TABLE 64-1 Compartments of the Lower Leg
PAIN WITH MOVEMENT
ON PHYSICAL
COMPARTMENT NERVES MUSCLES EXAMINATION
Anterior Deep peroneal Tibialis anterior Plantarflexion of the foot
Extensor hallucis longus Flexion or extension of toes
Extensor digitorum
Deep posterior Tibial Tibialis posterior Extension of toes
Flexor hallucis longus
Flexor digitorum
Lateral Superficial peroneal Peroneus longus Inversion of the foot
Deep peroneal Peroneus brevis
Superfical posterior Sural Gastrocnemius Dorsiflexion of the foot
Soleus
tibial fracture. It is most important to evaluate and
document the dorsalis pedis and posterior tibial pulses
as well as the function of the peroneal nerve.- The physician must also rule out compartment syn-
drome in a patient with a fractured tibia. Common
sensitive predictors of compartment syndrome are
pain with passive stretch of the musculotendinous unit
that travels through the respective compartment or
sensory loss in the distribution of nerves that traverse
the compartment. Further discussion of compartment
syndrome can be found in Chapter 56. Table 64-1 out-
lines the various compartments of the lower leg. - The joints above and below all tibia fractures must be
thoroughly examined. Therefore, a careful clinical
and radiologic evaluation and assessment of the ipsi-
lateral knee and ankle is mandatory. The physician
should evaluate the range of motion and the integrity
of the ligamentous complex at both joints respec-
tively. Studies have shown that there is an increased
incidence of ligamentous injury to the knee with frac-
tures of the tibial shaft (Templeman and Marder,
1989).
RADIOGRAPHIC EXAMINATION
- The physician evaluating a tibial fracture must include
anterior-posterior and lateral radiographic views of
the tibia and three-view radiographs of the ipsilateral
knee and ankle. - Computed tomography (CT) may aid in determining
the precise location, depth, and articular involvement
of tibial plateau and plafond fractures; however, these
are not a part of the initial radiological evaluation for
fractures of the tibial shaft. Magnetic resonance imag-
ing may be used to investigate stress fractures, but a
bone scan is the radiographic study of choice (Daffner
and Pavlov, 1992).- When describing fractures of the tibia, the reporting
physician should include the following: open versus
closed, proximal versus middle versus distal 1/3, com-
munition with number of fragments, transverse/spiral/
oblique, angulation, shortening or overlap, and dis-
placement.
- When describing fractures of the tibia, the reporting
TIBIAL SHAFT FRACTURES•Fractures of the tibial shaft are due to varying
amounts of energy. High energy fractures more com-
monly present with a higher likelihood of compart-
ment syndrome, higher likelihood of being open, and
tend to be more comminuted with soft tissue damage.
Tscherne and Gotzen first described and classified the
soft tissue injury associated with these fractures
(Tscherne and Gotzen, 1984) (see Table 64-2).
•Treatment options for tibial shaft fractures vary widely
and depend upon the degree of comminution, displace-
ment of fragments, and location of fracture. Treatment
options range from closed reduction with long leg cast-
ing to open reduction with internal fixation or
intramedullary nailing. External fixation may be appro-
priate in cases of open fracture, high energy trauma, and
soft tissue injury or infection. Studies have suggested
that operative intramedullary nailing is more successful378 SECTION 4 • MUSCULOSKELETAL PROBLEMS IN THE ATHLETE
TABLE 64-2 Soft Tissue Injury Associated with Fractures
GRADE INJURY
0 Minimal soft tissue damage; indirect violence; simple
fracture pattern
1 Superficial abrasion or contusion from internal pressure,
mild to moderate fracture configuration
2 Deep, contaminated abrasion with associated contusion;
impending compartment syndrome
3 Extensive skin contusion or crush injury; associated muscle
injury; major vascular injury; severely comminuted
fracture pattern