Tibia + fibula #

Types of #’s

• tibial plataeu #’s

  • Undisplaced: No separation of bone fragments.

  • Condylar depression: Articular surface has sunk downwards.

  • Vertical shear: A vertical split through the condyle.

  • Comminuted: Bone is broken into multiple pieces.

• tibial spine #’s (avulsion # of tibial plateau)

• tibia-fibula shaft #’s

What does management of these #’s depend on?

• amount of displacement

• degree of stabilty

• feasibility for surgical fixation

Tibial plateau #’s

• common mechanism = valgus/varus force with axial loading

• high energy (most common pattern = spilitting) = MVA or sport injuries

• low energy = insufficiency fractures, associated w soft tissue injuries (falls in elderly → osteoporosis → typically depressed #’s)

Schatzer’s classification of tibial plataeu #’s:

• Schatzker 1 → lateral split

• Schatzker 2 → lateral split w depression

• Schatzker 3 → lateral depression

• Schatzker 4 → medial depression

• Schatzker 5 → bicondylar

• Schatzker 6 → fracture of both condyles + shaft involvement

Main aims of medical management

• Anatomical reduction of the joint surface: Restoring the normal shape of the bone, especially in articular fractures.

• Stable osteosynthesis: Securely fixing the bone fragments to allow for early healing and mobilization.

• Prevention of complications: Such as joint stiffness, deep vein thrombosis (DVT), and pulmonary embolism (PE).

Conservative management:

• full length POP w ankle in neutral (4 weeks)

• leg brace allowing knee ROM (4 weeks after)

Management/ Physiotherapy treatment of undisplaced #’s

Main aim of physio:

• improve knee joint mvmnt

• prevent loss or ROM of joint or stiffness

Treatment (0-4 weeks):

• Affected leg:

  • isometric co-contractions of muscles around the knee + ankle joint

  • circulation exercises with toes + elevation do leg in extension on bed/chair

  • hip ROM + strengthening exercises

• Maintain/↑ ROM + muscle power of unaffected limbs

• bed mobility (one leg bridging, moving side to side)

• transfer from lying to sitting

• standing + mobs with NWB on affected leg (with appropriate walking aid)

Treatment (4-8 weeks):

• knee in brace (allowing knee movement)

• start AAROM of knee (flex/ext.)

• bed mobility (PWB on knee in bridging)

• continue with crutch walking NWB → PWB @8wks → FWB @12wks

• gradually ↑ WB activities, AROM + strengthening exercises (closed chain) on operated leg from 8 weeks on. → FOCUS ON FUNCTION

Management/ Physiotherapy treatment of displaced #’

Conservative management → skeletal traction (4-6 weeks)

In traction/treatment (0-6 weeks):

• active knee movement (work twrd 90 deg knee flex in traction pain dependent)

• co-contractions/isometric of muscles around knee joint

• circulatory exercises (toes + foot)

• maintain ROM + strength of unaffected leg

• NB = ROM exercises of knee to mould the developing callus

Treatment (> 6 weeks):

• progress ROM of knee + strengthening ecercises of muscles around knee

• transfer from lying to sitting

• standing + mobs with NWB on affected leg (use appropriate walking aids)

• gradually ↑ WB activities, AROM + strengthening exercises (closed chain) on operated leg from 12 weeks on

Management of tibial plateau fractures

Displaced or unstable tibial plateau fractures (especially with condylar depression) require surgical fixation (ORIF), sometimes with bone grafting, and may still need a cast or brace afterwards for additional stability.

Post-op physiotherapy of tibial plateau #’s

• early ROM on affected leg to mould callus

• CPM (continuous passive movements)

• isometrics or co-contractions of muscles around knee

• mobilise NWB crutches until union 2-3 months

• risk of deformity if early WB

• maintain/↑ ROM + muscle power of unaffected limbs

• bed mobility

• NB = bone graft donor site

Complications of tibial plateau #’s

• compartment syndrome

• collateral ligamentous tears → risk of unstable knee

• common peroneal nerve palsy

• late knee instability due to bony collapse + progressive ligament laxity

• secondary osteoarthritis

• meniscal tears (lat more common than med, associated with schatzker 2, med tear = schatzker 4)

TIbial spine #’s

• avulsion # of tibial plateau

• caused by twisting, abduction, adduction of knee

• pull of ACL or PCL

• conservative management → AK POP for 6 weeks

• surgical management → if displaced = ORIF, followed by AK POP

Management/ Physiotherapy treatment of tibial spine #’s

• Affected leg:

  • isometric + co-contractions of muscles around knee joint

  • ROM + muscle power around hip + ankle joints

  • bed mobility exercises

  • maintain/improve ROM/muscle power of unaffected limbs

  • removal of POP → regain ROM/MP of knee joint

Tibia and fibula shaft #’s

• tibia is sucutaneous bone therefore open #’s comon

• poor muscle coverage + poor vascularity = slow healing + increased risk of infection

• compartment syndrome common

• twisting force = spiral # at different levels

• angular force = transverse or oblique #’s

Open #’s classification:(according to severity fo soft tissue damage)

• Type I: Wound <1 cm, clean.

• Type II: Wound >1 cm, no major soft tissue damage.

• Type IIIA: Extensive soft tissue damage but bone covered.

• Type IIIB: Periosteal stripping, bone exposed, massive contamination.

• Type IIIC: Arterial injury requiring repair.

Management of tibia and fibula shaft #’s

Conservative management:

• closed #’s

• AKPOP with ankle in plantar grade for 6 weeks

• wedging of POP possible to correct residual tilt

• calcaneal skeletal traction → when skin viability compromised + massive oedema

• once reduction achieved + soft tissue viable → traction converted to POP

Surgical management:

• exo-fix

  • when reduction unlikely to be maintained by POP

  • compound # (grade 3B)

  • risk of infection + debridement of wound

• ORIF

  • intramedullary nail of shaft of tibia

  • plate + screws

  • fibula refuced w plate + screw if articular involvment

Management/ Physiotherapy treatment of tibia/fibula shaft #’s

• affected leg

  • isometrics + co-contractions around knee + ankle joints

  • maintain or improve ROM + muscle power around hip joint

• unaffected limbs maintain → maintain/↑ ROM + MP

• bed mobility

• mobilise from lying-sitting-standing w walking aid

• NWB mobs w crutches

• NB to elevate pt leg when sitting → To reduce post-injury oedema, thereby reducing pain, speeding healing times, and ensuring skin viability over the fracture/surgical site

Physiotherapy after surgical management:

• affected limb

  • aim = regain knee and ankle ROM → observe level of pins in exofix

  • note surgical approach for intermedullary nail (NB quads)

  • regain active muecle power → hams, quads, tib ant, gastros, peroneii, tib post

• unaffected limbs

  • maintain/↑ ROM / MP

  • bed mobility

  • mobilise NWB for exofix for 6 weeks

  • FeWB → PWB for ORIF for 6 weeks

  • if split skin graft → no passive stretching or isotonic / active exercise for 5 days post-graft

    • once SSG stable → continue with gentle stretching + isometric exercises

Isolated #’s of the fibula

• usually secondary to direct blow

• symptomatic treatment

• NWB bone therefore does not need reduction or fixation unless articular involvement

• mobs PWB w crutches until acute pain aubsides

• NB strengthening of peroneii

Fracture of the patella

• mechanism of injury

  • direct violence (dashboard + knee → comminuted #)

  • indirect violence (strong muscle contraction pull off patella → transverse #)

Types of # patterns

• comminuted #
  transverse #

• undisplaced #

• displaced #

Management / physiotherapy treatment of patella #’s

Undisplaced #

• conservative management

• AK POP locked in extension for 6 weeks

Physiotherapy:

• co-contractions and isometric of muscles around knee

• ROM + MP of hip and ankle (above and below!)

• mobilise w crutches NWB for 4-6 weeks

• bed mobility exercises

• maintain ot improve ROm + MP in unaffected limbs

Displaved #’s

• associated w rupture of knee extensors (quads)

Surgical management:

• ORIF

• tension band wiring or K-wire to stabilise # or screw fixation

Dislocations of the patella

• patella forced laterally put of groove

• May self-reduce or stay displaced.

• Atraumatic form more common in females (shallow groove, hypermobility).

• Symptoms: Sudden pain/giving way on twisting/jumping, “popping” sensation.

• Exam: Apprehension test (+), pain medially & with quadriceps contraction, limited flexion, marked swelling.

• X-ray: To rule out fracture.

Management of dislocations of the patella

• conservative for both traumatic and atraumatic

• closed reduction

• cylinder cast → 4-6wks

• aim to prevent reccurence

• rehab is essential (NB vastus medialis obliquus exercises between 0-15 deg)

Complications of tib-fib #’s

• Non‑union: No union by 16 weeks → bone grafting indicated. Smokers at higher risk.

• Malunion: Caused by inadequate reduction or failure to maintain reduction.

• DVT: Pain on passive ankle dorsiflexion, increased calf swelling, warmth, redness, tender calf squeeze, fever.

• Peroneal nerve palsy: Neck of fibula fracture → foot drop; motor weakness + sensory deficit (decreased/absent sensation).

• Infection (open fractures): Spiking fever, wound oozing, swelling.

• Cause: Increased pressure within a muscle compartment (e.g., proximal third tibia fracture).

• Pathophysiology: Oedema → rising pressure → capillary blood flow reduced → ischaemia → necrosis within hours.

• Timing: Muscle dies in 6–8 hrs (fibrosis → Volkmann's contracture); nerves die in 2–4 hrs (permanent motor/sensory loss).

• 5 P's: Pallor, Pain (on passive stretch), Paraesthesia/anaesthesia, Pulses present (late sign), Progressive weakness → Paralysis.

• Management: Fasciotomy to reduce pressure

• Ankle stiffness complications:

  • POP must keep ankle in plantigrade (prevents equinus deformity).

  • Leads to ↓ ROM, ↓ muscle power, gait abnormalities.

  • Early OA (due to articular damage or malalignment).

  • Severe disability → osteotomy, arthrodesis, joint replacement.

  Popliteal artery occlusion (e.g., proximal tibia # or knee dislocation):

  • Caused by raised compartment pressure or bony fragment laceration.

  • Signs: Cyanosed (blue) skin, cold extremity, absent/weak popliteal/DP pulse, numb toes.

  • Requires immediate arterial repair.