1. TIBIA AND FIBULA FRACTURE Abby Whitacre

2. ANATOMY The tibia and fibula are both located in the lower leg. The fibula is the outer bone and the tibia is the inner bone on the lower leg. Out of the two bones, the tibia is the only weight bearing bone. The fracture usually involves both bones because the force is transmitted across the interosseous membrane to the fibula.

3. MECHANISM OF INJURY Many tib fib fractures can be caused by a direct blow which can lead to a break in the skin, a twisting force is also common in young children, and low trauma fractures can occur from activities such as jogging or activities that involve repetitive impact. Other common tib fib fractures are caused by:  Child abuse  Contact sports such as football  Falling from toddlers that are learning to walk  Young children falling while playing  Motor vehicle accidents  Either involve another car or a pedestrian

4. DIAGNOSIS Many tib fib fractures are diagnosed just by sight. This is because the layer of skin and tissue around the bones is so thin that often times the bone protrudes through the skin so that it is in plain sight.  If it is an open fracture, a careful examination of the nerves, blood vessels, and muscles along the leg is required. An arteriogram may be done if a problem with blood circulation (vascular compromise) is suspected.  A complete blood count (CBC), blood typing, coagulation profiles, and electrocardiogram (ECG) are part of routine preparation for surgery.

5. DIAGNOSIS CONTINUED If it is not obvious that the injury is a tib fib fracture, an x- ray is required for diagnosis. A tib fib fracture may also be diagnosed by palpation, but an x-ray usually soon follows.  Ct scans and MRI’s, may also be needed if the fracture extends to the knee or ankle. A bone scan is also often used to determine a stress fracture since normal x rays don’t show stress fractures in the earliest stages.  The patient will most likely be able to walk if only the fibula is fractured since the bone is non weight bearing.  The patient will show swelling, bruising and tenderness at the area of the fracture site.  There may also be swelling at the knee or ankle to indicate a fracture.

6. TREATMENT PLAN Tib Fib fractures almost always require surgery following a cast.  No weight is allowed on the leg and as time progresses, a walking boot will be applied, allowing the patient to gradually put weight on the injured leg.  For uncomplicated fractures, closed reduction and a cast may be the only treatment required.  Compound or displaced fractures may require pins placed externally (external fixation devices), or surgery for open reduction.  The treatment of open fractures begins with thorough irrigation under pressure, followed by surgical removal of dead tissue.  Bone grafting may be done early or late in the course of treatment. If there is no surgery, then a boot or cast is require depending on the severity and where the fracture is located. The biggest factor for a tib fib fracture is time and allowing the injury to heal properly so that no further injuries follow. Treatment is followed by physical therapy and slowly getting back into all athletic and every day activites.  Treat the injury like any other: icing if possible, pain medications multiple times daily, and elevate the injury. Medications include analgesics for pain and antibiotics and a tetanus shot (tetanus prophylaxis) for open fractures.

7. PREDICTED OUTCOME The outcome depends on the location, severity of the fracture, and extent of soft tissue injury, along with the presence of any complications. The Most Common Outcome The average time that people are in a cast after surgery for a tib fib injury is about 8 weeks (if everything goes as planned without having a serious tib fib fracture.) After 8 weeks the patient will most likely start slight weight bearing by walking on crutches or in a boot and will attend physical therapy. At ten weeks, the patient will most likely be out of the boot and will be allowed to wear tennis shoes while continuing physical therapy and starting on their track of recovery.

8. HOW TO RETURN TO PLAY  Rehabilitation emphasizes restoring full range of motion, strength, proprioception, and endurance of all adjacent joints while maintaining all activities of daily living without stalling the healing process. The patient may progress from walker to crutches to cane based on ability and weight bearing status. If they are in a cast, range of motion exercises of the adjacent joints may be beneficial. After the cast is removed, range of motion, proprioceptive activities, and strengthening exercises should be started. Exercise intensity and difficulty should be progressed until full function is achieved, and the individual should be instructed in a home exercise program to be performed independently. The resumption of heavy work and sports should be guided by the treating physician. Rehabilitation may not begin until tissue healing, about 6 to 8 weeks after the fracture. FREQUENCY OF REHABILITATION VISITS Nonsurgical † SpecialistFracture, Tibia or Fibula Physical TherapistUp to 20 visits within 8 weeks Surgical SpecialistFracture, Tibia or Fibula ** Physical TherapistUp to 16 visits within 8 weeks

9. CITATIONS http://orthopedics.about.com/od/footanklefractures/qt/F ibula-Fractures.htmhttp://orthopedics.about.com/od/footanklefractures/qt/F ibula-Fractures.htm http://www.sports-injury-info.com/tibfib-fracture- recovery.htmlhttp://www.sports-injury-info.com/tibfib-fracture- recovery.html http://www.sporttaco.com/rec.running/Back_to_running_a fter_a_broken_tibfib_recovery_3975.htmlhttp://www.sporttaco.com/rec.running/Back_to_running_a fter_a_broken_tibfib_recovery_3975.html http://emedicine.medscape.com/article/826304- overviewhttp://emedicine.medscape.com/article/826304- overview http://practicalplasticsurgery.org/docs/Practical_21.pdf http://www.mdguidelines.com/fracture-tibia-or-fibula