Fractures of the Proximal Tibia (Shinbone)
A fracture, or break, in the shinbone just below the knee is called a proximal tibia fracture. The proximal tibia is the upper portion of the bone where it widens to help form the knee joint.
In addition to the broken bone, soft tissues (skin, muscle, nerves, blood vessels, and ligaments) may be injured at the time of the fracture. Both the broken bone and any soft-tissue injuries must be treated together. In many cases, surgery is required to restore strength, motion, and stability to the leg, and reduce the risk for arthritis.
There are several types of proximal tibia fractures. The bone can break straight across (transverse fracture) or into many pieces (comminuted fracture).
Reproduced and modified from Bono CM, Levine RG, Juluru PR, Behrens FF: Nonarticular proximal tibia fractures: treatment options and decision making. J Am Acad Orthop Surg 2001; 9:176-186.
Sometimes these fractures extend into the knee joint and separate the surface of the bone into a few (or many) parts. These types of fractures are called intra-articular or tibial plateau fractures.
This damage to the surface of the bone may result in improper limb alignment, and over time may contribute to arthritis, instability, and loss of motion.
A fracture of the upper tibia can occur from stress (minor breaks from unusual excessive activity) or from already compromised bone (as in cancer or infection). Most, however, are the result of trauma (injury).
Young people experience these fractures often as a result of a high-energy injury, such as a fall from considerable height, sports-related trauma, and motor vehicle accidents.
Older persons with poorer quality bone often require only low-energy injury (fall from a standing position) to create these fractures.
- Pain that is worse when weight is placed on the affected leg
- Swelling around the knee and limited bending of the joint
- Deformity — The knee may look "out of place"
- Pale, cool foot — A pale appearance or cool feeling to the foot may suggest that the blood supply is in some way impaired.
- Numbness around the foot — Numbness, or "pins and needles," around the foot raises concern about nerve injury or excessive swelling within the leg.
If you have these symptoms after an injury, go to the nearest hospital emergency room for an evaluation.
Medical History and Physical Examination
Dr. Wilson will ask for details about how the injury happened. He will also talk to you about your symptoms and any other medical problems you may have, such as diabetes.
He will examine the soft tissue surrounding the knee joint, and will check for bruising, swelling, and open wounds, and will assess the nerve and blood supply to your injured leg and foot.
- X-rays. The most common way to evaluate a fracture is with x-rays, which provide clear images of bone. X-rays can show whether a bone is intact or broken. They can also show the type of fracture and where it is located within the tibia.
- Computed tomography (CT) scan. A CT scan shows more detail about your fracture. It can provide Dr. Wilson with valuable information about the severity of the fracture and help him decide if and how to fix the break.
A proximal tibia fracture can be treated nonsurgically or surgically. There are benefits and risks associated with both forms of treatment.
Whether to have surgery is a combined decision made by the patient, the family, and the doctor. The preferred treatment is accordingly based on the type of injury and the general needs of the patient.
When planning treatment, Dr. Wilson will consider several things, including your expectations, lifestyle, and medical condition.
In an active individual, restoring the joint through surgery is often appropriate because this will maximize the joint's stability and motion, and minimize the risk of arthritis.
In other individuals, however, surgery may be of limited benefit. Medical concerns or pre-existing limb problems might make it unlikely that the individual will benefit from surgery. In such cases, surgical treatment may only expose these individuals to its risks (anesthesia and infection, for example).
Nonsurgical treatment may include casting and bracing, in addition to restrictions on motion and weight bearing. Dr. Wilson will most likely schedule additional x-rays during your recovery to monitor whether the bones are healing well while in the cast. Knee motion and weight-bearing activities begin as the injury and method of treatment allow.
There are a few different methods that a surgeon may use to obtain alignment of the broken bone fragments and keep them in place while they heal.
Internal fixation. During this type of procedure, the bone fragments are first repositioned (reduced) into their normal position. They are held together with special devices, such as an intramedullary rod or plates and screws.
In cases in which the upper one fourth of the tibia is broken, but the joint is not injured, a rod or plate may be used to stabilize the fracture. A rod is placed in the hollow medullary cavity in the center of the bone. A plate is placed on the outside surface of the bone.
Plates and screws are commonly used for fractures that enter the joint. If the fracture enters the joint and pushes the bone down, lifting the bone fragments may be required to restore joint function.
Fractures that extend into the knee joint frequently require plate fixation. The plate is applied to the surface of the bone.
Reproduced with permission from Koval KJ, Helfet DL: Tibial Plateau Fractures: Evaluation and Treatment. J Am Acad Orthop Surg 1995; 3: 86-94.
Dr. Wilson will decide when it is best to begin moving your knee in order to prevent stiffness. This depends on how well the soft tissues (skin and muscle) are recovering and how secure the fracture is after having been fixed.
Early motion sometimes starts with passive exercise: a physical therapist will gently move your knee for you, or your knee may be placed in a continuous passive motion machine that cradles and moves your leg.
If your bone was fractured in many pieces or your bone is weak, it may take longer to heal, and it may be a longer time before motion is allowed.
To avoid problems, it is very important to follow Dr. Wilson’s instructions for putting weight on your injured leg.
Whether your fracture is treated with surgery or not, he will most likely discourage full weight bearing until some healing has occurred. This may require as much as 3 months or more of healing before full weight bearing can be done safely. During this time, you will need crutches or a walker to move around. You may also wear a knee brace for additional support.
Dr. Wilson will regularly schedule x-rays to see how well your fracture is healing. If treated with a brace or cast, these regular x-rays show him if the bone is changing position. Once Dr. Wilson determines that your fracture is not at risk for changing position, you may start putting more weight on your leg. Even though you can put weight on your leg, you may still need crutches or a walker at times.
When you are allowed to put weight on your leg, it is very normal to feel weak, unsteady, and stiff. Even though this is expected, be sure to share your concerns with Dr. Wilson and your physical therapist. A rehabilitation plan will be designed to help your regain as much function as possible.