Summary
Tibial and fibular fractures are common types of long bone injuries and are usually caused by direct trauma. Fractures may occur proximally, at the shaft, or distally. Since only a small amount of soft tissue covers the tibia and fibula, there is a high risk of open fractures. X-rays are the initial diagnostic test of choice. Initial management varies by fracture location and commonly involves consulting orthopedic surgery, splinting, and weight-bearing restrictions. Complications include common peroneal nerve injury and compartment syndrome.
For distal tibial or fibular fractures, see “Ankle fractures.” See also “Tibial stress fractures.”
Classification
- Tibial fractures
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Fibular fractures
- Isolated proximal fibular fracture
- Isolated fibular shaft fracture
- Combined tibial and fibular shaft fractures (managed similarly to tibial shaft fracture)
- Distal tibial or fibular fractures: See “Ankle fractures.”
Clinical features
- Local pain, tenderness, and/or deformity
- Swelling, bruising, and/or hematoma
- Skin abnormalities, e.g., lacerations, tenting
- Signs of neurovascular injury, e.g.:
- Common peroneal nerve injury, e.g., foot drop, impaired foot eversion, sensory deficits
- Posterior tibial nerve injury, e.g., impaired plantar flexion, sensory deficit over the sole of foot
- Arterial injury, e.g., hard signs of extremity vascular injury, diminished distal pulses
- Signs of compartment syndrome
- See “Fracture signs.”
Tibial and fibular fractures are at high risk of open fractures due to minimal surrounding soft tissue. [1]
Diagnosis
Clinical evaluation [1]
Urgent orthopedic consultation is indicated for any findings that suggest neurovascular injury or an open fracture.
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Neurovascular examination
- Assess dorsalis pedis and posterior tibial pulses and capillary refill time.
- Evaluate for peroneal nerve injury and posterior tibial nerve injury.
- Skin examination: Evaluate for laceration, tearing, and tenting.
X-ray [1][2]
Imaging for tibial and/or fibular fractures generally includes x-rays of the knee, tibia and fibula, and ankle.
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Views
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Knee
- Anterioposterior (AP) and lateral views
- Intercondylar view for suspected tibial plateau fractures
- Tibia and fibula: AP and lateral views
- Ankle: AP, lateral, and mortise views
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Knee
-
Findings
- Radiographic fracture signs, fracture fragments, displacement, angulation, and/or dislocation
- In tibial plateau fractures, lipohemarthrosis may be visible as a fat-fluid level. [1]
- See also “Ankle fracture diagnostics.”
Evaluate for a Maisonneuve fracture in patients with a proximal fibular fracture, as Maisonneuve fractures are often unstable and require urgent orthopedic evaluation. [1]
Advanced imaging [1][2]
- CT: may be indicated for preoperative planning, fractures with intraarticular extension, or inconclusive x-rays with high clinical suspicion
- MRI: may be indicated for diagnosis of associated tendon and/or ligament injuries, e.g., meniscal injury associated with tibial plateau fracture [3]
In patients with acute traumatic knee pain, tibial tenderness, inability to bear weight, and nondiagnostic x-rays, obtain a CT to rule out a tibial plateau fracture. [1]
Management
Initial management by fracture type [1]
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All patients
- Initiate general fracture care, including analgesia.
- Place patients on non-weight-bearing status.
- Identify fractures requiring urgent orthopedic consultation.
- Consider VTE prophylaxis in consultation with orthopedics. [1]
-
Tibial plateau fractures
- Apply a knee immobilizer.
- Arrange orthopedic follow-up within 1 week.
-
Tibial shaft fractures (with or without fibular shaft fracture)
- Perform closed reduction for displaced, deformed, or angulated fractures with neurovascular compromise.
- Immobilize in a posterior long-leg splint; consider adding a stirrup splint for open fractures.
- Consult orthopedics urgently.
-
Isolated proximal or midshaft fibular fractures
- Immobilize in a stirrup splint.
- Arrange orthopedic follow-up within 1–2 weeks.
- Distal tibial or fibular fractures: See “Ankle fractures.”
For proximal fibular fractures, rule out associated Maisonneuve fracture and common peroneal nerve injury. [1]
Identify and treat acute compartment syndrome in high-energy tibial and fibular fractures if present. [4]
Nonoperative management [1]
- Indicated for most nondisplaced closed fractures, e.g.:
- Tibial plateau fractures
- Isolated proximal or midshaft fibular fractures
- Options include knee immobilizers and posterior long-leg splints.
- See “Conservative treatment of fractures.”
Surgical management [1]
-
Fractures commonly requiring surgery include:
- Open fractures
- Displaced fractures
- Fractures with neurovascular injury
- Severe tibial plateau fractures (e.g., with comminution, significant articular step-off deformity, condylar widening, multiple condylar involvement) [4]
- Operative techniques include:
Subtypes and variants
Toddler fracture [5][6]
- Definition: a nondisplaced fracture of the distal tibial shaft, usually following acute trauma (e.g., falling, tripping), causing rotation of the body around a fixed foot
- Epidemiology: : commonly seen in children between 9 months and 3 years of age [6]
- Etiology: trauma (e.g., low-energy fall from a chair or table, tripping while running)
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Clinical features
- Irritability
- Abnormal gait (limping or inability to bear weight)
- Localized tenderness over the distal tibial shaft
-
Diagnostics
- Often goes undetected due to subtle clinical and radiographic findings
- Imaging
- AP, lateral, and oblique x-ray
- MRI and/or CT: indicated in cases of prolonged symptoms and suspicion of infection (e.g., osteomyelitis)
- Treatment: immobilization with a long cast, controlled ankle movement walker boot, short cast, or splint [7]
Complications
- Patients with tibial fractures should be monitored for:
- High risk of compartment syndrome in any of the compartments, given that the tibia is surrounded by the anterior, lateral, and deep posterior compartments of the lower leg
- Fat embolism
- Peroneal nerve injury (foot drop)
- Deep vein thrombosis
- Nonunion
- Posttraumatic arthritis [8]
- See “Fracture complications.”
We list the most important complications. The selection is not exhaustive.