Fractures of the diaphysis of the tibia are of great variety. There are not very complex fractures caused by low-energy force with an indirect "twisting" mechanism of injury, which respond well to conservative treatment. Along with this, high-energy exposure leads to severe fractures with extensive soft tissue damage and often acute manifestations of subfascial hypertension syndrome.

Assessment of the energy absorbed by the lower leg can be given based on x-ray findings of a fractured tibia. The overall outcome of fractures depends mainly on the severity of soft tissue injuries, both open and closed. For example, the presence of pronounced crushing of the soleus and gastrocnemius muscles does not allow closing the defects formed as a result of an open fracture with local rotational flaps.

Medial surface of the tibia is poorly protected by soft tissues, so even small open fractures can cause significant difficulties in choosing the optimal treatment tactics for the exposed area of ​​the bone. Assistance varies from skin grafting and transplantation of local or free flaps with the creation of capillary microanastomoses, to limb amputation.

fractures diaphysis often lead to the acute development of the compartment syndrome, which is associated with the direct impact of compressive forces. Clinical manifestations of increased subfascial pressure are especially typical for cases of soft tissue crushing or temporary hypoxia. The first sign is disproportionate to the clinical picture pain in the lower leg or ankle joint, aggravated by passive movements in the joint or in the forefoot.

There is an increasing density in the calf region or, in rare cases, in the foot region. Reduced sensitivity of the foot and weakness when performing active movements are associated with hypoxic damage to the muscles and nerves located within the muscle sheaths, and are late manifestations (not timely diagnosed) of subfascial hypertension syndrome. The blood supply to the skin and the pulse in the distal parts of the limb do not suffer until the late stage of the disease, since the obstruction of blood flow in the subfascial spaces involved in the process affects capillaries more than the main arteries.

Diagnosis based on clinical examination. Measurement of subfascial pressure should be performed in patients with depressed consciousness or in a coma, as well as to exclude subfascial syndrome in unclear or borderline cases. With acute involvement of the gastrocnemius muscle in the process, treatment consists in immediate decompression by dissecting four muscle cases with incisions along the medial and lateral surface of the leg.

Time and ways treatment of diaphyseal fractures depend on the severity of the injury and associated complications. Limb viability-threatening injuries such as open fractures, arterial injuries, and subfascial hypertension require immediate surgical intervention. In the absence of such complications, preliminary closed manual reduction and the application of a plaster cast on the entire limb provide primary immobilization of the fracture.

At less severe fractures and the absence of significant displacement of fragments, the method of choice is conservative treatment. It is allowed to walk in a plaster cast, loading the limb as much as possible. In the future, when there are signs of stabilization of the fracture and the general condition improves, they switch to wearing an orthosis or a shortened plaster bandage covering the patellar ligament. This tactic can be successful.

But with more severe fractures it leads to untimely fusion, permanent deformation and increases the duration of disability. In this regard, operative fixation has more advantages, as it allows better control of the correct reposition, does not restrict movement in the foot and ankle joint, and allows early weight loading. The method of choice for fractures of the tibial shaft is intramedullary osteosynthesis.

Expanding testimony to the use of intraosseous fixators for the treatment of more distal and more proximal metaphyseal fractures. This is due to the use of the latest models of rods, which allow blocking in three planes in the most proximal and distal parts of the tibia. The main danger in intraosseous osteosynthesis of fractures of this localization lies in the valgus or varus installation of the lower leg, if anatomical reduction is not achieved using, for example, blocking screws.

Reaming of the medullary canal creates conditions for the introduction of sufficiently large diameter rods, which ensures reliable fixation in almost all diaphyseal fractures of the tibia. The diameter of these rods allows the use of locking screws of suitable strength for reliable reposition stability. The strength and resistance to fatigue failure of small-diameter intramedullary nails inserted without reaming, and especially the small diameter of the locking screws intended for them, do not allow maintaining the stability of reposition throughout the entire period of fracture healing.

Kernel without reaming is associated with a high risk of complications such as locking screw breakage, malunion and non-union of the fracture. Numerous large clinical studies have shown that conservative treatment and intraosseous osteosynthesis without reaming often entail impaired fracture consolidation, as opposed to fixation of fragments with cannulated rods with reaming. Moreover, intramedullary nailing has proven to be an acceptable treatment for open Gustilo type I to IIIB fractures.

For treatment some fractures still require external fixation. This applies to fractures caused by high energy, accompanied by severe damage to soft tissues, damage to the great vessels with the need for their reconstruction, or cases of multiple trauma, when external fixation is used to limit the consequences of injury. External circular fixators can be applied to move a segment of bone in cases of severe fracture or to correct malunion and non-union fractures.

Long-term (more than two weeks) use external fixation device is the cause of bacterial contamination in the places where the wires pass and increases the risk of suppuration during subsequent intraosseous osteosynthesis. Short-term (several days) use of external structures is quite safe before the final treatment of a tibial shaft fracture with intramedullary nailing.

With all the variety structures for external fixation, no significant benefits of either of them have been established. In most cases, piercing pins or wires are used in the most proximal and distal portions of the tibia, while "half pins" and long screws inserted transcutaneously in the ventral-medial surface are used to secure the frame of the external fixator. The external fixator should not be removed until the fusion process is complete. Premature removal of the structure in most cases leads to a typical late complication in the form of a curvature of the bone axis.
To speed up union of fractures of the diaphysis with a primary bone defect, it is advisable to perform posterolateral osteoplasty from the very beginning.

nakostny osteosynthesis a plate in acute cases of diaphyseal fractures is best left for periarticular injuries that are difficult to fix with intramedullary rods. In case of severe damage to soft tissues, osteosynthesis is dangerous in relation to tissue necrosis in the area of ​​surgical access and/or infection.

One of the most common injuries of the lower extremities is a fracture of the head of the fibula and its diaphysis. Sometimes, with severe injuries, a fracture of the adjacent tibia can be added to the fracture of the small bone. The fibula is one of the structures of the tibia joint, which, along with the tibia, bears a significant weight load. It thickens downward and with a flattened protrusion forms the outer malleolus of the ankle. In relation to the tibia, the fibula is practically motionless, they are connected only by a fibrous interosseous membrane, tightly stretched between them.

Fracture of the tibia can be of several types:

1. A bumper injury is the mildest non-displaced fracture. With such an impact, several fragments are formed, usually they do not move.
2. Indirect trauma is accompanied by the occurrence of a large number of fragments. The fracture occurs as a result of rotation of the tibia along the axis towards the direction of the traumatic factor. A fracture of the fibula with displacement is complicated by the possibility of displacement of fragments, which, when oriented in different directions, injure soft tissues.

examples of possible fractures

According to the type of damage formed, the following types of fractures are distinguished:

• transverse (for example, with a bumper impact);
• fragmentary, or splintered;
• in a spiral (for example, when turning the leg with a fixed foot);
• fibula fibula without displacement (it is not a fracture in itself, but requires proper treatment).

The reasons

We list the most common causes leading to a fracture of the fibula:

• hitting an obstacle;
• sports injury, for example, in skiers, skaters, football players;
• seasonal injuries, for example, during ice;
• falling on your feet from a great height;
• traffic accidents;
• osteomyelitis;
• bone tuberculosis;
• osteoporosis;
• bone sarcoma.

Characteristic manifestations

The symptoms of a fibula fracture become noticeable immediately after the incident. The victim complains of severe pain when trying to lean on his leg. In people with a low pain threshold, soreness may be barely noticeable. In the region of the diaphysis of the fibula, a hematoma is formed and edema is formed. Depending on the injury, the leg may appear to be turned forward from its normal position, and sometimes it seems to be shorter than healthy. If the axis of the fibula has not shifted during damage, then the victim can rotate his leg in the knee area.

With a fracture of the head and neck of the fibula, there is a high risk of compromising the integrity of the nerve. If a nerve is affected during a fracture, then the patient's foot becomes numb, he loses sensitivity in the lower part of the leg, and with a complete rupture of the nerve, the foot hangs completely lifeless.

Diagnostic methods

Upon admission to the clinic, the doctor conducts a visual examination and specifies the circumstances under which the fracture occurred. According to the patient's stories, the strength of the blow, the direction of its action are estimated, and the amount of possible damage is revealed. Such a keen interest in the circumstances of the injury is not accidental, because in some cases the diagnosis of a fracture is difficult. This occurs for the following reasons:

• the inability to palpate the bone due to the thick layer of muscles;
• pain does not appear if the patient has experienced shock and is in a state of stupor (for example, after a car accident), is under the influence of alcohol or drugs, and suffers from senile brain disorders.

After the initial examination, the doctor takes an x-ray in two projections, which allows you to specify the picture of what happened. Based on the results of the examination, the type of fracture, the presence or absence of bone displacement is determined. If the fracture of the head of the fibula and its body is of an open type, then the diagnosis of damage is not difficult. In the area of ​​damage, a rupture of soft tissues is visible, where a fragment of the fibula can be displaced. With an open fracture, it is very important to treat the wound with an antiseptic, and try not to infect. This will save the leg from soft tissue infection.

Usually, the diagnosis is not difficult for doctors, but the circumstances largely allow us to clarify the picture. Particular attention is paid to the preservation of innervation and the integrity of blood vessels, therefore, if necessary, the traumatologist consults with a neurologist and a vascular surgeon. The most common type of complication is a violation of the integrity of the diaphysis of the fibula, which is not a serious injury, but requires competent treatment.

Therapeutic measures

Treatment for a fibula fracture depends on the severity of the fracture. With a closed-type fracture and no displacement, the injury can be cured in a fairly short time. In this case, the doctor applies a plaster cast to immobilize the limb for a while. This will avoid the movement of bone fragments. After applying a plaster cast, a control x-ray is taken, which can be used to control the displacement of the fragments. Typically, a cast is worn for two to three months, depending on the degree of restoration of the fibula. When plastering the leg, the patient retains the ability to move, but this is done with the support of a crutch. With a good recovery rate, a callus can form in a month and a half, but sick leave, as a rule, is given for a longer period.

When treating displaced elements, it is first necessary to restore their previous position. For this, the technique of osteosynthesis is used. Restoration can be done with periosteal plates or pins. Metal elements are screwed into parts of the bone so that its natural integrity is restored. When installing these structures, doctors try once again not to damage soft tissues so that there are no problems with blood supply.

In order for the bones to grow together better, the patient is prescribed physiotherapy procedures and massages that will help strengthen the muscles so that rehabilitation is less painless. The recovery period for fractures complicated by displacement takes about six months. After the bone is completely healed, the metal plates or pins are removed.

rehabilitation period

A fracture of the fibula with displacement requires mandatory rehabilitation after treatment. If it is not carried out, then the patient's recovery will be delayed for a long time and further provoke complications. A significant part of the time is devoted to physical therapy, which helps restore normal blood flow in the damaged area. All exercises are selected individually for patients, taking into account the nature of the injury and the optimal load in this case. Exercise can be done at home. The rehabilitation process after a fracture can take up to three months, during which the patient will do exercises from the physiotherapy complex, undergo physiotherapy procedures.

Physical therapy includes the following set of exercises:

1. Rotation of the foot in different directions ten times each (performed a week after removing the plaster cast).
2. Abduction of the sore leg thirty degrees from the body and holding it in this position for 3-5 seconds (performed with both legs ten times).
3. Exercise for alternating swings to the side and back (performed with each leg 10 times).
4. From a supporting standing position, a person needs to rise on his toe 10 times (the exercise is first performed on two legs, and after 2 weeks - on one).
5. In a supine position, it is necessary to perform leg swings, crossing them in front of you (ten repetitions must be done at a time).
6. Daily walking (performed as you get tired).

During rehabilitation, to relieve tension in the muscles, you can do baths with sea salt. One hundred grams of sea salt is pre-dissolved in a liter of water, and then the liquid is stirred in a warm bath. At the end of the procedure, you can raise your legs on a pillow. These techniques will help improve lymph flow and blood flow in the affected limb.

tibia at the site of their transition to the diaphysis along a stainless steel nail 15 cm long, 4 mm thick, and then applied a longet-circular bandage. Thus, the nails were cast into the bandage. The patient in such a bandage was allowed to walk. After 4-5 weeks, the nails were removed, and a plaster cast was applied for another 6 weeks.

After the simultaneous reduction of oblique and spiral fractures of the shin bones, we successfully performed temporary closed percutaneous fixation of fragments using one wire (diafixation according to Pope) or two Kirschner wires. If the displacement along the length is eliminated or absent, but there is a wide gap between the fragments in oblique and helical fractures, they can be brought together by means of two spokes with thrust pads. The sharp end of both spokes is pulled in the opposite direction in one Kirschner arc until the fragments approach each other.

After X-ray control, a plaster cast is applied. The pins are removed after 6 weeks. A plaster bandage to the middle of the thigh or to the gluteal fold remains until the bone fusion of the fragments occurs, usually 2.5-3 months after the injury.

Treatment of a fracture of the diaphysis of the tibia

In case of fractures in the lower third of the lower leg without displacement, a bedless plaster bandage is applied to the middle of the thigh, and in case of fractures in the middle and upper thirds, to the gluteal fold. The bandage is applied for 8 weeks. With transverse fractures, after 8-10 days, a stirrup is applied and patients are allowed to walk with two crutches, and on the 15-20th day - with one crutch or with a stick. With oblique, screw and comminuted fractures of the tibia without displacement, the stirrup is applied on the 35th day. In order to avoid secondary displacement of fragments inside the plaster cast, patients should use two crutches when walking, without loading the limb, for 6 weeks. Ability to work is restored after 2-3 months.

For displaced fractures, skeletal traction is first applied on a standard splint. The needle is passed through the supramallear region or calcaneus. A load of 6-9 kg is suspended from the arc. After 2-3 days, a control radiograph is taken. If the fragments are reduced, the load, starting from the 8th-10th day, is gradually reduced and by the 15th day is brought to 4-6 kg. On the 25th day, the traction is removed and a plaster bandage is applied to the middle of the thigh with low fractures, and with high fractures - up to the gluteal fold. After 2 days, the stirrup is cast and the patient is allowed to walk at first with two crutches without load on the leg. From the 30-40th day, the load can be gradually increased. After 8-10 weeks after the injury, the plaster cast is removed. The term of restoration of working capacity is 2.5-3.5 months.

Treatment of a fracture of the fibula

Isolated fractures without displacement and with displacement of fragments do not impair the function of the limb, if they are not associated with the ankle joint and are not accompanied by damage to the peroneal nerve. About fractures of the fibula in the lower third.

For fractures of the fibula in the middle third, a plaster bandage is applied from the middle of the thigh for 2-3 weeks, the knee and ankle joints are immobilized, and for fractures in the upper half that are not accompanied by damage to the peroneal nerve, a plaster splint is applied for 2-3 weeks. On the 2-3rd day, the patient is allowed to walk without a stick with a full load on the leg. After removing the plaster bandage, therapeutic exercises and physiotherapy are prescribed. Ability to work is restored in 3-5 weeks after the injury.

Fractures of the head of the fibula can be complicated by trauma to the peroneal nerve. In such cases, hemorrhages and nerve bruises are predominantly observed. With such fractures, a plaster cast is applied to the middle of the thigh. The foot is fixed at a right angle. Dibazol, prozerin, vitamins B1 and B12 are prescribed, physiotherapy procedures,

massage, therapeutic exercises. After 2-3 weeks, the plaster cast is replaced with a removable splint up to the knee. With complete ruptures of the peroneal nerve, surgery is indicated - suturing the nerve. In cases of persistent foot drop due to damage to the peroneal nerve, muscle transplantation or tenodesis, which fixes the foot in a functionally correct position, can give a good result. If the patient refuses the operation, there are contraindications to it, as well as in the process of aftercare after the operation, wearing orthopedic shoes is indicated.

Avulsion fractures of the apex of the fibula are treated surgically. The task is to sew the detached part of the head, together with the lateral ligament attached to it, to its bed, otherwise the same instability of the knee remains as with a rupture of the lateral ligament.

Rice. 183. Spiral fracture of the leg bones (a). Osteosynthesis with one screw with plaster immobilization (b).

Treatment of a fracture of the diaphysis of both bones of the lower leg

For transverse fractures of both bones of the lower leg without displacement, a plaster cast is applied to the middle of the thigh, and for high fractures, to the inguinal fold. In the case of an increase in edema, the plaster cast must be cut in the longitudinal direction along the entire length. After the swelling subsides, the plaster cast is changed. On the 11-12th day, the stirrup is plastered. On the 12-15th day, the patient is allowed to walk with the help of two crutches with a load on the leg, and on the 20-25th day he begins to walk with a stick.

In case of oblique, screw and comminuted fractures of both bones of the lower leg without displacement, especially if edema increases, it is better to use skeletal traction on a standard splint, since secondary displacements are observed during the treatment with a plaster cast, despite immobilization. We have proven this many times. Traction should be applied immediately after the patient arrives. The needle is passed through the supramallear region of the tibia or through the calcaneus. A load of 4-5 kg ​​is suspended from the arc. On the 20-30th day, when there is already a “soft soldering” of fragments, a plaster cast is applied to the middle of the thigh. A day later, the stirrup is plastered. On the 27-30th day, the patient begins to walk with the help of two crutches, first without load, and then with a slight load on the leg; on the 45th day, it is allowed to walk with one crutch or stick.

The plaster bandage is removed 2-2.5 months after the injury. Assign therapeutic exercises, massage and physiotherapy. Ability to work is restored after 3-3.5 months.

Fractures of the diaphysis of both bones of the lower leg with displacement of fragments are treated with traction on a standard splint, which is applied immediately after the patient arrives. The needle is passed through the calcaneus, through the supramallear region. A load of 7-9 kg is suspended from the arc. In 2 3 days do the control roentgenogram. If the fragments are reduced, the load is gradually reduced and by the 15th day is adjusted to 5-7 kg.

The valgus position, as mentioned above, is usually corrected by lateral traction or pressure with a pad on the inner surface of the lower leg. We rarely use this technique and restore the natural slight varus position of the lower leg by traction on a splint placed on the bed in adducted position. With helical and oblique fractures, there is practically no danger of overstretching and the formation of diastasis due to traction.

With transverse fractures, in order to avoid overstretching, as soon as the fragments are set, the load is reduced to 4-5 kg. On the 24-27th day, the traction is stopped and a plaster cast is applied to the middle of the thigh. In this case, it is necessary to prevent the possibility of curvature of the axis of the lower leg backward and outward by simultaneous pressure on the lower leg at the level of the fracture from back to front and from inside to outside. After 2 days, the stirrup is plastered. For oblique, spiral and comminuted fractures, the plaster bandage is removed 2.5-3 months after the injury, and for transverse fractures, the period of wearing the bandage is extended by another 2 weeks. Fractures in the lower third of the tibia grow together more slowly than fractures in the overlying sections. Employability is restored after

Supramallear fractures of the lower leg are treated in the same way as other fractures of the diaphysis of the bones of the lower third of the lower third. Treatment of avulsions of the posterior and anterior edges of the tibia, as well as intra-articular fracture of the lower end of the tibia, is described in the section "Ankle fractures".

Rice. 184. Transverse fracture of the lower leg with a large displacement. Intraosseous osteosynthesis with a metal rod, bone fusion of fragments after 4 months

Surgical treatment of fractures of the diaphysis of the bones of the lower leg is indicated for: 1) the danger of skin breakthrough, compression of blood vessels and nerves, or when reposition is associated with the possibility of damaging them; 2) interposition of soft tissues or bone fragments between fragments; 3) bad

repaired, easily displaced and difficult to hold fractures, double fractures of the tibia with a large displacement, as well as with unsuccessful reposition of fragments in a closed way; 4) delayed union and nonunion of fractures.

The operation should be started early, as soon as the general condition of the patient and local conditions allow. It is best to operate on the 1st - 5th day after the injury. During this period, reduction in an open way usually does not present great difficulties.

Operative reduction without additional fixation of fragments, as a rule, should not be used because of the danger of secondary displacement.

Rice. 185. Intraosseous osteosynthesis with a metal rod and artificial narrowing of the bone canal according to Kaplan.

The operation is performed under intraosseous or general anesthesia. The patient is placed on his back with a slightly bent leg. After the lower leg is lubricated with iodine and the operating field is protected with sterile sheets, an incision is made at the level of the tibial fracture 12–16 cm long, 1–2 cm away from the anterior crest of the tibia. The site of the tibial fracture is exposed. Often, between the fragments, strangulated soft tissues are visible, which interfere with reduction. Subperiosteally release first central and then peripheral fragments. Incarcerated soft tissues are released and removed. If you make a traction for the foot, then in most cases it is not difficult to set the fragments of the tibia with the help of single-pronged hooks, bone forceps or elevators. The position of the fibula fragments is of no practical importance and does not require special reduction. After reduction and fixation of fragments of the tibia using one of the methods described below, the wound is sutured tightly in layers and a plaster cast is immediately applied to the foot, lower leg and thigh. The skin wound can be sutured with thin catgut threads, then you do not have to remove the sutures and cut the plaster bandage for this.

Rice. 186. Oblique fracture of both bones of the lower leg with displacement of fragments. Reposition and fixation with the Gudushauri apparatus (a); after 7 months – bone fusion (b).

Rice. 187. False joint after a comminuted fracture of the leg bones, osteosynthesis of the tibia with a metal rod and circularly applied wires. The nail has broken and the proximal end of the nail has been removed (a). The Volkov-Oganesyan apparatus was applied in a closed way, without removing the nail (b).

Rice. 188. False joint, osteomyelitis and fistulas after an open fracture complicated by infection (a); osteotomy of the fibula and gradual reposition using the Volkov-Oganesyan apparatus with a repositioning device (b, c); fusion after 6 months (d).

Osteosynthesis with metal plates. For this purpose, Lena's plates, Klimov's T-beam, Kaplan-Antonov's detorsion-compressive plate, etc. are used. The incision should be made 1-2 cm outward from the anterior crest of the tibia. A metal retainer is placed on the outer surface of the tibia. Laying the plate on the anterior surface of the tibia is a gross mistake, since in this case the plate lies under the skin and causes a decubitus.

The Lena plate with six screws is rarely used for osteosynthesis. During osteosynthesis with Lena's plate of transverse fractures, diastasis often remains or forms due to resorption of the ends of fragments, which is one of the reasons for delayed union and non-union of fractures.

Klimov's T-beam can be successfully used for oblique and transverse fractures. With helical and strongly beveled fractures, it is not advisable to use it.

The Kaplan-Antonov detorsion-compressive plate should be used for transverse, oblique, helical and double fractures. With transverse fractures, the use of this plate allows you to tightly bring the fragments together and prevent diastasis.

Osteosynthesis with screws (Fig. 183). It is advisable to use it for comminuted, helical and oblique fractures. The method is simple and less traumatic.

Osteosynthesis with knitting needles. One, two needles, and sometimes more are used to fix fragments. The ends of the needles can be bevelled and left under or over the skin. The pins, the ends of which are left above the skin, are easy to remove, which is usually done 4-6 weeks after osteosynthesis. This simple method is useful for children, older people with significant osteoporosis, debilitated patients, etc.

Rice. 189. Osteosynthesis of the fibula and bone autoplasty with an infected false joint of the tibia.

a - false, the joint after intraosseous osteosynthesis for an open fracture, the metal rod was removed due to suppuration; osteomyelitis and fistulas; within 10: months after the application of the compression apparatus, there is no adhesion; b, c – bone autoplasty of the tibia and osteosynthesis of the fibula with the Kaplan-Antonov plate. Bone fusion has set in.

Osteosynthesis with circularly applied wire, metal tape and metal ring. It is used for oblique and spiral fractures of the diaphysis of the bones of the leg. Usually impose 2-4 circular rings. The wound is sutured tightly with catgut or silk sutures and a bedless plaster bandage is necessarily applied to immobilize the knee and ankle joints, since plates, rings, wire sutures, tapes, knitting needles do not provide the necessary immobilization of fragments. In the future, proceed in the same way as with conservative treatment. The metal plate is removed 3-6 months after the bone fusion of fragments.

Intraosseous fixation of a fracture of the diaphysis of the tibia with a metal rod. It is used for fractures located at least 7-8 cm below the knee joint and not closer than 6-7 cm from the ankle joint. The thickness of the rod should correspond to the canal of the tibia; its lower end is slightly curved. The length of the rod should be such that its lower end does not reach the lower articular surface of the tibia by 2 cm, and the upper end stands out of the hole made in the tibia by 1.5-2 cm. In some cases, with oblique and spiral fractures, in order to prevent secondary displacement of fragments during intraosseous osteosynthesis with a metal rod, it is advisable

additionally connect the fragments with one or two wire or narrow-band metal rings.

Rice. 190. Defect of the tibia after osteomyelitis, complicating an open fracture. The fibula is fused at an angle (a); grafting of a fibula taken from a healthy leg into the area of ​​a defect in the tibia (b).

Intraosseous fixation of a fracture of the diaphysis of the lower leg with a metal rod with exposure of the fracture site (open method). This operation does not require special equipment and is widespread. A longitudinal incision is made on the anterointernal surface of the tibia in the area of ​​the fracture. The fragments are set and then the rod is inserted into the medullary canal of the proximal fragment through a specially made hole in the upper part of the tibia, as in the closed method. When inserting the rod, the lower leg should be bent at the knee.

As the rod advances, bone marrow flows out of the proximal fragment. As soon as the end of the rod appears from this fragment, the distal end of the tibia is brought to it. Having given the correct position of the peripheral part of the lower leg and having well fixed the matched fragments with bone forceps, the rod is driven into the medullary canal of the lower fragment with gentle blows of the hammer; at the same time, measures should be taken so that a gap does not form between the fragments and the end of the rod does not penetrate the ankle joint (Fig. 184). If the medullary canal of the tibia at the level of the fracture is wider than the inserted nail, then for the stability of osteosynthesis, before inserting the nail into the distal fragment, we make an artificial narrowing of the canal (Fig. 185). After that, both wounds are sewn up tightly. In the future, proceed in the same way as with the closed method.

Compression-distraction method of treatment. It is indicated for any fractures of the bones of the lower leg (Fig. 186). The positive aspects of this method are especially evident in the treatment of fractures of the bones of the lower leg, including open and infected ones, as well as with delayed union and false joints.

Tibia and fibula are arranged parallel to each other and are firmly interconnected by ligaments. As a rule, a displaced fracture of one bone is associated with an obligatory fracture or damage to the ligaments of another. Tibia fractures are not only the most common of all long bone fractures, but also the most common open fracture.

Fractures of the diaphysis of the fibula are rare in isolation, usually associated with tibial fractures. The fibula is non-supporting and can therefore be resected proximally without compromising function. In the distal region, the fibula is important for maintaining ankle stability.
Isolated fractures of the diaphysis of the fibula treat only symptomatically; they usually heal without complications.

Fractures of the tibia classified based on the provisions put forward by Nicoll and used by Rockwood and Green. Nicoll found that the outcome of tibial fractures is determined by three factors: 1) initial displacement; 2) the degree of fragmentation; 3) the presence of soft tissue damage (open fracture).

At type I fractures the displacement is only slight (from 0 to 50%) and there is no fragmentation. In type II fractures, the displacement exceeds 50% and there may be partial crushing while maintaining bone contact. In type III fractures, there is a complete displacement with fragmentation. Type II and III fractures can be either open or closed. In type I fractures, union occurs in 90% of cases, while in type III fractures, the chance of union is only 70%.

Shin has three fascial sheaths containing muscles, nerves and blood vessels.
1. The anterior sheath contains the tibialis anterior, extensor hallucis longus, third peroneal, extensor digitorum longus, anterior tibial artery, and deep peroneal nerve.
2. The outer sheath contains the long and short peroneal muscles and the superficial peroneal nerve.
3. The posterior sheath contains the soleus, gastrocnemius, tibialis posterior, flexor hallucis longus, and flexor digitorum longus.

To fractures diaphysis tibial and peroneal muscles lead two mechanisms. Direct trauma, such as from a car accident or some type of skiing injury, is responsible for the majority of tibial and fibula shaft fractures. Direct trauma usually results in a transverse or comminuted fracture. Indirect trauma caused by rotational or compressive forces, such as skiing or a fall, usually results in a spiral or oblique fracture.

Fracture of the lower articular tibial platforms, as a rule, occurs when falling from a height, when the talus is embedded in the tibia.

At fibula fractures there is pain that worsens with walking. Tibia fractures are commonly associated with pain, swelling, and deformity. Although neurovascular injury is uncommon, investigation and documentation of the pulse and peroneal nerve function (dorsal and plantar flexion of the fingers) is necessary.

To determine the position fragments usually enough pictures in frontal and lateral projections. When describing these fractures, it is important to find out:
1) localization of the fracture - upper, middle or lower third;
2) type - transverse, oblique, spiral or splintered;
3) displacement - the area of ​​contact surfaces in percent;
4) angular displacement - valgus or varus position of the distal fragment.

As it was mentioned, with trauma, concomitant damage to blood vessels and nerves is rare. Following tibial fractures, carpal tunnel syndrome may develop, which usually begins 24-48 hours after the injury. If its development is suspected, the muscles of the anterior sheath should be palpated in order to identify their soreness or rigidity.

It is necessary to determine the pulse on the dorsal artery and compare it with the pulse on an intact limb, in addition, you should check the sensitivity between fingers I and II, which is an indicator of the function of the peroneal nerve.

Treatment of fractures of the diaphysis of the tibia and fibula

Emergency care for fractures of the diaphysis includes initial examination, immobilization with a long leg splint, and urgent referral to an orthopedist. Open fractures must be carefully treated and a sterile dressing applied immediately to the wound. Urgent reduction of a closed fracture is indicated prior to radiography if there is vascular damage that threatens the viability of the limb.

because of high rate of complications after an x-ray examination, an urgent consultation with an orthopedist is necessary. Patients with tibial shaft fractures tend to have concomitant carpal tunnel syndrome that develops later. Therefore, most patients with serious fractures of the tibial shaft should be hospitalized, the limb should be elevated and monitored to prevent the development of a tunnel syndrome.

Fractures of the diaphysis of the tibia Type I without displacement can be treated with a long leg cast with full limb unloading. The average recovery time for uncomplicated fractures without displacement is 10-13 weeks. With displaced, open or comminuted fractures, it lengthens to 16-26 weeks.

In patients with unfused fractures of the tibia, some researchers removed a small section of the fibula and found that the degree of compression between the two ends of the tibia increased. This led to an increase in the frequency of union in patients with complicated tibial fractures. Nonunion in tibial shaft fractures is a complex problem.

For improvement consolidation pulsating electromagnetic fields were applied. Successful results were obtained in approximately 87% of cases, and no further surgical treatment was required. Isolated fractures of the diaphysis of the fibula are treated symptomatically. A cast can be applied to relieve pain. At first, a long leg cast is more comfortable, then after 2 weeks a short bandage is applied, which can be removed after 4 weeks.
Some patients had minor pain, and they easily tolerated walking on crutches without a plaster cast.

Complications of fractures of the diaphysis of the tibia and fibula

With fractures of the diaphysis of the tibia and fibula several serious complications may develop.
1. Non-union or delayed union is typical, especially if:
a) significant bias;
b) fragmentation;
c) open fracture or severe damage to soft tissues;
d) infections.

2. After treatment, the development of edema can cause neurovascular insufficiency.

3. Chronic joint pain or joint stiffness is rare, except for fractures involving the distal tibial epiphysis.
Axiom: in any patient with a fracture of the tibia and increased pain within 24-48 hours after the application of a plaster cast, the development of carpal tunnel should be suspected. The gypsum should be dissected, the limb carefully examined.

6651 0

The reasons: load falling on the leg, direct impact or pressing of the lower leg against a solid object by moving vehicles. An indirect fracture mechanism is observed when falling with support on the leg with a fixed foot or when walking on a slippery road, when the leg turns sharply around its axis.

In childhood and adolescence, along with complete fractures, there are also subperiosteal fractures; the latter are sometimes also referred to as green stick fractures.

Signs: curvature of the axis of the lower leg at an angle open outwards and anteriorly. With oblique and helical fractures, the sharp end of the upper fragment is visible and easily palpable under the skin; mobility and crepitus of bone fragments, pain at the fracture site with pressure on the anterior surface or along the axis of the leg are determined.

In the absence of displacement of bone fragments, the diagnosis is helped by a history of significant trauma to the lower leg, local swelling, deformity that increases when the leg is raised, the inability to support the limb, pain and crepitus with gentle pressure on the fracture site. In case of incomplete and subperiosteal fractures of the tibia, the diagnosis is based on the presence of sharp pain during axial load and with pressure on the anterior surface of the lower leg, sometimes a slight pathological mobility at the fracture site is determined. Diagnosis of isolated fractures of the fibula is difficult. In these cases, the appearance of pain at the fracture site with transverse compression of the bones of the lower leg away from the fracture helps in establishing the correct diagnosis.

To clarify the type and level of the fracture, radiographs are taken in the anteroposterior and lateral projections.

Treatment. When rendering first aid and evacuation of the victim to a medical institution, the lower leg is immobilized with standard stair tires, and in their absence, with auxiliary means (plywood strips, boards, tree branches).

Fracture treatment no displacement or slight displacement, not requiring reposition of fragments, begin with anesthesia of the fracture site of both bones with novocaine. Then a longet or circular plaster bandage is applied from the fingertips to the middle of the thigh. After 7-10 days, a control radiography is performed.

Terms of immobilization - 14-16 weeks.

Rehabilitation - 2-4 weeks.

Ability to work is restored after 3 1/2 -4 1/2 months.

For fractures with displacement of fragments surgical treatment is indicated, if it is impossible to perform it, skeletal traction is applied. In the process of treatment, clinical and radiological monitoring of the state of the limb and the position of the fragments is systematically carried out. After 4-6 weeks. (after the formation of a primary callus between the fragments), skeletal traction is replaced with a circular plaster cast up to the upper third of the thigh for a period of 2 1/2 to 3 months.

If within 3 days from the moment of injury it is not possible to reposition the fragments, then indications for surgery are given.

Intramedullary fixation with locking nails is preferable, which does not require additional external immobilization and allows you to restore your ability to work after 3 months.

Plain osteosynthesis with plates and screws is also effective (Fig. 1 and 2). With stable osteosynthesis, external immobilization is not required. Regardless of the type of osteosynthesis, a load of up to 20–25% of body weight is possible immediately after surgery. After osteosynthesis with a plate of oblique and helical fractures, the load is increased after 6–8 weeks, and during osteosynthesis with a plate of comminuted fractures, in order to avoid displacement of fragments and violation of the axis of the limb, the loading time is postponed by 6–12 weeks. In osteoporosis and metaphyseal fractures, the use of plates with angular stability is indicated. In case of osteosynthesis with intramedullary rods with blocking, an increase in the load is recommended after 2 weeks. (Table 1).

Rice. one. Osteosynthesis of diaphyseal fractures of the tibia with a plate with screws: a — front view, b — side view

Rice. 2. Osteosynthesis of a diaphyseal fracture of the tibia with a locking nail (a) and an external fixation device according to G. A. Ilizarov (b)

Table 1. Terms of loading on the operated limb after surgical treatment of fractures of the tibial shaft

Features of osteosynthesis	Initial, up to 25% of body weight	Load increase
Osteosynthesis with a plate - oblique fractures and fractures of the "butterfly" type Osteosynthesis with a plate - comminuted fractures and fractures at several levels (with and without bone grafting) Osteosynthesis with a pin with reaming of the bone marrow cavity Osteosynthesis with a pin without reaming the medullary cavity with proximal and distal blocking	After 5-7 days After 5-7 days After 5-7 days After 5-7 days	After 6-8 weeks. After 6-12 weeks. After 6 weeks After 2 weeks

In all cases, external immobilization is not required.

Getting out of bed allowed after 15 days.

— depending on the pace of consolidation.

X-ray control in all cases, produce after 6, 10, 16 weeks. and before removal of metal structures.

Removal of a metal structure: plates - after 16-18 months; pins with reaming of the medullary canal - after 18-24 months.

Compression-distraction osteosynthesis with the Ilizarov apparatus and its modifications is indicated in the treatment of patients with open fractures of the leg bones (Fig. 2b). Strong fixation of fragments in the apparatus makes it possible to allow the patient to walk with support on the injured limb in the early stages, which contributes to the normalization of the processes of fracture union, facilitates patient care, and also prevents the development of cardiopulmonary complications, especially in elderly patients. The success of treatment with extrafocal osteosynthesis is largely determined by the thoroughness of observing the rules of asepsis when applying the apparatus and subsequently. To do this, in the first days after the application of the apparatus, the condition of the skin is checked at the points of exit of the spokes, the tension of the skin is eliminated with the needles, the degree of tension of the spokes and the fixation of the rings to the rods of the apparatus are checked. Carefully isolate the exit points of the spokes with napkins with ethyl alcohol. Possible complications of extrafocal osteosynthesis:

1) penetration of infection into soft tissues and bones through the exit points of the pins;

2) damage to blood vessels, nerves, tendons during the wires;

3) violation of the fixation of fragments when loosening (untwisting) nuts and screws.

The working capacity of patients is restored within 3-4 months.

Traumatology and orthopedics. N. V. Kornilov