Fracture of the shaft of the tibia and fibula

　　What causes the fracture of the shaft of the tibia and fibula?

　　Firstly, the cause of the disease

　　Direct violence, crushing, and indirect violence can all cause this fracture.

　　Secondly, the pathogenesis

　　1. Direct violence:Fracture of the shaft of the tibia and fibula is commonly caused by heavy objects striking, kicking, impact injuries, or being rolled over by wheels, with most of the force coming from the outer front side of the lower leg. The fracture line is often transverse or short oblique. Fractures caused by massive violence or traffic accidents are often comminuted fractures.

　　(1) In the same plane, such as transverse fractures, there may be a triangular fragment of bone on the side affected by the force. After the fracture, the fracture ends often overlap, angulate, or rotate. Because the front of the tibia is located under the skin, there is a high possibility that the fracture ends will break through the skin, and there is a higher chance of muscle contusion. If the force is slight, although the skin is not pierced, severe contusion may occur.

　　(2) Poor blood supply can also lead to skin necrosis and bone exposure, which can lead to infection. Large-scale skin stripping, muscle tearing, and exposed fracture ends can occur in crush and绞轧 injuries with greater violence.

　　(3) Fracture sites are more common in the middle and lower 1/3, due to the characteristics of nutrient vessel injury, less soft tissue coverage, and poor blood supply. The incidence of delayed healing and non-union is high.

　　2. Indirect violence:Fractures caused by falling from a height, rotational force twisting injury, or slipping, especially when the fracture line is mostly oblique or spiral; the fracture line of the fibula is higher than that of the tibia, the soft tissue injury is small, but there is a higher chance of piercing open injury where the fracture tip pierces the skin.

　　(1) The displacement of the fracture depends on the magnitude and direction of the external force, the contraction of the muscles, and the weight of the distal part of the injured limb, etc. There are more opportunities for lateral lower leg to be exposed to violence, so it can make the fracture end angulate inward. The weight of the lower leg can make the fracture end tilt backward, the weight of the foot can make the distal end of the fracture rotate outward, and the contraction of the muscles can make the two fracture ends overlap and displace.

　　(2) The external force that children with tibial and fibular fractures suffer is generally small, and combined with the larger toughness of the child's bone cortex, it is mostly greenstick fractures.

　　What diseases can occur concurrently with fractures of the tibial and fibular shafts?

　　1. When the pressure within the fascial compartment increases due to hematoma and reactive edema in the lower leg fractures or soft tissue injuries such as muscles, it can cause circulatory disorders and form fascial compartment syndrome. Among them, the incidence of anterior compartment syndrome is the highest.

　　(1) The anterior compartment is located on the anterolateral side of the lower leg, where the anterior tibial muscle, long extensor muscle, extensor digitorum longus muscle, third peroneal muscle, common peroneal nerve, and anterior tibial artery and vein are located. When anterior compartment syndrome occurs, the anterolateral side of the lower leg becomes hard and there is marked tenderness, and the pain increases when the toes are passively extended and flexed. The pain is related to the degree of compression of the peroneal nerve, and in the early stage

　　(2) There may be decreased sensation between the first and second toe web, followed by paralysis of the extensor hallucis longus, extensor digitorum longus, and anterior tibial muscle. Since the peroneal artery has communicating branches with the anterior tibial artery, the dorsalis pedis artery can be palpated early.

　　(3) In addition to the anterior fascial compartment, the three compartments at the posterior tibia can also develop this syndrome. Among them, the incidence of posterior deep compartment syndrome is higher than that of posterior superficial compartment and lateral compartment. The characteristics are posterior compartment pain, numbness of the sole, weakened toe flexion strength, increased tension and tenderness of the deep fascia at the distal end of the gastrocnemius muscle when the toes are passively extended, and the pain increases. If the symptoms continue to develop without timely treatment, intracompartmental muscle group ischemic contracture can occur, leading to claw foot. A medial posterior lower leg incision can be made, starting from the origin of the gastrocnemius muscle, longitudinally incising the deep fascia, and it is necessary to incise the perimysium at the same time if necessary, which can achieve the purpose of decompression.

　　(4) Anterior compartment syndrome is formed by the continuous increase of pressure within the compartment, vascular spasm, increased tissue osmotic pressure, and tissue ischemia and hypoxia. Especially in cases of closed tibial and fibular fractures with obvious soft tissue contusions, there is a possibility of developing fascial compartment syndrome, so early fracture reduction and intravenous infusion of 20% mannitol should be performed to improve microcirculation and reduce edema, and strict observation should be made.

　　（5）In addition to the fascial compartment syndrome, the lower mouth of the anterior tibial compartment near the ankle joint is close to the tibialis anterior muscle, the long extensor muscle, and the digital long extensor tendon, which are tightly adhered to the tibia. After the fracture in this area heals and calluses form, it can cause wear of the tendons, leading to symptoms. If necessary, the fascia should be surgically incised to relieve pressure.

　　2. In the case of open tibial fractures with infection, the infection rate is highest in those treated with plate internal fixation after debridement. The reason is that open fractures have already damaged the soft tissues, and fixing with plates with more than 6 holes can strip too much periosteum and soft tissue, thus destroying the blood supply to the tibial fracture site, leading to a high infection rate. In the cases of chronic osteomyelitis after fracture internal fixation that the author has treated in recent years, those with open tibial fractures and plate internal fixation accounted for one-third. The anterior and medial aspect of the tibia is subcutaneous bone. Once infected, the wound can expose the internal fixation and bone surface, leading to healing for up to one year or even several years. Therefore, for grade I open tibial fractures, intramedullary nail fixation can be performed; for grade II, the wound can be debrided and closed, and then intramedullary nail fixation can be performed after the wound heals; for grade III, depending on the condition of soft tissue repair, external fixation can be used first, and then intramedullary nail fixation can be changed after the wound is closed.

　　3. Delayed healing, non-union, or malunion are caused by many factors in the delayed healing and non-union of the tibia, which can be roughly divided into two major categories: factors inherent in the fracture itself and improper treatment. However, regardless of the cause, it is often not caused by a single factor but by several factors coexisting. It is necessary to take corresponding measures for different causes during treatment to achieve the treatment goal.

　　（1）Delayed healing: This is a common complication of tibial fractures. Generally, if an adult's tibial fracture has not healed by 20 weeks, it is considered delayed healing, which accounts for 1% to 17% according to different statistics. Although most cases can still heal with continued fixation, extending the fixation time can exacerbate muscle atrophy and joint stiffness, increasing the degree of disability, and improper treatment can lead to non-union. Therefore, during the period of fracture treatment, it is necessary to observe regularly, ensure firm fixation, and guide the patient in functional exercise of the affected limb.

　　（2）Non-union: Non-union of tibial fractures is characterized by obvious ossification at the fracture ends visible on X-rays. Although there are calluses at both fracture ends, there is no bony union. Clinical signs include local tenderness, pain with weight-bearing, or abnormal movement. Many cases of non-union have inherent factors, such as excessive comminution of the fracture, severe displacement, open wounds, or skin defects. Open wounds complicated by infection are an important cause of non-union. In addition, improper treatment, such as excessive traction, inadequate external fixation, or improper use of internal fixation, can also lead to non-union.

　　①The boundary between delayed healing and non-union of the tibia is not very clear. In cases of delayed healing, the load-bearing of the affected limb can promote fracture healing, but if non-union has already occurred, excessive activity can instead cause the fracture ends to form pseudoarthrosis. Therefore, active surgical treatment should be adopted.

　　②Generally, the tibia does not heal, but if the alignment is good, there is already fibrous connection at the fracture end. During surgery, it is important to protect the soft tissues with good blood circulation around the fracture site, avoid extensive stripping of the fracture site, and implant sufficient cancellous bone around the fracture end. In most cases, this can lead to healing.

　　③ In the early stage or delayed healing stage of nonunion, Brown, Sorenson, and others believe that osteotomy of the fibula should be performed to increase the physiological stress at the fracture end of the tibia, promote fracture healing without bone grafting. However, if a pseudarthrosis has formed at the fracture end, and there is a gap at the fracture end of the tibia after the fibula is healed, bone grafting surgery should be performed at the same time as osteotomy. Mullen and others believe that in the case of nonunion, the simple use of compression plate fixation and early weight-bearing of the affected limb, combined with early functional exercise, can achieve bone union without bone grafting. However, if the fracture alignment is poor and the fibrous tissue at the fracture end heals poorly, it is still necessary to use坚强内固定 and implant cancellous bone. Lottes and others believe that performing medullary cavity expansion and intramedullary nail fixation surgery, at the same time cutting off the fibula, and early weight-bearing of the affected limb after surgery, it is not necessarily necessary to perform bone grafting at the same time. However, according to a large amount of statistical data, the effect of bone grafting at the same time as internal fixation is better than that of simple internal fixation.

　　(3) Malunion: If the reduction of the tibial fracture results in varus, valgus, or angular deformity exceeding 5° in front and back after the fracture, it should be timely replaced with plaster or wedge-shaped incision of the plaster for correction. If there is already bony union, whether osteotomy and correction should be performed should be determined based on whether the function of the affected limb is affected or whether the deformity is obvious; it should not be solely based on X-ray findings as the basis for surgery. In the case of rotational deformity, varus deformity has a greater impact, and generally, a varus deformity of more than 5° can cause abnormal gait, and an external rotation deformity of more than 20° may not have any obvious impact.

　　First, Symptoms

　　1. Fractures of the tibia and fibula are mostly caused by trauma, such as collision injury, compression injury, sprain, or fall from a height, and the injured limb is painful and swelling, and deformity occurs.

　　2. The position of the tibia is superficial, and the local symptoms are obvious. While paying attention to the symptoms of the fracture itself, attention should also be paid to the degree of soft tissue injury. Fractures of the tibia and fibula can cause many local and systemic complications, and the consequences produced are often more serious than the fracture itself. Attention should be paid to whether there is injury to important blood vessels and nerves, especially when the proximal end of the tibia is fractured, attention should be paid to whether there is injury to the anterior tibial artery, posterior tibial artery, and common peroneal nerve; attention should also be paid to the degree of swelling of the soft tissue of the lower leg, and whether there are symptoms of lower leg fascial compartment syndrome such as severe pain.

　　Second, Signs

　　1. It is necessary to observe the shape, length, circumference, and the tension of the entire soft tissue of the lower leg; the skin temperature and color of the lower leg skin; the pulse of the dorsal artery of the foot; the movement of the toes, and whether there is pain, etc. In addition, attention should also be paid to whether there is foot drop, etc. Normally, the inner edge of the foot, the inner malleolus, and the inner edge of the patella should be on the same line. If the tibial and fibular fractures occur, this normal relationship is lost.

　　2. For pediatric fractures, due to the thick periosteum of the tibia, the child can still stand after the fracture, and the knee can also move when lying down. Local swelling may not be obvious, and clinical signs may not be prominent. If there is significant tenderness in the lower leg, an X-ray film should be taken, and attention should be paid not to miss the diagnosis.

　　3. Tibial fractures can be divided into three types:

　　(1) Simple fracture: including oblique fracture, transverse fracture, and spiral fracture.

　　(2) Butterfly fractures: The size and shape of the butterfly bone fragments are different. The butterfly fracture fragments formed by torsional stress are longer, and there may be a fracture line on the butterfly fracture fragments directly struck by a blow.

　　(3) Comminuted fractures: One fracture is comminuted, and there are multiple fractures.

　　This disease is mainly caused by traumatic factors, so safety should be paid attention to in daily life. The focus of prevention is to prevent the occurrence of complications. For fractures at different planes, the direction of displacement is different, and复位 and fixation should be based on X-ray films. Fracture ends with excessive separation are prone to form non-union and pseudo-joints, so joint function exercises should be strengthened to prevent joint dysfunction.

　　If there is a suspicion of vascular injury, lower limb angiography can be performed to clarify the diagnosis. Hospitals with conditions can perform digital subtraction angiography or ultrasonic vascular diagnostic instruments for examination. When there is a traumatic vascular rupture or thrombosis in the lower leg, using an ultrasonic vascular diagnostic instrument for detection may show no arterial pulsation curve on the oscilloscope, appearing as a straight line, and the pen recorder also shows a straight line. In the flow-type Doppler imaging method, it does not show an image either. The ultrasonic vascular diagnostic instrument is a non-invasive examination that is gradually being popularized and applied in clinical practice.

　　Imaging examination: Currently, clinical examination of tibial and fibular fractures still relies on physical examination and routine X-ray imaging. If there is a long oblique or spiral fracture at the lower 1/3 of the tibia or if there is obvious displacement in the tibial and fibular fractures, attention should be paid to whether there is a fracture at the upper end of the fibula. Therefore, it is necessary to take a full-length X-ray film of the tibia and fibula to avoid missing the diagnosis.

　　First, what foods are good for the diet of tibial and fibular shaft fracture patients

　　1. It is advisable to eat more vegetables rich in fiber, and eat bananas, honey, and other foods that promote gastrointestinal digestion and defecation.

　　2. In the early stage, it is advisable to eat foods that promote blood circulation and remove blood stasis, such as vegetables, soy products, fish soup, eggs, etc.

　　3. In the middle stage, it is advisable to eat foods that help and relieve pain, remove blood stasis, and promote the formation of new tissue, such as bone soup, Cordyceps chicken, and animal liver, etc.

　　4. In the later stage, it is advisable to eat more foods that tonify the liver and kidney, nourish Qi and blood, and relax tendons and activate collaterals, which can help in the formation of callus, such as old hen soup, pork bone soup, and sheep bone soup, etc.

　　Second, what foods should be avoided for the best tibial and fibular shaft fractures

　　1. Avoid blind supplementation of calcium.

　　2. Avoid indigestible foods.

　　3. Avoid eating too much meat and drinking braised bone soup.

　　Precautions before the treatment of tibial and fibular shaft fractures

　　First, treatment

　　The treatment goal for tibial and fibular fractures is to restore the load-bearing function of the lower leg. Therefore, the angular deformity and rotational displacement at the fracture ends should be completely corrected to avoid affecting the load-bearing function of the knee and ankle joints and the occurrence of joint fatigue. For adult cases, although it is not emphasized to restore the length of the affected limb to be equal to the contralateral limb, it is still important to ensure that the affected limb is shortened by no more than 1cm, the deformity arc does not exceed 10°, and the alignment of the two fracture ends should be at least 2/3. The treatment method should be selected based on the type of fracture and the degree of soft tissue injury, choosing external fixation or open reduction and internal fixation.

　　1. Manual reduction and external fixation:Applicable to stable fractures or unstable fractures with traction for about 3 weeks, after fibrous healing, external fixation with plaster can be used again.

　　For stable fractures without displacement or stable contact of the fracture surface after reduction, such as transverse fractures, short oblique fractures, etc., manual reduction and external fixation can be performed under anesthesia, that is, long-leg plaster cast fixation. The knee should be kept in a slight flexion of about 20°, and after the plaster cast has dried, crutches can be used for practice of stepping and walking. After 2 to 3 weeks, crutches can be used to practice weight-bearing walking.

　　For unstable fractures with oblique, spiral, or slightly comminuted characteristics, it is impossible to maintain good alignment with simple external fixation: percutaneous needle traction can be performed under local anesthesia, and the fracture can be reduced with a spiral traction frame. Local external fixation is performed with a lower leg cast. After surgery, a continuous traction of 4 to 6 kg is maintained for about 3 weeks. After fibrous healing, in addition to

　　Remove traction and continue to fix with a long-leg plaster cast until bone healing. For stable fractures with good alignment, it can also be considered to use a small splint for fixation. The advantage of small splint fixation is that the range of fixation does not exceed the joint, and the function of the knee and ankle joints is not affected. If good fixation can be maintained and attention is paid to functional exercise, the fracture healing is often faster, so the healing period of small splint fixation is shorter than that of plaster cast fixation. However, the fixation site of the small splint is limited, the pressure is uneven, and the skin at the padding site can be necrotic, so close observation is required. Tight bandaging of the small splint can cause necrosis of the tissue in the intermuscular fascial space of the lower leg, and attention should be paid to avoid this.

　　The advantages of plaster cast fixation are that it can be shaped according to the contour of the limb and is firm. However, if the bandage is too tight, it can cause ischemia of the limb or even necrosis; if the bandage is too loose or the swelling subsides, muscle atrophy can cause the plaster to loosen, and the fracture will inevitably shift. Therefore, it is necessary to observe at any time during the fixation period, and if the bandage is too tight, it should be opened in time, and if it becomes loose, it should be replaced in time. Generally, after emergency fixation of tibial and fibular fractures, it is often necessary to change the plaster cast once every 3 weeks. After the plaster cast is well bandaged, it should not be changed at will to avoid affecting the healing of the fracture. However, regular follow-up should still be carried out to observe whether the plaster cast is loose and to guide the patient in functional exercises.

　　The disadvantages of long-leg plaster cast fixation include the range of fixation exceeding the joint, which leads to a longer healing time for tibial fractures and often affects the activity of the knee and ankle joints. For this purpose, when the plaster cast has been fixed for 6 to 8 weeks and callus has formed, it can be changed to a small splint for fixation and the joint activity can begin. Sarmiento reported that after 4 to 8 weeks of lower limb plaster cast fixation for tibial and fibular fractures, the knee cast (below knee cast) can be used, which means that attention should be paid to the shaping of the tibial condyle and patella during bandaging to reduce the rotation of the tibia. Its shape is slightly similar to the patella tendon bearing prosthesis, making the load-bearing line pass through the tibial condyle along the shaft to the heel. It is believed that this method can reduce the incidence of delayed healing and non-union, and help restore knee function early. Although the fracture ends may be slightly shortened, angular deformity will not occur.

　　2. Open reduction and internal fixation:The healing period of tibial and fibular fractures is generally longer, and long-term external fixation with plaster will inevitably affect the function of the knee and ankle joints. In addition, due to factors such as muscle atrophy and weight-bearing of the affected limb, displacement of the fracture may occur during the fixation period. Therefore, the number of patients with unstable fractures who undergo open reduction and internal fixation is increasing day by day, and different methods and internal fixation methods can be adopted according to different types of fractures.

　　① Screw internal fixation: For oblique or spiral fractures, internal fixation with screws can be used. After open reduction, 1 or 2 screws are fixed at the fracture site to maintain the position of the fracture, and then bandaged with padded plaster. After 2 to 3 weeks, switch to non-padded plaster for fixation for 10 to 12 weeks. However, 1 or 2 screws can only maintain the position of the fracture and only play the role of so-called bone suture (bonesuture), and the fixation is not strong enough. There must be strong external fixation with plaster throughout the treatment period.

　　② Plate and screw fixation: It can be applied to oblique, transverse or comminuted fractures. Due to the thin skin and subcutaneous tissue on the anterior and medial side of the tibia, the plate is best placed on the lateral side of the tibia and deep to the tibialis anterior muscle.

　　③ Intramedullary nail fixation: The anatomical feature of the tibia is that the medullary cavity is wide, and both ends are articular surfaces. Generally, the intramedullary nail is limited in insertion and difficult to control the external force of rotation; also, because the reduction of tibial fracture is relatively easy, and the time for bed traction for unstable fractures is short, the application of intramedullary nails in tibia was not as common as in femur in the past.

　　II. Prognosis

　　After the fracture of the superior and middle third of the tibia and fibula, it usually heals; while the fracture of the lower third often heals late or does not heal. Long-term immobilization leads to dysfunction of the ankle joint.