Tibia Shaft Fractures: Gustilo Classification, IM Nailing & MCQs

Fractures of Tibia & Fibula Shaft

The tibia is the most commonly fractured long bone. Because one-third of its surface is subcutaneous (shin), it has the highest rate of Open Fractures.

1. Gustilo-Anderson Classification (Open Fractures)

• Type I: Wound < 1 cm, clean.
• Type II: Wound 1-10 cm, minimal soft tissue damage.
• Type III: Wound > 10 cm, extensive damage.
  • IIIA: Adequate soft tissue coverage.
  • IIIB: Bone exposed (Needs Flap).
  • IIIC: Arterial injury (Needs Repair).

2. Management

• Conservative: For stable, closed fractures. Long leg cast followed by Patellar Tendon Bearing (PTB) Cast or Sarmiento Brace.
• Surgical:
  • Intramedullary (IM) Nailing: Gold standard for adult shaft fractures.
  • External Fixation: First line for severe open fractures (Type IIIB/C) or damage control.
  • Plating: Used for distal/proximal metaphyseal fractures.

3. Complications

Compartment Syndrome:
Most common in the leg (Ant. Compartment).
Signs (5 Ps): Pain out of proportion (passive stretch), Paresthesia, Pallor, Pulselessness, Paralysis.
Tx: Fasciotomy.

• Non-union: Common at the junction of middle and lower thirds (watershed vascular zone).
• Malunion: Varus/Valgus deformity.

20 Practice MCQs

Q1. The most common site for tibial non-union is:

Answer: A). Poor blood supply area.

Q2. Gustilo-Anderson Type IIIB implies:

Answer: A). Periosteal stripping is significant.

Q3. Gold standard fixation for closed adult tibial shaft fracture:

Answer: A). Biomechanically superior.

Q4. Earliest sign of compartment syndrome is:

Answer: A). Pain out of proportion to injury.

Q5. PTB (Patellar Tendon Bearing) cast transfers weight to:

Answer: A). Bypasses the fracture site.

Q6. Which nerve is at risk at the fibular neck?

Answer: A). Causes foot drop.

Q7. External fixation is preferred for:

Answer: A). Reduces infection risk by avoiding internal hardware.

Q8. "Toddler's Fracture" is:

Answer: A). Common cause of limp in young children.

Q9. Normal healing time for tibial shaft fracture is:

Answer: A). Tibia heals slowly compared to femur.

Q10. Surgical release for compartment syndrome is called:

Answer: A). Usually 4-compartment release (2 incisions).

Q11. The nutrient artery of the tibia arises from:

Answer: A). Enters proximal to the middle third.

Q12. Sarmiento brace works by:

Answer: A). Functional bracing.

Q13. Antibiotic prophylaxis for open fractures should start:

Answer: A). Reduces infection risk significantly.

Q14. Which fracture pattern suggests high energy trauma?

Answer: A). Direct blow or crush.

Q15. Ilizarov fixator is used for:

Answer: A). Ring fixator allows distraction osteogenesis.

Q16. Check X-rays should include:

Answer: A). "Rule of two joints".

Q17. Fibula fracture usually requires fixation if:

Answer: A). Fibula is non-weight bearing but crucial for ankle stability.

Q18. Fat Embolism Syndrome is diagnosed by:

Answer: A). Clinical diagnosis.

Q19. Anterior compartment contains:

Answer: A). Most common site for compartment syndrome.

Q20. Reaming of the canal:

Answer: A). Allows larger nail insertion.