic Surgeon