CHAPTER 81

The tibial shaft

81.1 Introduction

81.2 The principles of treatment

The tibia is the most common major long bone to be injured.

It has a long subcutaneous surface, so fractures of the tibia
are the commonest open fractures. If you dont treat these
fractures carefully, they cause much disability. As you see
from the long list of difficulties we give later (81.13), they
really can be difficult.

Internal fixation is possible, but is never advisable under

the conditions for which we write (69.1). External fixation
is also possible, but the standard equipment for it is expensive ($ 2000 for a single tibia), and you need special training
to use it. Simpler methods of external fixation are being devised, and when these have been adequately evaluated, they
may be described in later editions of this manual. The only
method of external fixation we do describe is the incorporation of two Steinmann pins in a cast (81.12).
Fortunately, you can use the closed methods described in
this chapter for all the fractures of a patients lower leg. They
avoid an operation, and the simpler ones require only a few
days admission to hospital. They do not always succeed,
but your failures will be less awful than those of internal
fixation. You will at least avoid the distress of seeing a metal
plate firmly fixed in a dead ununited bone at the bottom of
a wound pouring pus.
The fragments of a patients broken tibia are much more
likely to unite satisfactorily, if. (1) You get the fragments into
an acceptable position to begin with. And (2) you let him
walk on his fracture inside a snug well fitting cast early, and con-

EXAMINING THE LOWER LEG The patients anterior superior iliac spine, the middle of his patella, and his big toe
are usually in a straight line. Compare them with his uninjured leg. If he has had a leg injury, and they are not in line,
suspect a fracture.
Feel the subcutaneous border of his tibia, and spring his
fibula on it, by squeezing them together. If either of them is
fractured, this will be painful.
Have you examined his dorsalis pedis and his posterior
tibial pulses? Test his peroneal nerve for power (Can he
extend his toes?) and sensation (Can he feel a pin prick on
the dorsum of his foot?). Record your findings before doing
anything else.
X-RAYS Take an AP and a lateral view.
Raising an injured lower leg in a distal limb injury: (1)
Eases the patients pain. (2) Reduces the swelling. (3)
Minimizes the stiffness that follows the organization of any
oedema fluid. (4) Enables you to apply a cast to a limb
from which most of the swelling has gone. This will make
it less likely to become loose subsequently. So splint and elevate all leg fractures before you manipulate them, operate
on them, or put them in a cast. Elevate a patients injured
leg during an operation, and in the ward afterwards. Elevate
it from the moment you see him in casualty, until swelling is
no longer a problem. Resting his leg on a chair or on pillows
is not enough. His injured leg must be higher than his heart.
So, raise the end of his bed on a stool or chair, or on 30 cm
blocks for several days if necessary. Encourage him to move
his foot and ankle actively, so as to improve the circulation
in his calf muscles. Explain how important this is to all your
ward staff.

RAISE ALL SEVERELY INJURED LEGS

ELEVATE AN
INJURED LEG

watch the
circulation
in his toes

No!

This is not
good enough

fractured tibia
cast split

pillows

Fig. 81.1: RAISING AN INJURED LEG: (1) Eases the patients pain. (2)
Reduces the swelling. (3) Minimizes the stiffness that follows the organization of oedema fluid. (4) Enables you to apply a cast to a limb from
which most of the swelling has gone. Kindly contributed by Peter Bewes.

81 The tibial shaft

tinuously. Start as soon as the swelling has subsided, during

the first few days after the injury, and sometimes as early as
the first day. Early weight bearing will not make infection
worse, but it may shorten his leg 1 or 2 centimetres, particularly in oblique fractures, where one fragment can easily
slip over another. Although this is not ideal, it is not important, because he can, if necessary, compensate for up to 4
cm of shortening by tilting his pelvis, or, if he wears shoes,
by having one of them raised. You can, however, usually
prevent excessive shortening by a short period of traction to
start with. A little shortening (78.1) is a small price to pay
for the much greater certainty of union. But there is no way
in which he can compensate for the nonunion which all too
often complicates attempts to prevent shortening. Shortening is even less important in children, because a childs fractured tibia will grow faster than his normal one on the other
side, and will compensate for some, if not all, of it.
Although traction for 6 weeks or more is very useful for
treating fractures of the femur, never apply it for more than 2
weeks for an uninfected fracture of the tibia, because traction for
longer than this encourages nonunion. Sometimes, if a tibial fracture is open and infected, you may need to apply traction for as long as 3 weeks while you treat the patients soft
tissue injury. Apply traction from a Steinmann pin through
his calcaneus (70.12), or his distal tibia (80.5). If his fracture
is open or badly comminuted, his leg swollen, and his circulation poor, a week or two in traction will help to align the
fragments while his soft tissues heal. Some surgeons apply
traction to all but the easiest transverse tibial fractures. Others use it only for severely comminuted open ones. As with
the femur (78.4), try not to distract the fragments.
Uncomplicated fractures of an adults tibia take 16 weeks
to heal. Childrens fractures heal faster. Healing is delayed
if the tibia is comminuted, if soft tissue injury is severe, or
if a fracture is open or infected, union may take a year or
more.
Dehne E. and Nitz et al. The treatment of Fractures by Direct Weight
bearing.

enough to bear his weight. (4) He may have to walk several

kilometres in the rain, so if it is likely to get wet, paint it with
oil paint. (5) Fit his cast with a stirrup or, less satisfactorily,
with a walking heel, which will raise it out of the mud and
puddles. A stirrup will last longer because it is stronger and
will distribute his weight more evenly. You will get the stirrup back when you change his cast, so a stock of stirrups is
a useful investment. If you fit a walking heel, the patient
should be able to pivot on it. This means that: (a) it must
be sufficiently narrow, which is why trying to mould a sandal to the sole of a cast is less satisfactory, (b) it must project
about 2 cm below the sole of the cast to allow his foot to
rock, and (c) it must be aligned with the anterior surface of
his tibia.
There is no point in removing any leg cast, unless it is
loose, until the patient is walking on it painlessly without a
stick. If he is walking with pain or difficulty, the cast usually
needs to be replaced with another one in which treatment
can continue.

DONT REMOVE A CAST UNTIL THE PATIENT IS WALKING

PAINLESSLY WITHOUT A STICK

81.4 A long leg walking cast

This is the first cast for an unstable fracture of the tibia. Its
purpose is to immobilize the fragments and to get a patient
walking as soon as he can.
(1) Make sure that a patients foot points in the right direction to begin with, because a foot which points in the wrong
direction is a great disability, especially if it points inwards.
So, in all tibial and malleolar casts (82.6), make sure that his
foot points in the same direction in relation to his knee on the injured side as it does on the normal one.

Journal of Trauma 1961;1:514535

MAKE SURE HIS FOOT POINTS

IN THE RIGHT DIRECTION
GET THE FRAGMENTS INTO AN ACCEPTABLE POSITION
GET THE PATIENT WALKING EARLY INSIDE A CAST

81.3 Casts for the lower leg

A patient can walk and bear weight in any of the following
three casts. In order of decreasing stability, but increasing
mobility and , convenience, they are: (1) a long leg walking
cast from his groin to the bases of his toes, (2) a short leg
walking cast from just below his knee to the bases of his
toes, and (3) a plaster gaiter from just below his knee to just
above his ankle. A long leg cast is applied first, and renewed
if necessary, followed by shorter ones as his fracture heals.
If a patient walks on the sole of his cast it soon becomes
useless, and children, especially, rapidly wear through the
soles of their casts. So the way in which a cast is made is important: (1) The patients ankle should usually be in neutral.
(2) His heel and his foot must also be in neutral and not be
everted or inverted. (3) The sole of the cast should be strong
2

lower fragment

this angle varies from one

patient to another

Fig. 81.2: MAKE SURE THE PATIENTS FOOT POINTS IN THE

RIGHT DIRECTION. Some patients have feet which are almost parallel, like patient A. Others, like patient C, have markedly externally rotated
feet. Symmetry is more important than making sure that a patients feet
always point in the same direction as his patella. Patient As cast was
applied with the lower fragment in too much external rotation. This is undesirable, but too much internal rotation would have been worsesee Fig.
78-3. Kindly contributed by John Stewart.

81.4 A long leg walking cast

neck of his fibula.

CAUTION! (1) If you neglect to pad the neck of the patients fibula, the cast may compress his common peroneal
nerve and cause foot drop. (2) Dont apply the cast with his
leg horizontal, because controlling the position of the fragments will be more difficult. (3) If you fail to align the fragments, union will take longer and his leg will be crooked.
Make the cast in two parts.

A LONG LEG
WALKING CAST
A

align the
fragments
pad his
leg

let his leg

hang down

First part. Use two 15 cm plaster bandages to make a thin

belowknee cast which is just strong enough to control the
fragments. This is easily done if the patients knee is flexed
over the end of the table so that gravity helps to align the
fragments.

apply the distal part

of the cast

distal part of the

cast now firm

I
E
these are the
parts of a
walking heel

support cast
complete the
upper part of
the cast

rubber
this is the result
of not fitting
a walking heel

No!

heel protrudes far enough

to allow foot to rock

walking heel aligned with

anterior surface of tibia

Fig. 81.3: MAKING A LONG LEG WALKING CAST. A, the patients

leg must hang down so that you can align the fragments more easily. B,
applying the padding. C, applying the distal part of the cast. D, the distal
part of the cast is now firm and the upper part is being completed. E, and F,
a locally made walking heel. G, how a walking heel should be aligned with
the tibia. H, what happens if you dont fit a walking heel. I, if possible, fit
a stirrup like this. Kindly contributed by John Stewart.

(2) The cast must stop the distal fragment rotating on the
proximal one, and so delaying union. When union is well
advanced, rotation is less likely, but the fragments can easily rotate in a recent fracture. Prevent the proximal fragment
from rotating by applying a long leg cast with the patients
knee in 15 of flexion. Prevent the distal fragment from rotating by including his foot and ankle in the cast.

MAKE SURE THE PATIENTS FEET ARE SYMMETRICAL

PREVENT THE FRAGMENTS FROM ROTATING ON ONE
ANOTHER

A LONG LEG WALKING CAST

Let the patients leg hang over the end of the table. If he is
conscious, let him sit on the table. If he is anaesthetized,
pull him down to the end of the table, and let his legs hang
over it.
Pad his injured leg paying especial attention to his malleoli, the subcutaneous surface of his tibia, and the head and

Second part. When the below-knee part of the cast has

hardened, ask one assistant to hold the patients lower leg,
and another one to support his thigh. Cover the first part
of the cast with a further layer of plaster from his toes to
his groin, with his knee in 15 of flexion. If you apply it in
full extension, it will be less effective in controlling rotation,
and his knee will be painful. Apply enough layers of plaster
bandage for the upper part of the cast to grip the lower part.
Incorporate medial and lateral slabs to strengthen the knee
part of the cast. Finally, apply some more turns of bandage
to make the upper part adequately strong.
CAUTION! (1) While you are applying the cast, check the
position of the patients ankle carefully; it should be in neutral, and neither inverted nor everted. (2) Make sure that his
foot has the same relation to his patella as on the uninjured
side. (3) A normal tibia has a slight natural inward bow, so
try to restore this. (4) Make a shelf of plaster under his toes,
to protect them and prevent flexion contractures. (5) Take
care to strengthen the knee, and the ankle parts of the cast,
because these are its weakest places.
If the patients fracture is very recent, split the cast from
top to bottom that evening (70.4). Monitor the circulation in
his feet meanwhile. Make sure you split the cast on the same
day that you apply it, but dont split it immediately, because
the junction of the top to bottom parts of the cast take an
hour or two to become sufficiently firm to split.
If he has been in calcaneal traction for 2 weeks, any
swelling will have gone, so there is less need to split the
cast.
Dont worry about a little angulation in a recent fracture. If
necessary, correct this 2 or 3 weeks later, when the healing
bone at the fracture site is still soft, and more stable. Either
wedge the cast (70.7) or, preferably, replace it by another
one with his leg in a better position. Replacing a cast is
safer and less likely to cause pressure sores than wedging.
CAUTION! (1) If possible, admit him, so that he does not
walk on his cast until it is dry and hard. This may take 24
hours or more in wet weather. If he walks on a soft cast, it
will soon become useless. (2) Be sure to tighten or renew
the cast if his leg becomes loose within it. If you fail to do
this, the fragments may displace.
CLOSING A CAST If you split it and the swelling has gone
down, close it with a few turns of plaster bandage.
If it is loose, remove a small strip of plaster from the front
of it, and then close it with with a few turns of plaster bandage. This is easily done with an electric cast cutter.
FIT A STIRRUP OR A WALKING HEEL Either fit them
immediately, or later, when the patients wound is no longer
3

81 The tibial shaft

a problem and he can manage crutches. If possible, fit a

metal stirrup. If you dont have one, fit a walking heel. There
are several ways of making a heel. Even a piece of wood is
better than nothing: (1) Nail a piece of car tyre to a wooden
block, mould this to the cast with a plaster bandage, and
bind it on with more bandages, as in Fig. 81-3. (2) Cut a
piece from the tyre of a small car, put this around the cast,
and hold it in place with laces.
ALTERNATIVELY: (1) Start the cast by applying medial
and lateral slabs, or a posterior slab only. This will make
a smoother cast. (2) Incorporate strips of bamboo in the
cast, particularly across fracture lines and joints. This is a
considerable economy in plaster.

TRIANGULAR
COMPRESSION

the leg below the knee is triangular

in cross section, this enables you
to anchor a below knee cast

oblique
upper end

pressure with
your fingers

GOOD

BAD

DIFFICULTIES WITH LONG LEG CASTS

If the patients ANKLE SWELLS when the cast is removed, treat it by raising his leg, asking him to do exercises, and compressing the swelling with a crepe bandage.
Swelling is so common as to be normal, and soon improves.
If his KNEE IS STIFF when you remove the cast, one
reason may be that you left it on too long.

DONTT LET A PATIENT WALK HOME IN A WET CAST

thickness
where it
is needed

unnecessarely
thick

Fig. 81.5: TRIANGULAR COMPRESSION. While a short leg cast is

setting, compress its upper end so as to mould it to the patients leg.After
Sarmiento.

81.5 A short leg walking cast

You can use a shorter cast to protect a fracture of the middle or lower third of a patients tibia as soon as the fracture has become stable and the swelling has gone. A shorter
cast is not absolutely necessary, and some surgeons dont
use them. The advantages of a short cast are that: (1) It allows a patient to move his knee earlier; if you fit him with

A SHORT LEG
WALKING CAST

a gaiter, as described in the next section, he can also use his

ankle earlier. (2)A short cast uses less plaster than a long
one.
As with a long leg cast, try to prevent the fragments from
rotating. There are two ways you can do this: (1) You can
mould the cast carefully to the patients upper leg, using
Sarmientos total contact method of triangular compression,
as described below. Or, (2) you can pass a Steinmann pin
through the upper end of the patients tibia and incorporate
it in the cast. This is the most certain method, and is the one
to use if he has a fracture of his femur in the same leg (78.6).
Sarmiento A, A functional below knee cast for tibial fractures.
Journal of Bone Joint Surgery. 1967; 49A: 855
Sarmiento A, Below the knee total contact cast.

cast moulded around

patellar tendon

cast allows knee

to flex

Fig. 81.4: A SARMIENTO TYPE SHORT LEG WALKING CAST is

applied with the patients knee flexed to 90. It has an oblique upper edge,
and is moulded by triangular compression, as in the next figure.

Clinical Orthopaedics. 1972;82:213

A SARMIENTO SHORT LEG WALKING CAST Apply a

cast from just proximal to the patients toes, to as high as
possible in his popliteal fossa with his leg bent to 90 . Bring
the cast above his tibial tuberosity in front, and below his
popliteal fossa behind, so that it has an oblique upper end
as in Fig. 81-4.
As the cast hardens, apply compression between the patients upper calf and the anterior surface of his leg, as in
Fig. 81-5. This will give the cast a triangular crosssection,
as in A in this figure, and help to prevent rotation.
CAUTION! (1) Triangular compression is safe in a short
leg cast, where muscular activity can relieve excessive pressure. But, dont apply it in a long leg cast, because pressure
necrosis can occur. (2) Dont try to economize by cutting
off a long leg cast below the knee. It is always loose and
unstable.

81.8 Fatigue fractures of the tibia

FRACTURES OF A
SINGLE BONE

MAKING A PLASTER GAITER

CHILDREN

adhesive
strapping

padding

strapping turned up

strapping incorporated
in cast

Fig. 81.6: MAKING A PLASTER GAITER. Use this for protecting fractures of the middle third of the tibia as it heals. Kindly contributed by Peter
Bewes.

81.6 A plaster gaiter

This is the simplest and lightest leg cast; it is the easiest one
to walk with, but it is also the least secure. Use it for protecting fractures of the middle third of the tibia, after union has
taken place. It does not provide enough stability for fractures
of the proximal or distal thirds. If you put it on immediately
after a patient has been in a long leg cast, his foot and ankle
will swell immediately. Some surgeons dont use gaiters.
MAKING A PLASTER GAITER Apply pieces of adhesive
strapping to either side of the patients leg, as if you were going to apply traction. Pad his leg and especially his Achilles
tendon. Then apply the cast. Just as you apply the last layer
of plaster bandage, fold up the two pieces of strapping and
incorporate them in the cast. They will stop it slipping down
his leg and rubbing against the top of his foot.
As the cast sets, mould it around the expanding upper and
lower ends of his tibia, so that it grips them firmly. His knee,
foot, and ankle should be free.

81.7 Closed fractures of the shaft of the tibia

(alone) in adults
Two kinds of injury can break an adults tibia without breaking his fibula: (1) If his leg is struck from the side, it may
break transversely or obliquely, leaving his fibula intact, and
thus able to splint the fragments, so that they shift very little.
(2) A combination of compression and twisting can cause a
long spiral oblique fracture with almost no displacement,
and very little soft tissue injury. These fractures usually heal
rapidly.
CLOSED FRACTURES OF THE SHAFT OF THE TIBIA IN
ADULTS
REDUCTION If displacement is minimal, leave the fragments as they are. If displacement is significant, anaesthetize the patient and reduce them.
Apply a long leg cast or medial and lateral splints, held
with a crepe bandage until the acute swelling has subsided.
Close the cast, fit a walking heel, get the patient up as soon
as he can bear weight with crutches, and make him bear
weight on his leg.

long spiral
oblique

short
oblique

transverse transverse

spiral

solitary fracture
of tibia

Fig. 81.7: FRACTURES OF THE SHAFT OF A SINGLE BONE IN

THE LOWER LEG. A, a long spiral oblique fracture heals readily. B, a
short oblique fracture takes longest to heal. C, a transverse fracture. D,
and E, transverse and spiral fractures of children. F, a fracture of the fibula
only.

If he has a long, spiral oblique fracture, discard the

long leg walking cast in about 6 weeks, and apply a protective gaiter for another 2 weeks.
If he has a transverse fracture, it will probably take 12
to 16 weeks to heal. It will heal sooner if the fragments are
nicely impacted and he starts weight bearing immediately.
If the fracture is in the middle third of his tibia and has
united, fit a plaster gaiter (81.6). If the fracture is elsewhere,
fit a short leg walking cast. Continue protection until he has
no pain when you spring his tibia and fibula together. As
soon as his tibia is solid and no longer springy, remove the
cast or gaiter.
If he has a short oblique fracture, expect it to heal more
slowly due to the shearing stress. Remove his long leg cast
at 8 weeks, and test for clinical union (69-4).
If clinical union is not present, apply a close fitting short
leg cast, as in Fig. 81-4, for another 6 weeks.
If clinical union is present, apply another long leg walking cast for 6 weeks, or a Sarmiento short leg walking cast
(81.5).

81.8 Fatigue fractures of the tibia

Bones need to get into training in the same ways as soft tissues. If they are repeatedly stressed without adequate training, they may break as fatigue fractures. This can happen
when an athlete starts sudden training, when a raw recruit
starts marching, or when an invalid gets out of bed. Fatigue
fractures start without any history of injury as microscopic
lesions which steadily progress. The first symptoms are
bone pain at night after heavy exercise, then pain after ordinary exercise, and finally bone pain during exercise. They
are a common cause of undiagnosed pain in: (1) the tibia,
(2) the metatarsals (especially the second and third), (3) the
calcaneus, and (4) the neck of the femur.
The callus that forms presents as a tender bony lump, and
the fracture may not be visible on X-rays for 5 weeks. When
it does appear, the only signs may be slight periosteal el5

81 The tibial shaft

evation and increased density of the cancellous bone. The

danger in these fractures is that they may be mistaken for
tumours. No treatment is needed, apart from the protection
of a plaster gaiter in the tibia.

Treatment depends on whether or not there is shortening.

If there is significant shortening, a week of calcaneal traction
will reduce it. Many of the details described in the Section
81.12 on open fractures also apply to closed ones.

81.9 Closed fractures of the shaft of the tibia

in children

CLOSED FRACTURES OF THE TIBIA AND FIBULA

A child falls, and afterwards refuses to walk. He has few

signs and you have to make the diagnosis from his history.
X-rays usually show a long spiral fracture with little displacement, commonly in the lower half of his tibia. If the
fracture is transverse it may be sufficiently displaced to need
reducing.
CLOSED TIBIAL FRACTURES IN CHILDREN
INCOMPLETE FRACTURES Although neither reduction nor
splinting is strictly necessary, apply a long leg walking cast
(81.4), for 2 or 3 weeks, as described below, to relieve the
childs pain and prevent his fracture from becoming complete.
COMPLETE FRACTURES If there is no significant displacement, apply a long leg walking cast. Anaesthesia is
usually unnecessary. If he is too young to cooperate and is
in much pain, give him ketamine.
If there is significant displacement, anaesthetize the
child and reduce it.
Elevate the fracture above the level of his heart (Fig. 811), by raising his foot off his bed on pillows.
CAUTION! Always split the cast, because nobody will
watch the circulation in his foot carefully enough, especially
during the night. There is no need to spread it (70-3), unless
there are signs that the circulation in his leg is in danger.
As soon as the swelling has gone, renew or complete the
cast by pulling its split edges together, and binding it round
with a plaster bandage. Apply a walking heel, and allow him
up with crutches. Let him bear his full weight on his leg as
soon as pain allows.
Leave the cast on for 6 weeks. When you remove it, he will
be unable to walk for the first few days, but full movements
will then return quickly.

81.10 Closed fractures of the shaft of the

fibula
A force applied to the outer side of the patients leg can
break his fibula transversely anywhere. His tibia remains
intact, so there is either no displacement or only a little sideways shift. He is usually able to stand. The muscles of his
leg cover the fracture, so that you need X-rays to confirm the
diagnosis.
Reduction, splinting, and protection are unnecessary, so
provided his ankle joint is normal (82.1), get him walking as
soon as his soft tissue injury allows.

81.11 Closed fractures of both bones

In this fracture a patient twists his leg, and in doing so
breaks both the bones in his lower leg obliquely, usually
in their lower thirds. The fragments shift laterally, overlap,
and rotate.
6

Admit the patient. He needs close observation, because his

leg may swell severely.
WITHOUT SIGNIFICANT SHORTENING If there is
swelling, or signs of threatened ischaemia, maintain the position of the fragments by applying: (1) Medial and lateral
slabs from the patients foot to his groin held on with crepe
bandages.Or, (2) a temporary long leg cast split to allow
swelling.
When the swelling has subsided, apply a long leg walking
cast (81.4), or close the split in the cast he already has. If
the fracture is oblique, take care to correct rotation. Then
continue weight bearing on crutches. Review him and X-ray
the fracture regularly. Wedge (70.7) and replace the cast as
necessary. A closed transverse fracture should unite in 12
to 16 weeks. The last 8 weeks can be in a short leg cast,
especially if it is a total contact one of the Sarmiento type
(81.5).
WITH SIGNIFICANT SHORTENING The patient probably
has an oblique fracture. Anaesthetize him. Apply medial and
lateral slabs as above. Pass a Steinmann pin through his
calcaneus (70.11) and rotate his leg to correct any external
rotation.
Apply 5 kg traction, and raise the foot of his bed 25 cm to
counteract it. Put a pillow longitudinally under his leg. This
will hold his knee in a comfortable semiflexed position and
prevent his heel from pressing on the bed uncomfortably.
Leave his leg in traction for a week, and treat its soft parts
energetically meanwhile. Encourage him to move his toes,
his ankle, and his knee. This period of traction will allow his
soft tissues to heal.
After a week, remove the pin, apply a long leg cast, and
encourage him to walk.
Leave the cast on for at least 8 weeks. Then remove it
and examine his leg for signs of clinical union (Fig. 69-4).
If the fracture has united and is barely springy, apply
a close fitting short leg cast (81.5) for 6 to 8 more weeks.
Encourage him to walk normally.
If the fracture has not united, reapply a long leg cast
and continue weight bearing for another 5 weeks, then apply
a short leg cast.

81.12 Open fractures of both bones of the

lower leg
Open fractures of the tibia and fibula are the commonest
open fractures in man, and are one of the more unfortunate
results of a traffic accident, particularly a motor cycle accident. They vary from a minor cut over a broken bone to
the grossest mutilation, and displacement of the bony fragments. This is worst when the wheel of a car has run over a
patients leg, squashed his muscles, and torn his skin from
the underlying fascia over a wide area (54.8). His fracture
may be transverse or oblique, or comminuted into many
widely scattered pieces.
These are dangerous fractures: (1) They are often infected
and, if you allow gas gangrene to occur, they can be fatal. (2)

81.12 Open fractures of both bones of the lower leg

FRACTURES OF THE
TIBIA AND FIBULA
fractured femur

transverse

oblique

spiral

these take longest to unite, especially

if they are in the lower third

malunion

fractured tibia and fibula

transverse
with
butterfly
fragments

transverse
and
shifted

transverse
and
overlapped
bayonet
position

severe
angulation

double tibia
and fibula
fractures

Fig. 81.8: FRACTURES OF THE SHAFTS OF BOTH THE BONES OF THE LOWER LEG. A, transverse, B, oblique and C, spiral fractures. D, a
transverse fragment with a butterfly (triangular) fragment. E, a transverse shifted fracture. F, the fragments are in a bayonet position. Never leave a
fracture like this. H, double fractures of both bones. I, shows the malunion that may result if a fracture like G is inadequately treated.

They are often transverse, and pieces of bone may be lost,

so that great care has to be taken to make them unite. (3)
If treatment is prolonged, the patient may become very demoralized, and may be away from work so long that he loses
his job. (4) Serious complications may occur later, including
a stiff ankle, and foot drop.
Fortunately, the following method is satisfactory for most
cases. A really thorough wound toilet is critical. After this,
you must leave the wound open unsutured until the danger of
infection is over. Never close it by immediate suture. As soon
as it is safe to do so, apply a long leg cast and encourage
the patient to walk. The secret of success is early weight bearing
while his leg is still in a cast, and while his skin woun is still
incompletely healed. Many severe injuries heal dramatically,
even some of those which might at first seem to need a bone
graft.
If a patients skin and muscles have been widely damaged, his leg will swell severely. Applying a cast too soon
is dangerous, so admit him to allow the swelling to subside,
and his soft tissues to start healing, before you apply it. If
you apply a cast immediately and discharge him, he may
return in great pain 24 hours later with the compartment
syndrome (73.7).

LEAVE THE PATIENTS WOUND UNSUTURED UNTIL THE

DANGER OF INFECTION IS OVER
NEVER ATTEMPT PRIMARY SUTURE OVER AN OPEN
FRACTURE
EARLY WEIGHT BEARING IS ESSENTIAL

Two periods of treatment are necessary. The first is a period of provisional treatment during which the spread of infection is prevented by a thorough wound toilet. After this
you can leave the patients wound open to the air to allow drainage, to reduce the risk of sepsis, and to prevent
gas gangrene. Antibiotics are no substitute for an adequate
wound toilet. Close his wound a few days later by delayed
primary suture or skin grafting. Apply a cast and start the
period of definitive treatment as soon as: (1) the danger of gas
gangrene is over, (2) most of the swelling has gone, and (3)
most of his wound (not necessarily all of it) has been covered
by skin. He is usually ready for a cast at 5 to 17 days; his skin
wound will continue to heal while he is walking about in it.
If his soft tissues have not been widely damaged, you can
7

81 The tibial shaft

apply a long leg cast immediately, as described below, but

this is not so easy, nor so safe.
The first step in reducing an open tibial fracture is to get
the fragments into the best position you can through the
open skin wound during the wound toilet. After that you
can control their position in one of the two ways: (1) You
can apply a temporary plaster and bivalve it (70.3), so that
you can inspect and treat the patients wound. Or, (2) you
can apply traction with a Steinmann pin through his calcaneus, or just above his malleoli. A pin through his calcaneus: (a) corrects even severe displacement, (b) does not obstruct the circulation in his leg, (c) leaves his wound open
for inspection and treatment, and (d) requires that the foot
of his bed be raised. This is useful, because it helps to reduce swelling at the fracture site. The main disadvantage of
a pin through the calcaneus is the remote possibility of osteomyelitis (7.13). There is less risk of this if you put the pin
through his lower tibia, but traction there is less well placed
mechanically, and it may pull the lower fragment of his tibia
up into the wound, as in A, Fig. 81-9.
Treat the patient rather than his X-ray, and aim for a leg
which works, rather than for a beautiful film. This method
needs good plaster technique, and sometimes careful wedging (70.7). He may need much encouragement to make him
walk in his cast, especially if he can feel his broken bones
grating against one another with each step he takes. Persuade your nurses to encourage him to do this. If they fail,
persuade him yourself.

A THOROUGH WOUND TOILET IS CRITICAL

GET HIM WALKING EARLY IN A CAST

Brown P.W. and Urban J.G. Early weight bearing the treatment of open
fractures of the tibia.

Prepare the skin of his leg with an antiseptic solution, as

for any surgical operation. Drape it and do a careful surgical toilet. If the tissue is tense, incise the fascial planes to
prevent the compartment syndrome and minimise the risk of
gas gangrene (54.13). Remove any dirtencrusted fat and
muscle. Excise a millimetre or two of skin from the edges of
the wound.
If there are any loose bone fragments, leave them, especially if they have any attached periosteum. They may
settle down and act as a bone graft. If the wound becomes
infected, remove them at your next wound toilet.
When the whole of his wound is surgically clean, take off
the tourniquet. Stop bleeding with packs (3.1), and the minimum number of the fine ligatures. Cover it with sterile gauze
for delayed closure, or delayed skin grafting later. Some surgeons use hypochlorite pressure dressings.
CAUTION! (1) Dont close his open wound by primary suture. (2) Avoid relaxing incisions, rotation flaps, and pedicle
grafts as primary procedures.
EARLY TREATMENT OF THE FRACTURE Immediately
the wound toilet is complete, and while the patient is still
anaesthetized, reduce the fracture as best you can. Bringing the fragments into contact with one another is more important than correcting angulation, because you can correct
this later while the bone ends are still sticky.
If his fracture is transverse, try to get as much as possible of the diameters of the fragments to touch one another.
Even if they only touch over part of their circumference, this
will be useful. Bringing them into contact can be difficult if
there is soft tissue between them. Dont leave them in the
bayonet position, as in F, Fig. 81-8. If reducing overlap is
difficult, insert a periosteal elevator or some other suitable
instrument between the bone ends, and lever them into po-

TWO KINDS OF
PROVISIONAL TRACTION

Journal of Bone Joint Surgery. 1969;51A:5975

No!

Nicoll E.A. Fractures of the Tibial Shaft. Journal of Bone and Joint Surgery,
1964;46B:373.

OPEN FRACTURES OF THE TIBIA AND FIBULA

This section applies to any fracture over which there is any

skin wound, or skin which looks as if it might break down.
Have you felt the patients dorsalis pedis and posterior tibial pulses and tested the sensation in his toes?
Admit him. He needs careful observation. Give him penicillin, and tetanus prophylaxis (54.11). For the use of broad
spectrum antibiotics, see Sections 2.7 and 54.1.
PROVISIONAL TREATMENT FOR OPEN TIBIAL
FRACTURES
Resuscitate and anaesthetize the patient, give him a general
or a subarachnoid (spinal) anaesthetic (7.4), or ketamine (A
8.2).
THE EARLY WOUND TOILET must be thorough (54.1). If
necessary, apply a tourniquet.
Scrub the skin around the patients wound with water,
soap, and a soft nail brush, to remove all ingrained dirt.
Sponge his wound clean. Pour plenty of water over it, and if
it is severely contaminated, syringe it forcibly with saline.
8

Traction through the tibia may

raise the lower fragment

Traction through the calcaneus

keeps the lower fragment in place

Fig. 81.9: TWO METHODS OF PROVISIONAL TRACTION FOR

TIBIA FRACTURES. A, traction through the lower tibia may pull the
lower fragment out of the wound. B, traction through the calcaneus keeps
the lower fragment in place, but if osteomyelitis occurs it will be very troublesome. After Charnley with kind permission.

81.12 Open fractures of both bones of the lower leg

sition.
If you cannot get enough traction on the patients foot
to reduce the fragments, insert a Steinmann pin temporarily in his calcaneus and exert traction on this. Do this now
while he is still in the theatre.
CAUTION! In a transverse fracture avoid any end to end
distraction, no matter how slight, it is the great enemy of
union.
If his fracture is oblique or comminuted, calcaneal traction (see below) is particularly useful. You may be unable to
prevent mild overlap. Some separation of the fragments is
inevitable, but they will unite slowly.
If a pointed fragment of bone is sticking through the
patients skin and you cannot easily reduce it, nibble it
away.
Dress his wound, then splint his leg with medial and lateral
slabs, held on with crepe bandages. This will let you inspect
and treat it by unwrapping them.
CAUTION! (1) If his soft tissue injury is severe, remember the possibility of gas gangrene (54.13). Beware, especially, of fever, pain, a rising pulse, and a falling blood pressure. (2) Watch also for signs of the compartment syndrome
(81.14)severe pain, inability to move his toes, and numb
toes.
THREE DAYS LATER Open up the dressings and look at
the patients wound; there are several possibilities.
If his wound looks clean, and you can close it without
tension, consider delayed primary suture.
If his wound looks clean, but you cannot close it without tension, graft it with split skin (57.2). You may need to
repeat this on about the eighth and if necessary again on the
thirteenth day. Dont try grafting until there are good granulations to put the graft on. Dont let him start weight bearing
until the graft has taken.
If his wound is very dirty, toilet it again surgically in the
theatre.
DEFINITIVE TREATMENT FOR OPEN TIBIAL
FRACTURES
FIT A LONG LEG WALKING CAST When the patients
wound is mostly closed by skin, or a graft is taking, usually
at 14 to 17 days, fit him with a long leg walking cast (81.4).
The swelling will have subsided, so there is no need to split
it. Even so, watch the circulation in his foot carefully.
Put a dressing over his wound, but preferably dont window the cast (70.7). Inspect his wound when the cast needs
changing.
Apply the cast with his ankle in 10 of dorsiflexion, unless
this position causes posterior angulation of the fragments,
as it may do in a lower third fracture when a piece of the
tibia is comminuted anteriorly.
If dorsiflexion does cause posterior angulation, leave
his foot in equinus, but fit a stirrup as in Fig. 81-11, or a high
enough walking heel (81.3). If possible, raise his opposite
shoe. Make the cast strong enough to last 6 to 8 weeks.
Raise his leg for 12 hours after fitting the cast.
EARLY WALKING FOR OPEN TIBIAL FRACTURES The
next day allow the cast to rest on the floor. Give the patient crutches and encourage him to walk on his broken leg,
bearing as much weight as he can tolerate. Let him gradually increase the weight he bears on his cast, but dont push
him to the point of pain. If he feels crepitus, or he feels the

fragments are moving, tell him to persist. Explain that this is

normal and will help his bones to unite.
CAUTION! Early walking is critical to the success of this
method.
In the early days, when he is not walking, tell him to keep
his leg raised. This will minimize swelling and make it more
comfortable.
When he is bearing nearly all his weight on his injured
leg, exchange his crutches for a stick. Most patients reach
full weight bearing in a few weeks, and some within a few
days.
Send him home when he is walking well. Review him in 3
weeks. Make sure he is walking properly, and his plaster is
in good condition.
IF NECESSARY, CONTROL ANGULATION If an adults
fracture is angulated more than 5 in any direction, correct
it by renewing the plaster or, less safely, if plaster bandages
are scarce, by careful wedging (70.7). Dont do this immediately. The best time is usually at 3 to 4 weeks in an adult,
and sooner in a child. Be sure you do it while the patients
bone ends are still sticky, and before they have united.
Use an opening wedge a little above the fracture, so that
pressure does not increase over it. If his leg is angulated in
two planes, you may be able to control it with one wedge, or
you may need two. This may make the cast look ugly, but it
will improve the final look of his leg.
CAUTION! Dont try to wedge a cast more than once
change it. The risk of pressure sores is too great.
DRESSINGS Change the dressings when you change the
cast. This is better than repeatedly changing them through
a window.
CHANGING A LONG LEG CAST IN AN OPEN TIBIAL
FRACTURE If the cast is snug and comfortable, leave it for
5 to 8 weeks. Change it earlier if it becomes loose or uncomfortable, because the position of reduction is easily lost
inside a loose cast. If plaster bandages are scarce, you may
be able to cut a longitudinal strip out of a loose cast and
close it up. Change it if pus or blood soaks through excessively and stinks unbearably. A patient may need as few as
3 casts or as many as 15. He will probably need about 6.
TEST FOR CLINICAL UNION At 5 to 8 weeks, remove the
cast and examine the patients fracture for signs of clinical
union (Fig. 69-4). If you are in doubt, X-ray it and renew the

TEMPORARY CALCANEAL
TRACTION

This is the injury on the first day,

if the wound looks clean on the
third day, it will be grafted

fragments approximately aligned

Fig. 81.10: PROVISIONAL TRACTION FOR AN OPEN TIBIAL

FRACTURE. This is useful if the bone is very comminuted, but dont
apply it for more than 2 weeks. Kindly contributed by Peter Bewes.

81 The tibial shaft

cast. Dont discard a full length cast until: (1) The patient
can walk without crutches, and (2) there are signs of clinical
union as shown by: (a) no tenderness at the fracture site,
and (b) mature bridging callus in the X-ray. The clinical signs
are more important than the X-ray. Dont leave a long leg
cast on too long, because it will prevent him from bending
his knee, and make it stiff. Fit a short leg cast as soon as
you can.
Spiral or transverse fractures reach clinical union more
quickly, usually in about 12 weeks in adults, especially if a
patient starts weight bearing early. A short oblique fracture
usually takes 12 to 16 weeks to unite, but it may occasionally
take a year or more, especially in the lower third of the leg
where delayed union is a particular danger, and particularly
if you unwisely treated it in prolonged traction!
A SHORTER CAST As soon as there is good clinical
union, give the patient a shorter cast. If a middle third fracture of his tibia is now firm, give him a well padded plaster
gaiter (81.6), or a Sarmiento total contact cast (81.5), because fractures here need less protection than they do elsewhere. If his fracture is anywhere else in his tibia, apply a
Sarmiento cast which includes his foot. Keep him walking
and gradually increase his range of activities.
CAUTION! Pain and tenderness over a fracture site are
signs that clinical union is not yet complete, so continue to
protect his fracture in a short leg cast.

it is almost certain to cause a slough on the dorsum of his

foot.
USING A BHLERBRAUN FRAME This can be used for
provisional treatment, and is shown in Fig. 79-10. After the
first few days it is much less effective than early mobility in a
long leg walking cast.
APPLYING A LONG LEG CAST IMMEDIATELY If a patients soft tissue injury is minimal, some surgeons apply
a long leg cast without a period of provisional treatment. If
you are inexperienced, this is a method to be applied with
extreme caution.
After the wound toilet, align the fragments with the patients lower leg hanging over the end of the table. Sit, and
rest his foot on your knee, adjusting the height of the table
to make this possible. Study the X-ray and manipulate the
fragments into position.
EXTERNAL FIXATION WITH TWO STEINMANN PINS If
a patient has a severe soft tissue injury, you may be able
to apply two Steinmann pins, one well above and one well
below the fracture, and incorporate these in a cast, if necessary with a window, and get him walking. Later, you may
be able to remove the bottom pin and mould the cast around
his ankle. This will minimize shortening, but union may be
slower than if you accept it, and treat him as above.

81.13 Difficulties with fractures of the tibia

ALTERNATIVE METHODS FOR OPEN TIBIAL
FRACTURES
A STEINMANN PIN TO STOP A SHORT LEG CAST ROTATING A long leg cast is heavy, and because it prevents
a patient bending his knee, he cannot easily turn himself in
bed, so it makes nursing difficult. A long leg cast is thus
contraindicated: (1) if he is oId, or (2) if he has other serious
injuries, such as a femoral or malleolar fracture.
Under these conditions apply a short leg walking cast and
prevent rotation by incorporating a Steinmann pin in it. Insert the pin obliquely 1.5 to 2 cm distal to his tibial tuberosity
(70.11). Make sure the cast allows him to bend his knee.
Dont allow him to bear weight on on the cast while the pin
is in it, because the pin may break. Remove the pin as soon
as is practical, so as to allow him to bear weight on the fragments of his tibia.
TEMPORARY CALCANEAL OR LOWER TIBIAL TRACTION TO ALIGN THE FRAGMENTS If a fracture is very
comminuted, or a patients wound needs repeated toileting,
traction may be useful to hold the fragments approximately
in place during the first week or two only.
Insert a Steinmann or a Denham pin through the patients
calcaneus, or his lower tibia just above his ankle; apply 5 to
7 kg traction, and raise the foot of his bed 25 cm. This will
align his leg and make him comfortable. Dont leave the pin
in for longer than is necessary, preferably not more than 2
weeks. Keep him exercising his foot while he is on traction;
this will reduce oedema and minimize stiffness. When the
fragments have become sticky enough to stay in place on
their own, remove the traction, allow his leg to shorten to a
stable position, and then apply a long leg cast. CAUTION!
(1) Dont apply so much weight as to produce distraction at
the fracture site or endanger the blood supply of the patients
leg. (2) Dont apply traction to a cast unless you have put a
pin into his tibia and incorporated this in the cast, because
10

If a piece of a patients tibia is missing, treatment depends

on how much is missing, and where. Try to make the broken
ends of the tibia impact. Making the bone ends touch is more
important than maintaining length.

DIFFICULTIES WITH OPEN TIBIAL FRACTURES

If a patients FOOT IS SO SEVERELY INJURED that you
are thinking about amputation, preserve it if it still has a
pulse and normal sensation. Provided you do a thorough
wound toilet and avoid the danger of gas gangrene, you can,
if necessary, amputate later. Raise his leg, keep it cool, with
ice if possible, and resuscitate him meanwhile. Even the
severest bony injury is never by itself an indication for amputation.
If a small PIECE OF TIBIA IS MISSING, it will probably
heal adequately.
If his tibia is intact posteriorly, but a PIECE OF TIBIA
IS MISSING ANTERIORLY, the lower fragment is in danger of bending forwards, so refer him. If this is Impossible,
prevent forward angulation by putting his foot into plaster in
equinus, as in Fig. 81-11, until the comminuted area has
stabilized. Fit a metal stirrup on it instead of a walking heel.
This will let him walk on his injured leg, even though his ankle is in equinus.
If LESS THAN 3 cm OF TIBIA IS MISSING, wait for the
wound to heal, and for the patients skin to become clean. If
his fibula has not already been broken by the injury, make a
separate lateral incision far enough above or below his tibial
fracture to leave some stability at the fracture site. Cut his
fibula obliquely with a sharp osteotome. Push the ends of
his tibia together, so that the fragments of his fibula overlap.
If absolutely necessary, you can remove a piece of fibula.
Apply a long leg cast and get him walking and weight bearing as soon as possible. His tibia will unite, but it will take

81.13 Difficulties with fractures of the tibia

several months. If necessary, raise his shoe to compensate

for shortening.
If MORE THAN 3 cm OF TIBIA IS MISSING, apply calcaneal traction, but dont try to maintain its full length. Traction will stabilize his leg and make a wound toilet easier. Refer him for an operation in which cancellous bone chips or
part of his fibula is used to bridge the missing portion. When
this i s done, his fibula may hypertrophy surprisingly. If referral is impossible, you will have to treat him as above.
CAUTION! Dont attempt any early bone nibbling to remove supposed dead or infected bone. Instead, encourage
early weight bearing, and hope that the patients tibia will
unite posteriorly. Then, do any bone nibbling that is needed.
If PUS GATHERS IN HIS WOUND, it fails to heel, and
his tibia fails to unite, open the wound widely so that it
can drain. Remember that wounds drain by gravity so that
the bottom of a pus pocket must be open. Infection may
be caused by an inadequate wound toilet or by dead bone.
Continue irrigating and toileting the wound as necessary. As
soon as it is reasonably clean, put him into a long leg cast
and get him walking.
If OSTEOMYELITIS occurs, X-ray the fracture and look
for sequestra. If you find them, take the patient to the theatre, remove all pieces of dead bone, irrigate his wound, and

A PIECE OF TIBIA
IS MISSING

cut his
fibula
here
with an
osteotome

provide dependant drainage, or, better, suction drainage. Alterantively, raise his leg on a BhlerBraun splint, and apply
calcaneal traction. Lay a catheter alongside the wound, or
use the tube of a drip set with multiple holes cut in it. Irrigate his wound with saline (the addition of penicillin i s
optional), and let it drip into a basin underneath the splint.
Sterile saline is expensive, so you may have to use clean
tap water and salt. Irrigation needs much care and attention, and will require all the nursing skills you have. Later,
reapply the cast, keep the patient walking, and change the
cast when it becomes soft, or stinks excessively.
If GAS GANGRENE occurs, immediate amputation may
be necessary to save the patients life. Treat it as in Section
54.13. The way to prevent it is: (1) to explore and excise his
wound properly, (2) to open up all the fascial spaces where
pressure could build up, and (3) to lay his wound open without an encircling cast after you have explored it.
If there is DEAD BONE at the bottom of an infected
wound, you may be able to remove it without anaesthesia,
as in B Fig. 81-12, because bone is insensitive. Use a bone
gauge or chisel, and hammer, to remove any bone which
looks white and does not become pink or bleed, and especially any exposed bone, until you get to healthy bleeding
bone. Later, when granulations have appeared, graft it, as
in Section 57.2. Dont remove too much bone, or you will
weaken the patients tibia. Removing it to a depth of 1 or
2 mm is usually enough. Let the patient carry on walking,
and look at his wound a week later. If any exposed bone
remains, repeat the process. Go on doing this until healing
is complete.
If a patients TIBIA HAS NOT UNITED after 16 weeks,
dont be alarmed. Fractures of the upper third of the tibia
usually unite quite easily. It is fractures of the lower third
that often dont. Even so, most of them unite by 16 weeks,
but some take a year or even 2 years. Give him 6 months
to unite in a well fitted short leg walking cast (81.5). If there
is no union at 6 months consider referring him. If his tibia
has not united in a year, he will probably need bone grafting.
Here are some reasons for non-union. Faulty treatment may
be to blame.

SKIN GRAFTING AN
EXPOSED TIBIA
A

chip away dead white bone

until you get to healthy
bleeding bone

exposed bone
in an open
fracture

anterior
comminution

C
graft the healthy
exposed bone

rubber
foot in equinus

Fig. 81.11: A PIECE OF TIBIA IS MISSING. A, if a piece of the patients

tibia is missing anteriorly, his fibula will probably be broken also, so you
can let the fragments of his fibula over ride one another and push those of
his tibia together. If his fibula is intact, cut it. B, C, and D, if his tibia is
comminuted anteriorly, fit him with a stirrup with his foot in the equinus
position. If you dont have a stirrup, fit a wooden block under his heel.
Kindly contributed by John Stewart.

Fig. 81.12: SKIN GRAFTING AN EXPOSED TIBIA. A, chip away dead

bone. B, exposed bone at the bottom of an open fracture. C, grafting healthy
granulations. With the kind permission of Peter London.

11

81 The tibial shaft

He did not exercise his broken leg enough The fibula

unites quickly, and may hold the two ends of his tibia apart,
and so prevent them from uniting. Prevent this by teaching
him to contract the muscles of his foot, and get him walking as soon as possible. Each step he makes will help his
broken tibia to unite. Unfortunately, his other injuries may
prevent early exercise.
His tibia was extensively injured In severe open fractures, in which large bone fragments have protruded through
the skin and been stripped of their periosteum, much of the
injured bone dies. The callus that forms has to cross a wider
gap, so that union and consolidation take longer, and the risk
of nonunion is greater.
You applied too much traction, or tried internal fixation
under unsatisfactory conditions. Both of these errors
will delay union, especially if a patient has been discouraged
from walking early.
His wound has become infected. Infection delays union
greatly, particularly if pus has accumulated because you
have not opened up the patients tissues and allowed it to
drain freely through his open wound.
His ankle was immobilized in equinus without the application of a stirrup. When this has happened he cannot put his foot to the ground without bending the callus
around his fracture, and causing hinging stresses which lead
to healing with fibrous tissue, rather than with bone. Either
immoblize his ankle in neutral, or if you have to immobilize it
in equinus, fit the cast with a stirrup.
If there is MALUNION, it can take several forms:
(1) Shortening is usually minimal and unimportant (78.1).
If the patient is fortunate enough to wear shoes, you can
compensate for a loss of up to 4 cm by raising the heel of
one of them, and lowering the heel of the other one. (2)
Angulation is serious and unnecessary. Prevent it by: (a)
aligning the fragments carefully to begin with, (b) wedging
or changing the patients cast early (70.7), and (c) making
sure that when he starts weight bearing, he does so in a
cast which fully supports the fracture. It is not the weight
bearing that causes the malunion, it is improper casting
not having a snug cast. Valgus or varus malunions are more
serious than backward or forward bowing, because he can
compensate for them less easily.
(3) Rotation deformities in which a patients foot points inwards or outwards are also serious. Prevent them by making
sure that his foot points in the same direction relative to his
patella on the injured side as it does on the normal one (Fig.
81-2).
If his SKIN WILL NOT HEAL COMPLETELY over the
front of his tibia, despite one or two skin grafts, forget
this for the present, and keep him walking in a cast. Remove
the cast after 5 to 6 weeks, and look at the wound. It will
probably have healed.
If HIS FOOT SWELLS and he is in a cast, bring him into
hospital overnight. Let him sleep with his foot raised. The
following day before you allow him out of bed apply a new
cast which fits properly.
If he has been in a cast for many weeks, his foot is sure
to swell when it is removed. If necessary, compress it with
12

an elastic bandage, elevate his leg at night, and continue to

exercise it.
If a patients FOOT IS STIFF AND PAINFUL, there is little you can do. There is always some stiffness, especially
after a fracture of the lower third of the tibia, due to scar tissue forming around the extensor tendons. The preventable
causes include the tragedy of Volkmanns contracture (70.4),
or unnecessarily applying a cast with the patients foot in
equinus.
If he CANNOT DORSIFLEX HIS ANKLE (foot drop): (1)
He might have injured his common peroneal nerve at the
time of the accident, so when you first see him, ask him to
dorsiflex his foot so that you can test the sensation on its
dorsum, and record your findings. (2) His common peroneal
nerve may also have been injured by a cast, especially if it
was not padded around the neck of his fibula. If his paralysis persists, he will need a brace to support his foot. (3) In
the early days pressure in the anterior compartment of his
leg can prevent him from raising his foot. If this happens,
decompress his leg urgently as described in Section 81.14.

DONT LET A PATIENT WALK ABOUT IN A LOOSE CAST,

OR THE FRAGMENTS WILL MOVE OUT OF POSITION

DONT GIVE UP HOPE

TOO EARLY

early xray of fracture

inside a cast

successful union

Fig. 81.13: SKIN GRAFTING AN EXPOSED TIBIA. A, chip away dead

bone. B, exposed bone at the bottom of an open fracture. C, grafting healthy
granulations. With the kind permission of Peter London.

BRING THE ENDS OF THE PATIENTS TIBIA TOGETHER

81.14 The compartment syndrome in the leg

If a patient with a lower leg injury: (1) has severe pain, (2)
cannot move his toes, or (3) has numb toes, be careful. These

81.14 The compartment syndrome in the leg

DECOMPRESSION
FOR THE
COMPARTMENT
SYNDROME

THE COMPARTMENT SYNDROME

anterior
compartment

lateral
compartment

skin rotated
to expose
peroneal
muscles

If a patient with an injured lower leg complains of severe

pain, or cannot move his toes, believe him. If his leg is in
a cast, split it, spread it, and elevate his leg. If this does
not rapidly relieve his symptoms, remove the cast. If his
symptoms persist, proceed urgently with fasciotomy.
WHICH COMPARTMENT? Stretching an ischaemic muscle causes pain so:
If flexing his foot and toes causes pain, his anterior
compartment is ischaemic.
If extending his foot and toes causes pain, his posterior compartment is ischaemic.

B
FASCIOTOMY FOR THE COMPARTMENT SYNDROME
deep posterior
compartment

posterior
compartment

blunt scissors or
closed artery forceps

scissors thrust deep to

decompress the deep
posterior department
posterior tibial nerve and vessels

Fig. 81.14: TREATING THE COMPARTMENT SYNDROME. A, incisions for the lateral and posterior compartments. B, opening up the deep
posterior compartment. This diagram also shows how you can slide the
skin incision you have used to open the lateral compartment forwards, so
that you can also open the anterior compartment through it. Kindly contributed by Peter Bewes.

are signs of the compartment syndrome which can be followed by Volkmanns ischaemic contracture, as in the arm
(70.4). A normal pulse and apparently normal filling of his
nail beds do not exclude it. When a patients fracture is reduced his pain should become less. Severe postoperative pain
is thus the critical early sign.
There are four musclar compartments in the lower leg,
separated from one another by strong fascia: (1) The lateral compartment contains a patients peroneal muscles. (2)
The anterior compartment contains the extensor muscles of
his ankle and toes. (3) The superficial part of the posterior
compartment contains his gastrocnemius and soleus muscles. (4) The deep posterior compartment contains his deep
flexors. After a fracture, or even after bruising of his lower
leg, blood and oedema fluid may collect in all, or any, of
these compartments under such pressure that the circulation to his foot is obstructed. Unless you immediately open
up each compartment in turn through a generous longitudinal incision, Volkmanns ischaemic contracture or gangrene
may follow. The after effects of a fasciotomy are minimal,
but ischaemic muscle never recovers.

Medial incision Make a longitudinal 15 cm incision on the

medial side of the patients leg. Cut through the deep fascia
from his knee to his ankle. Incise the turgid, dark, reddish
blue, ischaemic muscle of his posterior compartment.
Lateral incision Make a similar 15 cm longitudinal incision on the outer side of his leg. Incise the fascia and the
muscle directly underneath it, and decompress his peroneal
compartment.
Slide the skin incision anteriorly over the subcutaneous
tissue, as shown by the arrow in B, Fig. 81-14, and incise
the muscle under it so as to decompress his anterior tibial compartment. This will enable you to decompress both
compartments through the same incision.
If the circulation returns to his foot, no further incisions
are necessary.
If the circulation does not return to his foot in a few
minutes, deepen the medial incision to open up his deep
posterior compartment. Push scissors deeply into it and
open the blades, as if you were exploring an abscess by
Hiltons method (Fig. 5-3). Dont use a knife in the depths,
or you may cut his posterior tibial artery, or his tibial nerve.
If he has a fracture, treat this by calcaneal traction until
definitive treatment is possible later.
CAUTION! Dont apply a cast until the swelling has subsided.
LATER TREATMENT The compartments cannot be
closed after these incisions, so leave them wide open, covered with gauze. They will close as the swelling subsides.
If necessary, close the wound with a skin graft, or delayed
primary suture.

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