Tibiofibular fracture

Tibiofibular fracture is the most common systemic fracture. Children under 10 are especially common. Among them, single fracture of tibia shaft is the most, followed by double fracture of tibia and fibula shaft, and single fracture of fibula shaft is the least. The tibia is the main bone connecting the lower femur to support the weight, and the fibula is an important bone attached to the calf muscle, bearing the load of 1/6. Morphological changes in the middle and lower tibia 1/3 are easy to fracture, and the displacement in the tibia 1/3 is easy to compress the popliteal artery, leading to severe ischemic gangrene of the leg. The blood stasis of tibia 1/3 fracture can be closed in the fascia compartment of calf, which increases the indoor pressure and causes ischemic muscle contracture to gangrene. Fracture of middle and lower tibia 1/3 breaks the nutrient artery, which is easy to cause fracture and delay healing. pathogenesis

The causes of fracture are external and internal.

External causes are mainly caused by external violence. It takes the form of direct and indirect violence. Indirect violence: the fracture occurs in a place far away from violent contact, that is, violence leaves the focus through conduction, leverage or torsion. Direct violence is mostly caused by rolling, bumping and impact, and the fracture line is transverse or rolling; Sometimes the two calves are fractured on the same plane, and the soft tissue injury is often serious, which is easy to cause open fractures. Sometimes the skin is not broken, but it is badly bruised, and secondary necrosis occurs due to poor blood circulation, leading to bone exposure infection and osteomyelitis. Indirect violence is more common in fractures caused by falling from high places, spraining or slipping when running and jumping; The fracture line is often oblique or spiral, and the tibia and fibula are not in the same plane. Tibiofibular fracture

Indirect or direct violence can lead to overlapping, angulation or rotation deformity of two broken ends. Most direct violence leads to tibia and fibula fractures, while indirect violence can lead to single tibia or fibula fractures. The former are mostly transverse fractures, short oblique fractures or comminuted fractures, and the fracture edges are mostly in the same plane, which is more open. The latter is easy to cause spiral, oblique or comminuted fractures, and the fracture edges are often not at the same horizontal edge, mostly closed, which is more common in sports injuries or falls.

Analysis on the causes of missed diagnosis of tibia and fibula fracture caused by wheel torsion injury in children

(1) Torsional injuries of children's limbs stuck in wheels are caused by indirect violence, which leads to fractures of the middle and lower tibia and fibula. Because the middle and lower tibia and fibula 1/3 is a triangular and square diaphysis transition part, this shaft is weak and easy to fracture. In the process of riding a car, children's lower limbs inadvertently extend into the rotating wheel, which leads to the inability of their bodies to move with them, and the tibia and fibula are pulled and bent inward, which exceeds the load that the tibia can bear, thus leading to fractures. (2) The ankle joint extended into the wheel with the rotating speed, resulting in the fracture of the middle and lower tibia and fibula, which is also in line with the theoretical basis of indirect violent fracture where the external force point of the injury is not together with the injured part. (3) By analyzing the causes of missed diagnosis of middle and lower tibia and fibula fractures caused by crush injury of bicycle wheels, it is considered that the overall examination is ignored in clinic and is often covered up by local symptoms, such as crush injury of external skin, bleeding and swelling. In particular, the examination of an uncooperative injured child failed to grasp the characteristics and found the corresponding hidden tenderness point at the fracture site. Children can't get the acute and unbearable fracture site correctly, which leads to missed X-ray examination, wrong positioning, less photography and missed diagnosis. It is worth mentioning that because the nutrient vessels penetrate into the lateral side of tibial shaft 1/3, if the nutrient vessels are injured by fracture here, the adverse consequences caused by long-term missed diagnosis or serious illness will lead to unnecessary medical disputes and medical compensation, which will bring certain losses to the reputation and economy of the hospital.

Edit this clinical symptom.

The main symptom is pain. Simple fibula fracture sometimes has mild tenderness locally, which is easy to be misdiagnosed as soft tissue injury. However, the local tenderness of tibial fracture is often obvious and it is not easy to be misdiagnosed. The fracture site can be determined by the tenderness site. The pain is aggravated when moving the calf, and it is more obvious when the unstable fracture moves the calf. When the fibula fracture is simple, the weight-bearing function of the calf sometimes still exists; In tibial fractures, even stable fractures without displacement lose their load-bearing function. The most obvious sign is deformity, which is often manifested as angulation, lateral displacement, shortening and rotation. In mild injuries, sometimes there are only external rotation and internal and external angulation deformity. Because of bleeding and tissue reaction at the fracture end, local swelling is very obvious. Open fracture caused by direct violence, skin and soft tissue injury is very obvious, often accompanied by tissue contusion and skin defect. However, the open fracture of tibia caused by piercing the skin from the inside out is often small in wound and light in pollution, so the prognosis is better than that of ordinary open fracture, but the possibility of secondary infection through small wound can not be ignored. Moving the tibia can cause severe pain, which is helpful for the diagnosis of tibiofibular fracture, but it will increase soft tissue injury and deformity. Therefore, when in doubt, X-rays should be taken to confirm or eliminate it. Tibiofibular fracture is rarely directly related to nerve injury, but fibular neck fracture is easily related to common peroneal nerve injury. However, every patient with tibiofibular fracture must record the nerve system such as ankle dorsiflexion, toe dorsiflexion and plantar flexion, as well as the skin sensation of the foot, so as to know whether plaster compresses the common peroneal nerve and whether there are signs of anterior fascial compartment syndrome in the later stage. It is also rare that the fracture of tibia and fibula shaft is directly associated with vascular injury. The fracture of the upper tibia is more likely to cause vascular injury, and the anterior tibial artery passes through the interosseous membrane there, which is easy to be pulled or pressed by the nearby fracture block. Another place that is easy to damage blood vessels is the fracture of the lower tibia. No matter which part of the tibia and fibula is fractured, patients should check whether the dorsal foot artery and posterior tibial artery are pulsating, and also check other signs related to blood supply, such as capillary filling, muscle contraction, skin sensation, pain type, etc., and make detailed records. The situation of soft tissue injury should be carefully estimated. Whether there is an open wound or not and whether there is a potential skin necrosis area is of great significance for prognosis estimation. Torsion and contusion will have a serious impact on skin and soft tissue, and sometimes the true scope of soft tissue and skin injury will take many days to estimate. Deep muscle and tendon injuries are not common, but they occasionally occur in open fractures under tibia14.

Edit this section of the physical diagnosis

The tibial position is superficial, and the local symptoms are obvious. X-ray examination is not difficult to diagnose. However, we should pay attention to the complications of fracture, carefully check the degree of soft tissue injury, find the symptoms in time and deal with them in time. The patient is being treated for tibia and fibula fracture.

X-ray examination is used for diagnosis, estimation of fracture healing degree, discovery of fracture complications and necessary differential diagnosis. Clinically, once a fracture of tibia and fibula is suspected, the X-ray film of the right leg should be taken, which requires high quality. In addition to obvious fractures, suspected linear fractures should also be determined, because linear fractures also affect healing and treatment, such as internal fixation, and its stability should consider the factors of linear fractures. When evaluating the degree of late healing, sometimes oblique films passing through the fracture end should be taken. The X-ray film after reduction should preferably include two joints, the knee joint and the ankle joint, to ensure that the axes of these two joints are in parallel positions, and to prevent complications caused by the non-parallel surfaces of the knee joint and the ankle joint in the later period. In principle, the X-ray film of calf should cover the whole length of tibia and fibula. In order to prevent the missed diagnosis of low tibial fracture and high fibular fracture. In the X-ray description of bones, firstly, determine the fracture site, whether it is upper L/3, middle L/3 or lower 1/3. Then determine whether the fracture type is horizontal, oblique or spiral, whether the fracture is shattered or not, and whether it is multi-segmental. Severe lateral displacement is difficult to heal. It is difficult to determine the rotational displacement of the upper and lower fracture segments on X-ray films, which should be judged and corrected clinically.

Edit this paragraph for differential diagnosis.

Usually, tibiofibular fractures do not need more differential diagnosis. The passage that nourishes blood vessels is not easily mistaken for a fracture. However, some stress fractures can lead to wrong diagnosis. Stress fracture should sometimes have periosteal reaction, and there is a thin transparent area at the fracture. In young people, this periosteal reaction is often suspected as a malignant tumor of bone. Some stress fractures were misdiagnosed as chronic osteomyelitis. Through local tenderness, L clinical process and repeated X-ray changes, differential diagnosis should not be difficult as long as stress fracture is considered. In addition, pathological fractures are prone to occur under pathological conditions such as benign or malignant tumors, or skeletal atrophy, and the pathological state cannot be ignored when diagnosing fractures. Mainly to restore the weight-bearing function of the calf, so the angulation deformity, rotational displacement and limb shortening of the broken end of the fracture should be completely corrected so as not to affect the weight-bearing function of the knee and ankle joint. The treatment of tibiofibular fracture depends on the type of fracture. If it is a stable fracture, the tibiofibular fracture of the hand can be used.

Methods After reduction, splint fixation was performed. If it is an unstable fracture, manual reduction, small splint fixation and bone traction can be used; If the fracture is serious, open reduction and internal fixation can be considered. If we can treat tibiofibular fractures in accordance with the principles and laws of three-stage treatment of fractures, we can improve the healing rate of fractures and greatly reduce the occurrence of delayed healing or nonunion of fractures.

Edit this paragraph for auxiliary inspection.

X-ray positive film should cover the whole length of tibia and fibula to avoid missed diagnosis. X-ray shows fracture lines, broken bone fragments, broken end displacement, etc.

Edit this paragraph of pathological treatment

Suitable for single or double fractures of tibia, with good stability and no displacement.

For example, a transverse fracture, a serrated fracture or a fracture with Fluttershy-shaped bone fragments can be easily recovered by manual operation, and it is usually easier to heal than an open fracture. For this kind of fracture, there is no need for anesthesia, just pay attention to correct the rotation of the affected limb, make the tibial crest align with the patella after the calf is suspended, and fix the knee joint with plaster or long leg plaster between the big toe and the second toe for slight flexion. Yes, you can walk on crutches for a few days after fixation. 2-3 weeks, you can start to turn around and practice walking with weight. Fault classification

Yes, unstable fracture.

Or double fracture of tibia and fibula with angular deformity, transverse or short oblique fracture, should be under anesthesia, after fracture reduction, small splint can be used for local fixation, and the affected foot can be placed in functional position.

Spiral unstable fracture

For the single spiral fracture of tibia, because the fibula is used as a scaffold, the displacement and overlap are not obvious, so it can only be reduced under anesthesia or without anesthesia, and the rotation can be corrected and fixed with a small splint or simply fixed with long leg plaster. If the double fracture of tibia and fibula is spiral with obvious overlapping displacement, calcaneal traction should be carried out to correct overlapping, shortening and rotation.

Management of open fracture

1) Only the broken end of the fracture pierces the skin, or the skin is damaged by external force, but the broken end has no obvious displacement. After full debridement and suture, it can be fixed with plaster. 2) The unstable fracture with obvious displacement of the fracture end is treated with full debridement and reduction, or screw internal fixation, and long leg plaster fixation after operation. 3) Open comminuted fracture, if the fracture is not easy to reset after debridement, calcaneal traction after suture is feasible. 4) If there is any defect in the soft tissue group of open fracture, skin grafting or skin flap transfer should be feasible after full debridement, and the fracture can be internally fixed with one or two screws or without bone traction with internal fixation. Steel plate and screw fixation should be used with caution or not.

Management of complications of double fracture of tibia and fibula

(1) Treatment of complicated infection or osteomyelitis: Open tibiofibular fracture can cause infection and osteomyelitis due to incomplete cleaning. Generally speaking, infection should be controlled first, and dead bones should be removed. After 6- 12 months of wound healing, open reduction, bone grafting and internal fixation should be performed again. Treatment of delayed union or nonunion of fractures: There are many cases of delayed union or nonunion in middle and lower tibia13. In recent years, due to the development of emblem surgery, composite tissue transplantation or vascular bone transplantation has been adopted, and satisfactory results have been achieved. Simple fibular fracture Simple fibular shaft fracture (II) Simple fibular fracture Simple fibular shaft fracture: rare. Most of them are caused by direct violence hitting the outside of the calf. The fracture occurred in the part affected by external force, and the fracture was transverse or shattered. Because the intact tibia is used as a scaffold, the fracture rarely shifts. Treatment generally does not require reduction, and it is fixed with plaster support or splint for 4-6 weeks. Slight fracture can be healed by dressing it with elastic bandage and walking on the handrail. (3) Fatigue fracture of fibula: Fatigue fracture of fibula mostly occurs in middle and lower13, and it is more common in athletes, soldiers or long-distance walkers. The cause of the disease is that repeated slight violence acts on the fibula, causing its trabecular bone to break constantly, and the speed of local repair can not keep up with the destruction of trabecular bone, which eventually leads to tibiofibular fracture.

There is no great violence when the fracture occurs, which is also called chronic fracture. Clinical symptoms and diagnosis: local pain after exercise or long-distance walking, improved after rest, aggravated after exercise, long-distance walking or work. Because the soft tissue of the lower fibula is very thin, there may be swelling and tenderness, and sometimes there will be a hard bulge. The changes on the X-ray film appeared late. Two weeks later, an unclear fracture line can be seen in adults, showing an osteoporotic area or a dense area. On subsequent X-ray films, periosteal new bone formation and callus growth were observed. The treatment of fatigue fracture of fibula is mostly without displacement. After diagnosis, you should stop exercising, walking and working for a long distance. Plaster fixation with obvious symptoms. (4) Open fracture of tibial shaft with severe indication of fixation is accompanied by extensive soft tissue injury, or skin grafting or extensive plastic surgery is needed. 2. Multiple fractures of ipsilateral limbs with major trauma such as femoral shaft fractures. 3. Multi-segment fracture of tibia with bone fragments displaced in the middle. 4. Tibial shaft fracture, bone loss, resulting in bone defect. 5. After closed reduction treatment of tibial shaft fracture, satisfactory results can not be achieved, and some people have rotation or angular displacement.

Surgical effect

There are different views on the early treatment of tibiofibular fractures, which can be roughly divided into three types: first, all fractures are internally fixed in the early stage; Second, all fractures were treated by closed method; Three, the general use of closed method, if there are special indications, can also be early surgical reduction and internal fixation. The lower tibia13 is under the skin, even the anterior and medial tibia are under the skin. The blood supply of tibia is worse than that of other bones surrounded by abundant muscles, so delayed healing, nonunion and infection are the most common complications. Open reduction and internal fixation is one of the effective methods to treat tibial shaft fractures. Pre-surgical

Contraindications

1. Patients with severe heart, lung, liver, kidney disease and diabetes can't afford surgery. There are potential sources of infection all over the body. Anesthesia method for one month after operation

Epidural anesthesia or spinal anesthesia is feasible for children or uncooperative people. Contraindications to anesthesia are safe and effective. Three months after the operation

Edit the pathological prognosis of this paragraph.

The prognosis of tibiofibular fracture mainly depends on the fracture itself and the injury mechanism that causes the fracture. Of course, the treatment will undoubtedly affect the prognosis, but the choice of treatment itself depends on the type of fracture. The main factors affecting the prognosis are: ① the degree of original displacement of fracture; ② Degree of soft tissue injury, including open wound; ③ Fracture crushing; ④ Whether there is infection. Tibiofibular Fracture-Prognosis

Healing time: it is difficult to determine the bone healing time, and the first is the standard problem. Most people think that the trabecular bone passes through the fracture end, and the patient can bear the weight completely without any support and pain. It takes 10- 13 weeks for bone healing of closed non-displaced fracture. Displaced fracture 13- 16 weeks; But open or comminuted fractures need 16-26 weeks. The average healing time of adults was 65438 06 weeks. It is also difficult to distinguish delayed healing and non-healing simply by time. However, to diagnose fracture nonunion, there must be a pseudojoint at the fracture end clinically. X-ray examination shows that the fracture end must be hardened, the bone marrow cavity is closed, and the bone end is atrophied or enlarged. It's no use waiting at this time. Further treatment measures must be taken. There is no obvious relationship between fracture line direction and healing time, but oblique or spiral fractures are mostly caused by indirect violence, and the local soft tissue injury is mild, while direct violence often causes transverse fractures or comminuted fractures, and severe soft tissue injury may affect healing time. Of course, the violence causing multiple fractures is more serious, and the soft tissue injury is also more serious. Bone healing often takes more than 6 months. Regarding the relationship between fracture site and healing time, most people think that the blood supply at the junction of middle and lower tibia 1/3 is poor, so the healing time is longer. However, after statistical research by many authors, there is no significant difference in fracture healing time between the middle and lower tibia 1/3 junction and other parts. The influence of fibula fracture on prognosis: the integrity of fibula itself shows that the violence caused by injury is less. So the soft tissue injury is also light. Because of the support of fibula, the tibia is relatively stable and the displacement is relatively light. However, the support of fibula also makes it difficult for tibia to recover completely, which is especially easy to cause outward angulation. At the same time, the contact between fracture ends is also poor, which delays the healing of tibia. When it is determined that there is delayed healing or nonunion of tibia, it is also a feasible method to interrupt fibula and increase the contact of tibia to promote tibial healing. The age of the patient at the time of injury is also a factor affecting the healing time. /kloc-under 0/6 years old, the fracture healed quickly; Over 65 years old, the fracture healing time is relatively prolonged. Excessive traction at the fracture end will obviously affect the healing time, and most people think that excessive traction less than 1.5 mm is acceptable. Some authors point out that a distance of 5 mm requires 12 months of bone filling to heal. In some cases, the healing time of traction treatment is obviously longer than other treatments, which can not be completely considered as excessive traction. Because some cases who choose traction treatment have serious injuries and are not suitable for other treatments, the healing time is much longer.

Edit this paragraph to prevent

(1) Attention should be paid to strengthening the sense of responsibility and professional learning of clinicians. Both clinicians and imaging doctors should fully understand the medical history. To analyze the mechanism of trauma, it is necessary to understand the formation process of injury and analyze the conditions of injury itself and its relationship with surrounding tissues. (2) Bicycle injuries should have their own characteristics and should be treated differently. According to one or two obvious superficial skin contusions, bleeding and swelling, they should not be mistaken for soft tissue contusions, and should be examined by X-ray. Tibia and Fibula Fractures-Prevention

(3) For the chief complaint of trauma, it is necessary to combine examination and in-depth analysis, make full use of the four diagnostic parameters of observation, hearing, questioning and cutting, and coordinate with each other among departments. The chest radiograph of children with lower limb injury caused by bicycle wheel torsion should include the anterior and posterior positions of tibia and fibula and ankle joint, which can reduce and avoid the missed diagnosis of middle and lower tibia and fibula fractures. (4) Prevention of direct or indirect violence can reduce the incidence. In case of fracture, we should actively prevent different complications according to different fracture sites to prevent ischemia, gangrene and affect function. (5) After the fracture, in order to restore the load-bearing function of the calf as soon as possible, it is necessary to completely correct the angulation deformity, rotational displacement and limb shortening of the fracture, so as not to affect the load-bearing function of the knee and ankle joint. After fixation, the patient should be instructed to do ankle flexion and quadriceps contraction immediately. After 2 weeks of stable fracture fixation, the legs were lifted and knees were bent under the guidance of a doctor. After three weeks, with the splint still fixed, you can get out of bed and walk with crutches without load. Later, it can be used to rub and relax muscles and pedals.