Introduction

• Leg fractures are the most common long bone fractures.
• In an average population there are approximately 26 tibia diaphyseal fractures per 100,000 inhabitants per year.
• In adults, the highest incidence of diaphyseal tibial fractures is observed in young males aged 15-19, with an incidence of 109 per 100,000 inhabitants per year.
• In adult women, the highest incidence of diaphyseal fractures of the tibia is observed between 90 and 99 years of age, with an incidence of 49 per 100,000 inhabitants per year.
• The mean age for tibial diaphysis fractures is 37 years; for men 31 years and for women 54 years of age.
• Tibial diaphysis fractures have the highest incidence of pseudoarthrosis of all long bones.

• The tibia is a long tubular bone with a triangular cross section. It has an anteromedial subcutaneous border and is surrounded by four fascial compartments (anterior, lateral, posterior superficial and posterior deep).
• The fibula supports 6% to 17% of the weight load across the limb. Its main function is to serve as an anchorage for muscle insertions.
• The common peroneal nerve runs around the neck of the tibia, where it is practically subcutaneous; therefore, in this location it is vulnerable to direct blows and traction injuries.

Injury mechanism

Direct mechanism:

• High energy flexion: traffic accidents: transverse, comminuted and displaced fractures often occur. Highly comminuted patterns or segmental fractures are associated with high soft-tissue compromise. It must always be ruled out that the fracture is open and that there is a compartment syndrome.
• Penetrating: gunshot wounds. The pattern of injury is variable, although usually comminuted. Low velocity projectiles (small arms) do not cause the same bone and soft tissue injuries as high-energy trauma (traffic accidents) or high velocity projectiles (shotguns or assault weapons).
• Low energy flexion: by three or four-point flexion. Short or transverse oblique fractures occur, with a possible butterfly wing fragment. They can be comminuted and associated with a great compromise of soft parts. Exposed fractures and compartment syndromes may occur.
• Fractures of the diaphysis of the fibula: these are typically the result of direct trauma to the lateral face of the leg.

Indirect mechanism:

• Torsion: the main causes are torsion with the foot fixed and falls from small heights. They are spiroid fractures, not displaced, with minimal comminution and little soft tissue involvement. They can be exposed fractures of type I. Spiroid fractures of the proximal portion of the fibula may be seen in rotational ankle fractures or low energy torsion tibia fractures.
• Stress: they are typical of recruits and are most frequently located in the metaphysiological junction, with more marked sclerosis in the posteromedial cortex. In ballet dancers, stress fractures occur more frequently in the middle third and are of insidious onset. Pathognomonic is the radiolucent "dark line" in x-rays. Radiological findings may be delayed by several weeks. MRI is very sensitive to detecting these lesions.

Intramedullary nail:

• Intramedullary nails have the advantage of preserving periosteal irrigation and limiting soft tissue injury. In addition, they have the biomechanical advantage of allowing control of alignment, translation and rotation. They are therefore the recommended treatment for most fracture patterns.

Intramedullary nail with locking screws versus without locking screws:

• Intramedullary nail with locking screws provides control of rotation; in comminuted fractures and those with significant bone loss, it is effective in preventing shortening. If necessary, locking screws can be removed in the later stages of evolution to dynamize the fracture focus.

• Intramedullary nail without locking screws allows impaction of the fracture when carrying weight, but it is difficult to control rotation. Intramedullary nails without locking screws are rarely used.

External fixation:

• It is mainly used in severe exposed fractures, although it may also be indicated in closed fractures complicated with compartment syndrome and in tibia fractures associated with head trauma or burns.

• Its popularity in the United States has declined as the use of milled nails has increased for most exposed fractures.

• Consolidation rate: up to 90%, with an average of 3.6 months to achieve.

• The incidence of infections in the fixator nail pathway is 10% to 15%.

Plates and screws

• They are usually reserved for fractures extending to the metaphysis or epiphysis.
• A consolidation rate of up to 97% has been observed.
• The rate of complications, such as infection, wound dehiscence, malpositioning (malunion) and pseudoarthrosis, increases in high-energy fractures.

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