Chapter 21

The tibia is the only weight-bearing bone in the leg. The fibula is bound to the tibia by the interosseous membrane, which divides into a “Y” both proximally and distally. The proximal arm of the “Y” is composed of the anterosuperior tibiofibular ligament and the posterosuperior tibiofibular ligament. A similar division occurs distally with an anterior and posterior inferior tibiofibular ligament. The fibula is of little importance in its upper portion, which can be excised with little consequence. The lower portion cannot, because of its importance in forming the ankle mortise.

The muscles of the leg are enclosed in four fascial compartments: anterior, peroneal, deep posterior, and superficial posterior compartments. The anterior compartment comprises the ankle and foot dorsiflexors and the posterior compartments (superficial and deep) contain the plantar flexors. The peroneal compartment houses the foot evertors.

### Tibial Shaft Fractures

Tibial shaft fractures are the most common long bone fracture in the body. Because of its superficial location in the leg, it is also the most common open fracture.

Because the tibia and fibula run parallel to each other and are tightly bound together by ligaments, a displaced fracture of one bone is frequently associated with an obligatory fracture of the other bone.

Tibial shaft fractures are classified on the basis of principles established by Nicoll.1 Three factors determine the outcome of tibial shaft fractures:

1. Initial displacement

2. Comminution

3. Soft-tissue injury

Fractures are divided based on displacement into three groups: (1) <50% displacement, (2) >50% displacement, and (3) complete displacement or severely comminuted (Fig. 21–1). Tibial shaft fractures with <50% displacement have a 90% chance of union, whereas fractures with complete displacement have only a 70% chance of union.

###### Figure 21–1.

Fractures of the tibia and fibula shaft. Tibia shaft fractures can occur alone but are treated similarly to combined fractures.

The degree of associated soft-tissue injury is an often unrecognized factor affecting prognosis and treatment of the fracture.2,3 Fractures associated with significant contusion of the overlying skin or muscles are associated with higher infection rates and poorer healing. The average healing time for uncomplicated, nondisplaced fractures is 3 months. For displaced, open, or comminuted fractures, the average healing time is 4 to 6 months.

#### Mechanism of Injury

Multiple mechanisms may result in fractures of the tibia and fibula shafts. Direct trauma is a common cause of injury and usually results in associated soft-tissue injury. These fractures are frequently secondary to automobile collisions and typically result in transverse or comminuted fractures.

Indirect trauma is associated with rotary and compressive forces, as from skiing or a fall, and usually result in a spiral or oblique fracture. Rotary forces occur when the leg and body rotate around a planted foot. These injuries are most likely to cause a spiral fracture. Bending forces may also result in a ...

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