10639-04a_ON2604-Miller.

qxd 7/17/07 1:23 PM Page 216

Tibia Fractures
An Overview of Evaluation and Treatment
Noreen C. Miller ▼ Aaron E. Askew

The purpose of this article is to increase the reader’s knowl- quently involve a tibia fracture. This is a high-energy im-
edge of tibial fractures, which are infrequently life threaten- pact that may shatter the tibia and frequently cause se-
ing but are often life changing. The focus is on the contin- vere soft tissue damage. Gun shot wounds or penetrating
uum of care, starting with the mechanism of injury, objects are further examples of high-energy injuries to
classification of the tibial fracture and soft tissue involvement, the tibia.
approaches to stabilization and treatment options, postoper- There are rare mechanisms of injury such as tibial in-
ative care, potential complications, and considerations to dis- sufficiency fractures. Insufficiency fractures are frac-
tures from normal load (walking, using steps, bending,
charge preparation. The parameters of nursing care extend to
sitting) on abnormal bone (osteopenic or underlying
pain relief and positioning, nerve and vascular assessments, disease) that result in pathologic fractures (Buckwalter
safe mobility, self-care, and prevention of complications. & Brandser, 1997).
By appreciating low- or high-energy mechanism of
Epidemiology injury and understanding whether there is a closed or
According to the National Center for Health Statistics, open fracture, the nurse can anticipate factors that will
the occurrence rate for tibia, fibula, and ankle fractures impact pain control, swelling, or possible contamina-
is 492,000 per year in the United States (Praemer, tion that would require multiple trips to the operating
Furner, & Rice, 1992). Tibia and fibula fractures in the room for wound irrigations and debridements.
same time period resulted in 77,000 hospitalizations,
accounting for 569,000 hospital days with an average Indications for Surgery
length of stay of 7.4 days, and in 825,000 physician of-
The care of tibia fractures is addressed once life threat-
fice visits. Because tibial fractures are the most common
ening injuries have been stabilized. The orthopaedic sur-
long bone fractures (Rockwood, Green, & Bucholz, 2006),
geon determines the extent of the tibia fracture and de-
it is important for the nurse to develop expertise in order
cides on the type of treatment, which may include casts
to help prevent and recognize complications and to max-
or functional cast bracing, intramedullary nails, exter-
imize favorable outcomes.
nal fixation devices, or open reduction and internal fixa-
tion with plates and screws. The surgeon identifies the
Mechanisms of Injury classification of the injury, which helps to determine
Mechanisms of injury for tibia–fibula fractures can be appropriate treatment (Rockwood et al., 2006).
grouped into two categories. The first is low-energy in-
juries, such as household falls or athletic injuries. The Classifications
second is high-energy injuries, such as motor cycle and
car crashes and pedestrians struck by motor vehicles, CLOSED TIBIA FRACTURE
which have the highest morbidity and mortality rates A closed fracture to the tibia is more common, whereas
(Barancik et al., 1986). Lower leg fractures include frac- an open fracture is thought to be higher risk for com-
tures of the tibia and fibula. Of these two bones, the tibia plications. Closed tibia fractures in young patients are
is the weight bearing bone. Fractures of the tibia gener- commonly sports-related injuries. Closed tibia fractures
ally are associated with fibula fractures. Fibula shaft in the elderly are commonly caused by ground level
fractures in isolation are rare (Rockwood et al., 2006) falls. (Court-Brown & McBirnie, 1995). The fracture
and so, at this point, tibia fractures will include tibia pattern of closed tibia fractures is usually simple, with
and/or tibia–fibula fractures. less severe soft tissue injury than is seen with open tibia
Bradley, Slauterbeck, and Benjamin (1992) examined
the distribution of fractures in pedestrians struck by Noreen C. Miller, RN, MSN, ONC, Case Manager for Orthopedics and
motor vehicles, who are the most unprotected and vulner- Neurosciences Service Line, St. Charles Medical Center, Bend, OR.
able victims of traffic accidents. The most frequent frac- Aaron E. Askew, MD, Orthopedic Trauma/Foot and Ankle, Desert
ture sites were tibia–fibula, and pelvis, followed by femur. Orthopedics, Bend, OR.
In addition to accidents or crashes, the tibia, which is The authors have no significant ties, financial or otherwise, to any
exposed and has a subcutaneous location, can be frac- company that might have an interest in the publication of this
tured from other forms of trauma. Logging accidents fre- educational activity.

216 Orthopaedic Nursing • July/August 2007 • Volume 26 • Number 4

10639-04a_ON2604-Miller.qxd 7/17/07 1:23 PM Page 217

fractures. The more complex, high-energy fractures are

often caused by motorized vehicle crashes. More com- TABLE 2. SOFT TISSUE INJURIES OF CLOSED TIBIA FRACTURE/
plex, soft tissue injury patterns are also frequently seen in TSCHERNE AND GOTZEN (1984) CLASSIFICATION
older, less fit patients with osteoporotic bone (Court-
Brown & McBirnie, 1995). Classification Description

C0 Absent or negligible soft tissue injury

BONEY FRACTURE PATTERN AND SOFT TISSUE INJURY C1 Superficial abrasion or contusion
CLASSIFICATIONS OF CLOSED TIBIAL FRACTURES C2 Deep, contaminated with impending
Closed fractures are classified to communicate the in- compartment syndrome
jury (bony fracture pattern) and are also classified to C3 Skin extensively contused or crushed,
communicate the soft tissue injury associated with the muscle damage may be severe
fracture (Schmidt, Finkemeier, & Tornetta, 2003). The
location of tibial fracture is described as proximal, mid-
dle, or distal third; the pattern is described as transverse,
a deer, swerved and steered the car head on into a tree.
oblique, spiral, segmental, or comminuted.
Both driver and passenger were using restraints, and their
The most common soft tissue classification in closed
air bags deployed. The driver had an obvious tibia frac-
tibial fractures is the Tscherne and Gotzen (1984) classi-
ture with bone protruding through a 12-cm laceration
fication that describes four types of soft tissue injury
with extensive soft tissue injury; however, there appeared
with increasing numbers indicating worsening severity
of injury ranging from absent or negligible soft tissue to be adequate skin coverage for the bone. The passen-
injury, superficial abrasion or contusion, deep abra- ger’s fracture was closed and had superficial abrasions.
sion that could lead to compartment syndrome, and With classification Tables 1, 2, and 3, the driver’s injury
lastly, crushing-type severe muscle damage (Tscherne & could be classified as Grade IIIA; and after X-rays, the pas-
Gotzen, 1984). It is important to classify both the bony senger’s fracture could be determined to be proximal and
fracture pattern and the soft tissue injury as both impact transverse, which would be classified as a Tscherne C1.
treatment and recovery greatly. Open tibial fractures are The emphasis should be to appreciate the significance
scored with a different system. of the soft tissue injury more than committing to memory
the scoring systems. The patient with an extensive soft tis-
CLASSIFICATION OF OPEN TIBIAL FRACTURES sue injury may experience delay in definitive fixation until
wound contamination has been treated by repeated trips
There are several scoring systems, and the most widely to the operating room for irrigation and debridement, de-
used system to classify open tibial fractures was devel- layed primary closure of the wound, and broad spectrum
oped by Gustillo and Anderson, which divides open frac- antibiotics for a longer period of time extending beyond
tures into three major grades (Tscherne & Gotzen, 1984). the usual number of prophylactic doses (Rockwood et al.,
Grade I open fractures are smaller than 1 cm. Grade II 2006). These factors result in prolonged healing time
open fractures have laceration injuries and are 1 to 10 cm, and present an opportunity for nurses to assess the pa-
with moderate tissue damage and possible contamination tient’s prior level of functioning, coping mechanisms,
of the wound. Grade III injuries are larger than 10 cm, and resources.
with extensive tissue damage and high degree of conta-
mination, making it difficult to cover exposed bone or
hardware. Grade III injuries are further divided into Timing of the OR
Types A, B, and C, depending on the severity of tissue loss After the surgeon decides the classification of the injury,
(Gustillo, Mendoza, & Williams, 1984). he or she will turn attention to the timing of the interven-
Grade IIIA injuries have adequate soft tissue for bone tion. If there is significant soft tissue injury, as evidenced
coverage. Grade IIIB injuries have extensive tissue dam- by swelling, ecchymosis, or abrasion, the surgeon may
age with periosteal stripping, making local soft tissue delay definitive operative treatment and may use options
coverage not possible. Grade IIIC injuries have vascular
injuries requiring repair and even possible amputation
(Gustillo et al., 1984). See Tables 1, 2, and 3.
To illustrate the application of the above described TABLE 3. SCORING SYSTEM FOR OPEN TIBIA FRACTURES
classifications, consider two friends in a car who, to avoid
Classification Wound Size Description

Grade I < 1 cm In/out injury

Grade II 1–10 cm Tissue damage, possible
TABLE 1. CLOSED TIBIA FRACTURES: BONEY FRACTURES contamination
PATTERN INJURIES Grade III >10 cm Extensive tissue damage,
contamination
Location Pattern
Grade IIIA Adequate soft tissue for
Proximal Transverse bone coverage
Middle Oblique Grade IIIB Extensive tissue damage,
Distal Spiral periosteal stripping
Segmented Grade IIIC Vascular injuries, possible
Comminuted amputation

Orthopaedic Nursing • July/August 2007 • Volume 26 • Number 4 217

10639-04a_ON2604-Miller.qxd 7/17/07 1:23 PM Page 218

such as splinting or external fixation (Rockwood et al., et al., 2006). Some surgeons will use skeletal or calcaneal
2006). Significant soft tissue swelling is indicated by traction to aid in reduction. The nail is placed down into
tight, tense skin that has no wrinkles and in the extreme the IM space with fluoroscopic guidance (c-arm x-ray).
case the presence of fracture blisters. Significant soft tis- The surgeon may use interlocking screws for better
sue swelling can interfere with surgical wound healing. stability, depending on the location of the fracture.
Definitive surgery must sometimes be delayed for weeks The procedure may involve reamed or unreamed nails.
in order for adequate resolution of swelling. Reaming is done by the surgeon, enlarging the IM
canal with a motorized curette to accept the placement
of a larger, stronger implant (Weinstein & Buckwalter,
Considerations to Comorbidities 2005). IM nailing can be used for closed or open tibial
Definitive treatment of fractures may also be delayed until fractures. The orthopaedic surgeon may consider stabi-
life threatening injuries, such as lung contusions, brain lization of the concomitant fibula fracture; this may
injury or hemodynamic instability, have been stabilized be considered in the case of an open or closed tibia frac-
(Weinstein & Buckwalter, 2005). Other reasons for delay ture (Egol et al., 2006). See Figure 1a and 1b (tibia
of treatment of fractures are described by Weinstein and fracture with IM rodding).
Buckwalter (2005) and often involve the elderly patient The external fixator provides stabilization and allows
and those with medical problems requiring comprehen- time for the soft tissue swelling to decrease or for other
sive work up and clearance prior to treatment of the frac- issues, such as compartment syndrome, head injury, pul-
tures. For instance, syncope from a new antihypertensive monary injury, burns, or impaired sensation, to be re-
medication or existing arrhythmia can cause a fall in an solved. External fixation can be applied to open or closed
elderly patient, producing a long bone fracture. A patient fractures. External fixation can provide stabilization
could have an acute myocardial infarction or a stroke during the time between irrigation and debridements of
while driving, which could lead to the crash. An internal open wounds.
medicine consult is key to optimize the patient’s medical
condition prior to surgery. Dehydration, hypertension, OPEN TIBIAL FRACTURES
infections (urinary tract infection, pneumonia) or renal Managing an open tibial fracture involves attention to
insufficiency should be resolved. Patients taking anti- the wound and appropriate time to close the wound.
coagulants require reversal, usually to international nor- The vacuum-assisted closure (wound vac) device (VAC;
malized ratio INR < 1.4. Consideration to chronic renal Kinetic Concepts Inc., San Antonio, TX) can be used for
failure, congestive heart failure, chronic obstructive pul- large wounds that are not amenable to closure and can
monary disease and an age greater than 70 years are cri- be used while the fracture is stabilized in an external fix-
tical risk factors for inpatient mortality. Complications ator. The sponge is placed in the open wound, covered,
and comorbidities identified preoperatively will again and connected to negative pressure that decreases tis-
be addressed postoperatively and will need continued sue edema, wound circumference, and increases granu-
care by the internal medicine consult. The care of older lation for tissue formation (Parrett, Matros, Pribaz, &
adults is gaining importance as a result of the sheer in- Orgill, 2005). When a surgeon elects to use a VAC, he or
crease in numbers and their special considerations, she can consult a wound care nurse to change dressing
such as decreased physiological resilience, frailty, de- sponges and maintain its functioning. As with any other
creased compensatory mechanism, increased number drain, the amount of drainage should be measured each
of comorbidities or polypharmacy (Jacoby, Ackerson, & shift and recorded. The suction of a VAC should not be
Richmond, 2006). disconnected because without suction the sponge could
serve as a source of infection.
Types of Treatment Plate fixation is most commonly used on the proxi-
mal and distal tibia fractures. Plate fixation for the treat-
CLOSED TIBIAL FRACTURES ment of acute, isolated tibial fractures is limited be-
Treatment for closed tibial fractures can include cast ap- cause of the subcutaneous location of the tibia, which
plication, functional bracing, or plate fixation; however can lead to wound complications (Bilat, Leutenegger, &
intramedullary (IM) nailing is the preferred treatment al- Ruedi, 1994). The recent introduction of percutaneous
ternative for high energy fractures especially with more plate fixation techniques have led to an increased use of
severe soft tissue injuries (Schmidt et al., 2003). Limited plate fixation for long bone fractures (Schmidt et al.,
situations for cast or functional bracing include min- 2003). See Figure 2a and 2b (tibia fracture with plate
imal soft tissue injury, stable fracture pattern, and and screw fixation).
ability to bear weight in a cast or functional brace. IM nailing for open tibia fractures depends on the sur-
Advantages of cast application over IM nailing are low geon’s determination for risk of infection, particularly
risk of infection, less knee pain, and no need for hardware when there is extensive soft tissue or vascular injury
removal. However, advantages of IM nailing include bet- (Finkemeier, Schmidt, Kyle, Templeman, & Varecka,
ter alignment, earlier range of motion of knee and ankle, 2000).
better mobility of patient, less frequent follow up visits,
and earlier return to work (Schmidt et al., 2003).
IM nailing is usually done with the patient in the su-
Postoperative Care
pine position under general anesthesia; the knee is flexed PAIN
while the surgeon inserts the IM nail through an inci- St. Charles Medical Center uses a healing healthcare phi-
sion made proximal to the tibial tuberosity (Rockwood losophy that emphasizes patient needs and strives for a

218 Orthopaedic Nursing • July/August 2007 • Volume 26 • Number 4

10639-04a_ON2604-Miller.qxd 7/17/07 1:23 PM Page 219

A B

FIGURE 1. A. Preoperative tibia fracture. B. Tibia fracture with postoperative intramedullary nailing (with fibular plate).

consistently positive experience reported by patients. and decreased need for narcotics. Together with the heal-
The healing healthcare philosophy is based on the belief ing healthcare philosophy and cutting-edge orthopaedic
that nearly everything in the environment has an effect care, the postoperative period is managed in the spirit of
on recovery and well-being, either enhancing or impair- love and compassion.
ing the healing process. There is no overhead paging Elevation of the extremity to the level of the heart and
except for emergencies. The rooms are built with a view the application of ice help to decrease swelling. The
of the Cascade Mountains of Central Oregon. Caregivers length of time for ice application should continue until
are encouraged and expected to sit at eye level with pa- dependent painful swelling subsides. Tolerance to pain,
tients to establish plan of care, use touch as appropriate, reaction to narcotics, and progression of diet can effect
and to offer alternative or adjunctive healing therapies, the postoperative period. Patients use patient-controlled
such as aroma therapy, therapeutic touch, intentional analgesic transitioning to oral medications the first or
breathing, and guided imagery. Families are encouraged second postoperative day. Although the patient may be
to feel comfortable to stay in the private room with the permitted to bear weight, the first postoperative day is
patient. The RN establishes priorities of patient care with often focused on pain relief. Estimated blood loss during
patient and physician and communicates with the team a tibial fixation is 100–300 cc so that acute postoperative
to coordinate plan of care. The RN case manager and anemia is not generally expected, but following hemo-
social worker are available to help coordinate care in the globin and hematocrit levels is helpful, especially if on
more complex, polytrauma patients. Request for pain the first time up out of bed the patient experiences light
relief is often the patient’s priority. Orthopaedic nurses headedness, increase in heart rate, or decrease blood
develop expertise in pain control and avoidance of over pressure.
sedation, which causes respiratory or neurological com-
promise, and in assessing the patient’s tolerance level. NEUROVASCULAR ASSESSMENT
The philosophy of the hospital is to promote healing while While frequently assessing pain status, the nurse also
encouraging patients to become actively involved in their assesses the nerve and vascular status or neurovascular
care. Providing patients with information about what to status. According to Rockwood et al. (2006), nerve as-
expect after their surgery and how they can participate sessment includes checking for sensation, for example,
in their recovery results in both shorter hospital stays asking the patient whether he or she can feel a touch to

Orthopaedic Nursing • July/August 2007 • Volume 26 • Number 4 219

10639-04a_ON2604-Miller.qxd 7/17/07 1:23 PM Page 220

A B

FIGURE 2. A. Preoperative tibia fracture. B. Tibia fracture with postoperative plates and screws.

the first web space of the foot, which tests the deep pero- nal pressure or external confinement or restriction can
neal nerve. Nerve assessment also includes checking for proceed to the point at which cellular exchange is dimin-
movement by asking the patient if he or she can dorsi ished; this process is known as compartment syndrome.
flex and plantar flex his big toe as well as by asking the This sets up an ischemic environment that, when left
patient to dorsi flex and plantar flex the ankle to toler- untreated, can cause irreversible damage to tissue and
ance. The movement can be slight as the lower extrem- nerves (Weinstein & Buckwalter, 2005).
ity will be immobilized in a splint. Vascular assessment The deep peroneal nerve runs through the anterior
includes checking color, temperature, capillary refill, aspect of the leg. Increased compartment pressure leads
and palpation of dorsalis pedis and posterior tibial to decreased blood and oxygen to the nerve and the
pulses if accessible. muscle causing ischemia. The change in normal envi-
ronment for the nerve cells can lead to peroneal nerve
palsy (Rockwood et al., 2006). Compartment syndrome
COMPARTMENT SYNDROME can occur in the face of intact pulse. The goal of fre-
Compartment syndrome is a complication in closed or quent neurovascular checks is to recognize and address
open tibial fractures before or after surgical treatment concerns early and to prevent compartment syndrome.
(Rockwood et al., 2006). Compartment syndrome can When reasonable pain medications have been given, all
cause rare but serious loss of function or disability. Inter- position changes have been tried, and pain is out of

220 Orthopaedic Nursing • July/August 2007 • Volume 26 • Number 4

10639-04a_ON2604-Miller.qxd 7/17/07 1:23 PM Page 221

proportion to the injury, suspect impending compart- annoying tribulations with pouring a cup of coffee and
ment syndrome. Simply loosening the splint down to sitting down without spilling, losing a crutch, or falling.
the layer next to the skin may at times be all that is Patients should be assessed for safety with mobility,
needed to relieve uncontrolled pain. Keep the surgeon which helps to prevent falls in the hospital or at home.
updated regarding neurovascular status and pain con- Walking down the steps, doing the laundry, or feeding
trol. Assess the six P’s: pain out of proportion to the in- the birds are activities that Gaydos cited were just be-
jury, pain with passive stretch of the toes, pallor, pulse- yond her ability to accomplish. “It is just a matter of
lessness, paresthesia, and paralysis; but take special time,” is a quote that Gaydos stated was told to her re-
notice of pain as it is listed first and can be the most sen- peatedly, but she asked “What does that mean, really?”
sitive early indicator of compromise. As the patient’s Each patient reacts differently to an injury, but nurses
pain and neurovascular status is stabilized, attention should help the patient plan for changes in self-image
can be turned to mobility training. and the potential for depression. The acute care inpa-
tient stay is brief, with the focus on pain control, mo-
ACTIVITY bility, and recognition of complications, but it is the
insightful nurse who can balance these issues with
Physical therapy and occupational therapy consults are
thoughtful consideration of the challenges ahead with
ordered to evaluate and treat mobility and self-care abil-
the patient or family members.
ities. Work begins with bed mobility, then to transfers in
and out of bed, to ambulation using crutches or walker,
and to meeting activities of daily living, including eating, POTENTIAL COMPLICATIONS
bathing, dressing, and toileting. The patient’s home and During the hospitalization, the nurse needs to recog-
family situations are addressed, planning for a safe dis- nize and help prevent complications and to alert the pa-
charge. The patient’s prior health and condition, the tient to potential complications that may occur after the
amount of weight he or she is allowed to bear, and the hospitalization.
overall response to care helps determine the plan for In addition to compartment syndrome and under or
discharge. Physical therapy, occupational therapy, and oversedation, other potential complications include
nursing collaborate to identify the amount of assistance infection, nonunion, or broken hardware, with loss of
the patient needs for safe mobility. Family members or alignment. Keep a high level of suspicion for infection
the patient’s selected caregivers for home can be trained in patients with an open tibia fracture, which can have
in the hospital so the transition to home is a smooth a varying degree of soft tissue injury (Parrett et al.,
one. Patients can have a concomitant injury that may 2005). Prophylactic intravenous antibiotics may be
further complicate mobility. used for longer durations with open fractures as com-
pared with closed fractures (Rockwood et al., 2006).
PLAN FOR DISCHARGE The nurse should assess for infection and report when
Discharge plans can include the following: home with fever, increased pain, redness, swelling, or discharge
home health or outpatient physical therapy, skilled from wound is noted. These signs and symptoms
nursing facility for increased strengthening and inde- are important to note during the hospitalization and
pendence training before returning home, or an inpa- should be taught to the patient for self-assessment after
tient stay in the rehabilitation unit. It is important to discharge.
involve family and to identify patient’s resources (home When an external fixator is used, pin loosening and pin
situation, family support, coping mechanisms, insur- tract infections are the biggest problems (Schmidt et al.,
ance coverage) as soon as possible. Tibial fractures are 2003). Depending on the duration of use of the external
not elective surgeries for which the patient could plan fixator and the preference of the surgeon, pin care should
for inconveniences and lifestyle changes. The goal is to be clarified; usually daily cleansing with half strength
discharge the patient with the clear understanding of hydrogen peroxide or per hospital policy is started on
weight bearing status, a plan for mobility and self-care the second postoperative day (Hart, Luther, & Grottkau,
needs, and discharge instructions. The nurse addresses 2006). It has been noted that when an external fixator
pain control, mobility, and self-care and assesses the pa- is removed after 2 weeks or more and IM nailing or
tient’s psycho/social status, anticipating the transition plate fixation is done, there is an increased risk of in-
to home. fection (Maurer, Markow, & Gustillo, 1989; Rockwood
The patient and family can be instructed on the signs et al., 2006).
and symptoms of infection at the wound site, pain not Nonunion, malalignment, or broken hardware will
relieved with pain medication, rest, ice and elevation, be assessed by the surgeon on follow-up office appoint-
and how to minimize the risk of falling. The nurse can ments. Patients with tibia fractures can be readmitted
emphasize the importance of follow-up with the surgeon to treat these issues with subsequent surgery. Patients
to assure proper healing. with a deep infection may require irrigation and de-
Not only does the tibial fracture necessitate an un- bridement and long-term intravenous antibiotics if
planned hospitalization, but also it forces the patient to the infection has reached the bone (osteomyelitis). The
confront the reality of a changed life while healing. It is patient’s compliance with weight-bearing status and
challenging and humbling to accomplish activities of smoking cessation can impact healing. Patients should
daily living while on crutches or when using a walker. In be asked about smoking or chewing tobacco and should
her article, Gaydos (2005) related her own experience be strongly encouraged to stop because tobacco use
with her tibial fracture. She is a PhD RN who describes can be detrimental to wound and bone healing (Adams,

Orthopaedic Nursing • July/August 2007 • Volume 26 • Number 4 221

10639-04a_ON2604-Miller.qxd 7/17/07 1:23 PM Page 222

Keating, & Court-Brown, 2001). Smoking cessation Barancik, J. E., Chatterjee, B. F., Greene-Cradden, Y. C.,
counseling and resources should be offered during the Michenzi, E. M., Kramer, C. F., Thode, H. C., Jr., & Fife,
hospitalization. D. (1986). Motor vehicle trauma in northeastern Ohio.
A complication specific to IM rodding is anterior knee Incidence and outcome by age, sex, and road category.
American Journal of Epidemiology, 123, 846–861.
pain and is seen more often in younger patients. It is
Bradley, J. B., Slauterbeck, J., & Benjamin, J. B. (1992).
most often mild, but it can affect function, including Fracture patterns and mechanisms in pedestrian motor
kneeling, squatting, and running (Court-Brown, Gustilo, vehicle trauma: The ipsilateral dyad. Journal of Ortho-
& Shaw, 1997). pedic Trauma, 6. 279–282.
Deep vein thrombosis (DVT) and pulmonary embolism Bilat, C., Leutenegger, A., Ruedi, T. (1994). Osteosynthesis
(PE) are important complications to recognize and to of 245 tibial shaft fractures: Early and late complica-
help prevent. The nurse may have orders for DVT pro- tions. Injury: International Journal of the Care of the
phylaxis, such as low-molecular-weight heparin, before Injured, 26, 349–358.
surgery and should expect orders to administer DVT pro- Buckwalter, J. A., & Brandser, E. A. (1997). Stress and insuf-
ficiency fractures. American Family Physician, 56, 175–182.
phylaxis after surgery, when bleeding risk is acceptable
Court-Brown, C. M., Gustilo, T., & Shaw, A. D. (1997). Knee
(Rogers, Cipolle, Velmahos, Rozycki, & Luchette, 2002). pain after intramedullary tibial nailing: Its incidence,
The nurse should expect to hold the dose of DVT prophy- etiology, and outcome. Journal of Trauma, Injury, In-
laxis medication, such as low-molecular-weight heparin, fection, and Critical Care, 11, 103–105.
the day of surgery (12 to 24 hr prior to surgery) and look Court-Brown, C. M., & McBirnie, J. (1995). The epidemiol-
for orders to resume the day after surgery (12 to 24 hr ogy of tibial fractures. Journal of Bone Joint Surgery
after surgery). He or she should report any increased ten- Britain, 77, 417–421.
derness, pain, or edema of the calf to the surgeon and an- Egol, K. A., Weisz, R., Hiebert, R., Tejwani, N. C., Koval,
ticipate an order for Doppler ultrasound to rule out a K. J., & Sander R. W. (2006). Does fibular plating improve
DVT. Long bone fractures, especially femur and tibia alignment after intramedullary nailing of distal meta-
physeal tibia fractures? Journal of Orthopedic Trauma,
fractures, have a high incidence of causing fat embolism
20, 94–103.
(Ganong, 1993). Estrada, L. S., Alonso, J. E., McGwin, G., Metzger, J., &
Rue, L. W. (2004). Restraint use and lower extremity
fractures in frontal motor vehicle collisions. Journal of
Conclusion Trauma, Injury, Infection, and Critical Care, 57, 323–328.
With nearly a half million tibia fractures in the United Finkemeir, C. G., Schmidt, A. H., Kyle, R. F., Templeman,
States per year, it is important for the nurse to be pre- D. C., & Vareka, T. F. (2000). A prospective randomized
pared to anticipate and understand the plan of care for study of intramedullary nails inserted with and without
a patient with a tibia fracture. This article provides in- reaming for the treatment of open and closed fractures
sight into the importance of understanding the mech- of the tibial shaft. Journal of Orthopedic Trauma, 14,
anism of injury, extent of injury, rationale for delay of 187–193.
Gaydos, H. L. (2005). The experience of immobility due to
surgery, and possible fixation techniques. Potential com-
trauma. Holistic Nurse Practitioner, 19, 40–43.
plications and considerations for discharge preparation Ganong, R. B. (1993). Fat emboli syndrome in isolated
are also discussed. The goal of treatment is alignment fractures of the tibia and femur. Clinical Orthopedics,
and function, along with a positive and empowering ex- 291, 208–214.
perience for the patient. The patient’s functional life sta- Gustillo, R. B. & Anderson, J. T. (1976). Prevention of in-
tus will be affected while healing, and coping mecha- fection in the treatment of one thousand and twenty-five
nisms will be challenged. The nurse can impact quality open fractures of the long bones: Retrospective and
of care and positive outcomes by discussing rationale prospective analysis. Journal of Bone Joint Surgery,
for interventions, specifically pain control, activity pro- 59(A), 453–458.
gression, smoking cessation, as well as safe and healthy Gustillo, R. B., Mendoza, R. M., & Williams, D. N. (1984).
lifestyle choices. Problems in the management of Type III (severe) open
fractures: A new classification of Type III open fractures.
Journal of Trauma, Injury, Infection, and Critical Care,
Recommendations 24, 742–746.
Hart, E. S., Luther, B., & Grottkau, B. E. (2006). Broken
Using restraints and having air bags reduce the risk and bones: Common pediatric lower extremity fractures—
prevent injuries to head, neck, spine, and vital organs Part III. Orthopedic Nursing, 25, 390–407.
(Lund & Ferguson, 1995; Zador & Ciccone, 1993). Fu- Jacoby, S. F., Ackerson, T. H., & Richmond, T. S. (2006).
ture car safety modifications may include knee bolster air Outcomes from serious injury in older adults. Journal of
bags to prevent the “submarining effect” in frontal car Nursing Scholarship, 38, 133–140.
crashes that may cause lower extremity trauma (Estrada, Lund, A. K., & Ferguson S. A. (1995). Driver fatalities in
Alonso, McGwin, Metzger, & Rue, 2004). Until there is 1985–1993 cars with airbags. Journal of Trauma, Injury,
built-in prevention for lower extremity trauma in motor Infection, and Critical Care, 38, 469–475.
vehicle crashes, the healthcare team will see these injuries Maurer, D. J., Merkow, R. L., & Gustillo R. B. (1989). In-
fection after intramedullary nailing of severe open tibial
that may not be life threatening but are life changing. fracture initially treated with external fixation. Journal of
Bone Joint Surgery, 71(A), 835–838.
REFERENCES Parrett, B. M., Matros, E., Pribaz, J. J., & Orgill, F. P.
Adams, C. I., Keating, J. F., & Court-Brown, C. M. (2001). (2005). Lower extremity trauma: Trends in the manage-
Cigarette smoking and open tibial fractures. Injury, 32, ment of soft-tissue reconstruction of open tibia–fibula
61–65. fractures. Plastic and Reconstructive Surgery, 1315–1322.

222 Orthopaedic Nursing • July/August 2007 • Volume 26 • Number 4

10639-04a_ON2604-Miller.qxd 7/17/07 1:23 PM Page 223

Praemer, A., Furner S., & Rice, D. P. (1992). Musculo- Schmidt, A. H., Finkemeier, C. G., & Tornetta, P. (2003).
skeletal conditions in the United States. Park Ridge, IL: Treatment of closed tibial fractures. AAOS Instructional
American Academy of Orthopedic Surgeons. Course Lectures, 52, 607–621.
Rockwood, C. A., Green, D. P., & Bucholz, R. W. (2006). Tscherne, H., & Gotzen, L. (Eds.). (1984). Fractures with
Rockwood and Green’s fractures in adults (6th ed., Vol. 2). soft tissue injuries. New York: Springer.
Philadelphia: Lippincott Williams & Wilkins. Weinstein, S. L., & Buckwalter, J. A. (2005). Turek’s
Rogers, F. B., Cipolle, M. D., Velmahos, G., Rozycki, G., & orthopaedics principles and their applications. (6th ed.,
Luchette, F. A. (2002). Practice management guidelines pp. 96–97). Philadelphia: Lippincott, Williams, & Wilkins.
for the prevention of venous thromboembolism in trauma Zador, P. L., & Ciccone, M. A. (1993). Automobile driver fa-
patients: The East Practice Management Guidelines Work talities in frontal impacts: Air bags compared with
Group. Journal of Trauma Injury, Infection and Critical manual belts. American Journal of Public Health, 83,
Care, 53, 142–164. 661–666.

Orthopaedic Nursing • July/August 2007 • Volume 26 • Number 4 223