Clinical evaluation
1. General considerations
Tibial fractures are common.
The isolated tibial shaft fracture is the most frequent fracture of the lower extremity (70% isolated vs 30% both bone fractures).
Toddler’s fractures
Toddler’s fractures are usually isolated, undisplaced spiral fractures of the tibial shaft. The mechanism is a torsional force in the infant < 4 years of age. These fractures are often not seen on an initial x-ray.
Skeletal maturity
The age of proximal tibial physeal closure is variable and should be assessed individually.
In a skeletally mature patient, adult proximal tibial fracture patterns occur and should be treated using adult principles.
If rigid nailing is considered, skeletal maturity and the stage of the physeal closure should be assessed to avoid iatrogenic physeal injury.
2. Patient assessment
Symptoms and signs
- Pain
- Local swelling
- Inability to walk
- Deformity of the injured leg
Clinical signs that suggest an evolving compartment syndrome include:
- Pain, unrelated to the posture of the limb, made worse by passive movement of muscles in the relevant compartment
- Paresthesia
- Progressive loss of light touch sensation
Later signs include:
- Muscle weakness
- Established ischemia
Clinical suspicion of an evolving compartment syndrome is a surgical emergency.
Physical examination
Check for soft-tissue injuries and neurovascular compromise.
Check for injuries at other sites, especially in high-energy trauma, using standard assessment algorithms (ATLS).
Check for localized bone tenderness.
Check for signs of compartment syndrome.
Measure the intracompartmental pressures in unconscious patients.
3. Preliminary treatment principles
Splinting the affected limb reduces pain and secondary muscle damage.
Circular casts should not be applied to the acutely injured limb.
