Fractures of the tibial and fibular shafts are among the most common long bone fractures in adults (average age 37), teenage males (15% of all fractures), and comprise 4% to 5% of all childhood fractures. Fibular fractures are usually associated with tibial fractures (see Fig. 7-1). Therefore, the focus will be on tibial injuries. The distal two thirds of the tibia is most often involved. Also, the lower leg is the most common site of combined osseous and soft tissue injury. The relatively exposed subcutaneous location of the tibia makes it vulnerable to direct high-velocity injury such as motor vehicle accidents or gunshot wounds. Direct trauma usually results in transverse, segmental, or comminuted fracture of the tibia with associated fibular fractures. Indirect trauma generally results in oblique or spiral fractures (see Fig. 7-2). Overuse injuries may also result in stress fractures of the tibia and fibula. Fractures should be described by precise anatomic location, pattern of the fracture line, position of the fragments, degree of comminution, and whether they are open or closed.

Treatment of tibial shaft fractures includes closed and open approaches. Treatment choice is based on the type of fracture, whether open or closed, patient status, and surgical preference. There are multiple classification systems designed to assist with treatment and prognosis. Gustilo and Anderson’s classification is specifically designed for open wounds, a common feature of tibial shaft fractures.

Imaging of tibial and fibular shaft injuries can be accomplished with anteroposterior (AP) and lateral radiographs for complete fractures (Figs. 7-1, 7-2, 7-3, 7-4, 7-5). Knee and ankle should be included. Subtle stress injuries or undisplaced fractures may be more easily assessed with magnetic resonance imaging (MRI). Radionuclide scans can also be useful for detection of subtle fractures. However, magnetic resonance (MR) features are typically more specific. Angiography may be required in patients with advanced soft tissue injury who may require vascular repair (Gustilo and Anderson IIIC) (Fig. 7-6).

Goals for management of tibial fractures include maintaining length, restoring normal weight-bearing alignment, and preservation of soft tissues. Alignment and rotation should be corrected to near anatomic position. The ankle and knee joints must be parallel. There should be no >5 degrees of varus or valgus angulation, 10 degrees of anterior or posterior angulation, 10 degrees of rotation, and 1 cm or less of leg length discrepancy (see Fig. 7-7). In children younger than 8 years, apposition is less critical. In older children, at least 50% apposition should be achieved (see Fig. 7-8). Treatment options include closed reduction with cast or brace immobilization, external fixation, intramedullary nailing, and open reduction with plate and screw fixation.