Tibial Fractures

Tibial fractures are often associated with fibular fractures. For purpose of simplicity the two will be dealt with as a combined fracture here.
In snowboarding tibial fractures are less common then in skiing. This is due to the type of boots worn, and the type of forces applied. The soft-shelled boots in snowboarding adds some protection against this frature, but it has a higher incidence amongst the hard-shelled boot wearers. It is seen due to the forces acting upon the tibia, during a fall, with the top of the boot holding on as a point of fulcrum, and the bone being the weakest in the system usually giving way to fracture.

It must be said that recent advances in the boot technology has helped dramatically in reducing this debilitating and cumbersome injury.

The average time for healing of the tibia is 10 weeks for the minor fractures, but more realistically 20 weekds for the more severe injuries. This time period can easily take 6 months or more to heal.

Clinical Features

• Pain.Following a fall the pain is immediate and sharp. Usually it is such that the person is unable to weigh-bear, but it has been known for some to be able to partial-weight bear until they reach a point of safety, or have been told of the nature of the injury.
• Swelling. there is some degree of swelling and bruising on the skin around the fracture. The skin can be broken or crushed to a degree which is important for the management descision.
• Deformity. The foot is rolled outwards, or the leg seems to be angled and obviously something is amiss!

If the skin is broken then the fracture is deemed 'OPEN' and this requires to a large extent an operation, where as a 'CLOSED' fracture is when the skin is intact and there is no wound.

Closed Fracture

This type of fracture is when the skin overlying the break is intact, ie cuts, puncture wounds or gashes. The skin may be severly contused, and if this is the case then the treatment will be more interventional.
Most fractures can be treated with application of a Full-length cast.

• Undisplaced/Minimal displacement. A full lenght cast from the upper thigh to the fore-foot is applied.
• Displaced. These require the fracture to be reduced under anaesthesia, and X-ray control. A full length plaster like above is placed, the patient is kept under observation for 48-72 hrs. If there is extensive swelling around the fracture, the cast is split.
  
  Following a period of observation to make certain that there are no complications, the patient is allowed home, with partial weight0-bearing.
  
  Follow-up. After 2 weeks an X-ray is taken to make sure that the position of the fracture is held, the plaster is still intact and the patient is still content.
  
  The plaster is retained for upto 8 weeks in children, and not less than 16 weeks in adults!

Excercise

The patient has to excercise the muscles of the foot, ankle and knee. When the patient has the plaster applied, they have to be taught how to mobilise with the plaster, on stairs, and elsewhere as to allow as much mobility as possible. Following removal of the plaster, a Crepe bandage is applied, and the patient must not allow the foot to dangle, but elevate it.

What happens if the fracture slips?

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If the follow-up Xray shows that the fracture is unsatisfactory, then a number of things are attempted:



• Wedging. This is the simplist. A small wedge is place in a cut part of the plaster, and this then attempts to push the fracture back into position. This is done in the out-patient and does not usually require anaesthesia, but some sedation may be used in the more sensitive patients.
  
  
• Open Reduction and internal Fixation
1. External Fixation.
2. Closed intermedullary nailing
3. Interfragmentary screws
4. Plate fixation

Open Fractures

The management of open fractures is as follows:

1. Antibiotics. To reduce chances of infection of the bone, antibiotics are started immediately.
2. debridement. The wound is cleaned immediately. This is done in the Operating Room.
3. stabilisation. The fracture is stabilised either with a n External fixator in contaminated wounds or with internal fixation if the wound is clean.
4. delayed closure. The wound may be left open, and close 48 hrs later in contaminated cases.
5. rehabilition

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