Description

• 80% have associated fibular fractures
• Most common long bone fracture in adults
• Open (24% are open) vs. closed
• Extent of soft tissue damage
• Gustilo–Anderson classification of open fractures:
  • Type I:
    • Wound <1 cm
    • Little soft tissue damage
    • No crush injury
  • Type II:
    • Wound >1 cm
    • Moderate soft tissue damage
    • Little or no devitalized soft tissue
  • Type III – severe soft tissue injury:
    • A – adequate soft tissue coverage of bone
    • B – tissue loss/periosteal stripping
    • C – neurovascular injury requiring surgery
• Anatomic location:
  • Proximal, middle, or distal third
  • Articular extension
• Displacement
• Degree of shortening
• Angulation
• Configuration:
  • Spiral, transverse, or oblique
  • Comminuted, with butterfly fragment or multiple fragments

• Proximal:
  • Associated with peroneal nerve injury
  • Disruption of ankle syndesmosis (Maisonneuve fracture)
• Middle
• Distal

• Third most common long bone fracture in children
• Second most common long bone fracture in nonaccidental trauma (usually apophyseal or metaphyseal corner)
• Nonphyseal fracture patterns:
  • Compression (torus): Distal metaphysis
  • Incomplete tension–compression (greenstick)
  • Plastic/bowing deformity of fibula may occur
  • Complete fractures
• Physeal fracture patterns:
  • Tibial shaft fractures may extend to the physis in Salter–Harris II pattern

• Increased risk with use of bisphosphonates
• Increased risk with obesity

Etiology

• High- vs. low-energy injury
• Amount of soft tissue injury is prognostic and determined by the degree of energy involved
• Indirect force – frequently low-energy trauma:
  • Rotary and compressive forces often result in oblique and spiral fractures
• Skiing, fall, child abuse
• Direct force:
  • High-energy comminuted fractures
  • Pedestrian vs. auto, motor vehicle crash (MVC):
  • More proximal
• Low-energy transverse fractures:
  • Sports related most common: Soccer, Rugby
  • Involve distal 1/3: little soft tissue coverage
  • Bending force over a fulcrum often produces comminution with a wedge-shaped butterfly fragment
• Skier's boot top, football tackle, MVC

• Bicycle-spoke injury: Age 2–6 yr
  • Foot and lower leg get caught between frame and wheel spoke when riding in passenger seat
  • Crush injury, soft tissue laceration, and shearing injuries accompany this injury
  • Initial benign appearance of the soft tissues is often deceiving:
    • Full-thickness skin loss can occur in days
  • Orthopedic surgery consultation should be obtained for all spoke-injury patients with associated fractures (31% with fracture)
• Toddler fracture:
  • Spiral fracture involving the distal third of the tibia with intact fibula secondary to rotational force (turning on planted foot)
  • Age range is 9 mo–6 yr, most often when learning to walk
  • Fractures in midshaft or more transverse are suggestive of nonaccidental trauma if not related to sports