Manual of Surgery Volume Second: Extremities—Head—Neck. Sixth Edition.

by Alexis Thomson; Alexander Miles

There is usually considerable displacement, the weight of the lower portion of the limb causing it to fall backwards and to roll away from the middle line, and the traction of the calf muscles pulling up the heel and pointing the toes. The proximal fragment forms a projection on the front of the limb.

On account of the superficial position of the tibia and the pointed character of the fragments, this fracture is frequently rendered compound by the bone being forced through the skin. The projecting piece of bone is usually the distal end of the proximal fragment. This fracture is often comminuted. It has been observed that when the line of fracture forms the letter V on the subcutaneous surface of the tibia, there is invariably a fissure passing down along the back of the bone into the ankle-joint—a complication which adds to the risk of subsequent stiffness and impaired usefulness of the limb. Apart from this, the ankle is usually sprained in fractures by indirect violence, and we have frequently found the superior tibio-fibular articulation torn open in severe fractures of both bones of the leg from indirect violence.

Clinical Features.—The tibial fracture is readily recognised by detecting an irregularity on running the fingers along the crest of the shin, and at this point abnormal mobility, tenderness, and crepitus can usually be elicited. It is often difficult to detect the fibular fracture, and it is not always advisable to attempt to do so, especially if the manipulations cause pain or tend to increase the displacement. The condition of the fibula is usually to be inferred by noting the amount of displacement and the extent of mobility of the tibial fragments. Not infrequently the seat of fracture may be recognised by locating a point at which pain is elicited on making pressure over the bone at a distance—pain on distal pressure.

On account of the close connection of the skin to the periosteum on the subcutaneous aspect of the tibia, the tension caused by extravasated blood is often extreme; blisters frequently form over the area of ecchymosis, and when these become infected, sloughing of the skin may take place and the fracture thus be rendered compound.

The vessels and nerves of the leg are seldom seriously damaged.

Treatment.—If there is marked displacement, reduction is most satisfactorily accomplished under anæsthesia. Traction is made upon the foot and the fragments are manipulated into position, the pointing of the toes and the outward rotation of the foot being at the same time corrected. The normal outline of the foot in relation to the leg is restored when the ball of the great toe, the medial malleolus, and the medial edge of the patella are in the same vertical plane. As in other fractures of the lower extremity, the limb should be placed in the natural position of slight eversion: not with the toes pointing straight forward.

The retentive apparatus to be applied depends upon the tendency to re-displacement, the degree of swelling, and the extent of the damage to the skin.

In the average case, the leg is supported between sand-bags, and massage and movements are employed from the outset. When there is a tendency to re-displacement, the limb may be immediately enclosed in a rigid apparatus, such as lateral poroplastic splints retained in position by an elastic bandage, or a Cline's splint, which can readily be removed to admit of massage. When the fracture is in the lower third of the leg, the ambulatory splint gives excellent results, and is of special service in hospital practice ([Fig. 95]).

As an emergency appliance, for example for purposes of transport, the box splint ([Fig. 91]) is simple and efficient. We have not found it effectual in controlling the fragments, particularly in oblique fractures, and it requires constant supervision and readjustment. It consists of two pieces of wood extending from above the knee to an inch or two beyond the sole, and a little broader than the maximum diameter of the leg. These are rolled into the opposite ends of a folded sheet, so as to form two sides of a box, of which the sheet constitutes a third side. It is found advantageous to insert another board, fitted with a foot-piece, between the folds of the sheet forming the third side of the box, to add to the rigidity of the splint, and to aid in controlling the foot. By folding one side of the sheet somewhat obliquely, the box is made a little wider at the knee than at the ankle, and so fits the limb more accurately.