Lower Leg Fractures

Essentials

• Risk of serious complications is associated even with an ordinary lower leg fracture (e.g. compartment syndrome Muscle Compartment Syndromes, deep venous thrombosis Deep Vein Thrombosis or fat embolism).

First aid

• Straighten the limb if it is distorted due to the injury, by pulling along the axis.
• Apply a splint to provide support, and elevate the limb with the aid of pillows.
• In the case of an open fracture, remove any loose foreign material from the wound and cover it with sterile, damp dressings and drapes. Start antimicrobial prophylaxis, and ensure that the patient is covered against tetanus.
• If the patient has suffered a vascular injury or some other severe soft tissue injury, inform the ultimate place of treatment in advance before transferring the patient.

Diagnosis and choosing the place of treatment

• Clarify the mechanism of injury and the associated energy.
• Examine the innervation and blood circulation (pulses with doppler if necessary, sensation, colour and temperature of the limb).
• X-rays of the limb should be taken (anteroposterior and lateral projections) in such a way that both the knee and ankle joints are included in the radiographs.
• It is important to differentiate between low energy and high energy injuries.
  • Any hospital treating lower leg fractures must be able to provide plastic surgery services as well.

Classification

• The extent of soft tissue injury associated with a closed tibial fracture is assessed by Tscherne classification using four grades (table T1).
• The Gustilo and Anderson classification, with three grades, is usually applied in the classification of open fractures (table T2).

Conservative treatment

• Lower leg fractures are treated conservatively in exceptional cases only. Conservative treatment is reserved only for the treatment of those non-displaced stable fractures where an acceptable position can be achieved without anaesthesia, or when surgical treatment is contraindicated.
• After the application of a long-leg cast, the position of the fracture is checked by radiography.
• The patient is taught crutch walking and muscle exercises.
• The fracture must be so stable that the patient can start cautious partial weight bearing after the cast has dried.
• Radiographs of the leg are to be taken 1-2 weeks and 4-6 weeks from casting.
• About 4-6 weeks after applying the cast, the stability of the fracture is tested and an evaluation is made whether the long-leg cast can be changed to a short-leg cast Cast Treatment of Lower Extremity Fractures or an orthosis.
  • An orthosis is applied on the patient if the fracture is stabilizing, if its position is still acceptable and if the patient - after removing the cast - is able to lift the limb with no pain and no deformity at the fracture site.
  • Give instructions on weight bearing according to pain and on muscle exercises.
  • Follow-up visits at an outpatient clinic take thereafter place every 3 weeks. Radiographs are examined and the stability of the fracture tested.
  • Use of the orthosis may be discontinued once the fracture is stable on the basis of clinical evaluation, the bone union is adequate based on radiographs, and the patient is able to bear weight on the limb without assisting devices.
• If adequate stabilization of the fracture is not reached within 12 weeks, intramedullary nailing is usually performed.

Surgical treatment

• Intramedullary nailing
  • The basic method of surgical treatment of lower leg fractures consists of reamed, locked intramedullary nailing Treatment of Tibial Shaft Fractures. Reaming refers to the enlarging of the medullary cavity by drilling.
  • Reamed intramedullary nailing is recommended as the first-line treatment both in closed lower leg fractures and in grade I-II open fractures (table T2). The method may also be applied in more severe open fractures.
• Plating
  • Superior to conservative treatment in low-energy, closed tibial shaft fractures
  • May be used in low-energy, proximal and distal metaphyseal fractures where an intramedullary nail would not provide satisfactory stability.
  • Locking plates have proven to be practical.
• External fixation
  • External fixation is used in high-energy, proximal and distal fractures when intramedullary nailing is not appropriate.
  • External fixation may also be used as temporary treatment before intramedullary nailing or plating.
  • In highly contaminated open fractures, external fixation is likely to be a safer option than intramedullary nailing.

Complications

• Smoking slows bone union in lower leg fractures and increases the frequency of complications in comparison to non-smoking patients.
• Acute compartment syndrome Muscle Compartment Syndromes
  • Prevalence 5-9%
  • Early symptoms include pain at the site of the compartment and pain induced by stretching the muscle.
  • Treatment of acute condition by fasciotomy within 6 hours from the onset of symptoms
  • If left untreated may result in permanent damage to the nerves and muscles.
• Deep vein thrombosis (DVT)
  • Prophylaxis against DVT with low molecular weight heparin is used in all patients with lower leg fractures, at least for the duration of hospitalization. See also Prevention of Venous Thromboembolism
  • Antithrombotic prophylaxis has not been shown to be effective in fractures below the knee, but should a thrombus occur it is reimbursed as a patient injury according to the local policy.
• Infections
  • Antimicrobial prophylaxis is recommended in association with surgical treatment.
• Failure of union
  • Failure of union (at 9 months after injury) occurs in 2-3% of all tibial shaft fractures and delayed union (at 4 months after injury) in 4-5%. In open fractures, failure of union is much more common.
  • Treatment options include dynamization of the intramedullary nail, exchange nailing or bone grafting.

Aftercare

• After the surgery, a light compression bandage should be applied to the limb. The limb should be kept elevated for several days if needed and, at the same time, mobilisation of the ankle and knee should start as well as muscle exercises.
• Swelling, pain and circulation of the limb should be closely monitored. The possibility of compartmental syndrome should be borne in mind.
• Walking exercises are usually started on the first postoperative day using elbow crutches or other aids.
• Weight bearing is dependent on the individual case and is allowed according to the instructions given by the operating surgeon. Usually the patient is allowed to bear the weight of the limb (touch-down weight bearing) immediately after surgery.
  • In non-comminuted fractures with well aligned fracture fragments, weight bearing as tolerated may be started already in the hospital, progressing to full weight bearing.
  • Otherwise, weight bearing is increased individually. The general aim should be to achieve partial weight bearing (50% of body weight) by week 6, progressing thereafter to full weight bearing.

• After the operation, a padded compressive dressing is applied on the lower limb. The limb is kept elevated until the swelling starts to subside.
• The ankle and knee joints should be mobilized immediately after surgery if possible. Touch-down weight bearing is allowed with the patient wearing a supportive bandage, an orthosis or a removable cast boot for 6-8 weeks, progressing thereafter to partial weight bearing.
• Full weight bearing is started in accordance with the clinical and radiological situation, usually about 8-12 weeks after the surgery.

Isolated fracture of the fibula

• If the trauma mechanism involved torsion of the ankle or the patient's ankle is otherwise painful and swollen, a rupture of the ankle syndesmosis may be associated with a fracture of the fibula.
• An isolated fracture of the fibula is caused by direct trauma and usually involves the middle-third of the fibular shaft. In this case, the ankle will be pain free.
• A proximal or shaft fracture of the fibula may be associated with a ligament injury of the knee, an arterial injury, a peroneal nerve damage or the compartment syndrome.
• Concerning treatment choices of proximal and shaft fractures of the fibula, consult a general or orthopaedic surgeon.
• The treatment of an isolated, nondisplaced fracture of the fibular shaft consists of bandaging the leg from the base of the toes to below the knee. The support bandage should be worn for 2-3 weeks.
• Surgical treatment is seldom warranted in isolated fracture of the fibula. It may consist of fixation of the fracture with a plate or a locking plate.