Outline:   
Among fractures of shaft of tibia and fibula, the fracture of shaft of tibia is the highest and the fracture of Shafts of both tibia and fibula is the second and the simple fracture of shafts of fibula is the least in incidence. The fracture of shafts of tibia and fibula often occurs in children, young and the middle-aged people. Greenstick fracture is usually seen in children. Different types of the fracture may be seen is adults because of different forms of violence and directions of forces. Fractures caused by direct violence are mostly transverse, short oblique or comminuted types. For fractures of shafts of both tibia and fibula, their fracture lines are usually at the same level, and they are often accompanied by obvious damage of skin and tissue.

Fracture of the upper one-third may be complicated by damage of blood vessel and nerve. Fractures caused by indirect force are oblique or spiral type. In fractures of both tibia and fibula, if the fracture line of fibula is higher, it will damage soft tissues a little Fractures of the lower one-third may be open type due to bone stump penetrating through the skin. In the severe cases of fracture of shafts of both tibia and fibula, there may occur compartment syndrome of crural fascia due to massive internal bleeding. The fracture in the middle and lower one-third may slowly heal due to deficient supply of blood.

Major points for diagnosis  
1. There is an evident traumatic history.
 
2. After trauma, the patient complains of obvious pain in the injured leg and failure to move.
 
3. There are marked local swellings in the injured leg with ecchymoses and tenderness. In the case of complete fracture, pseudoarthrosis movement and bony crepitus can be palpated. Fracture with marked displacement may show a feature of shortened leg, angulation and extorsion deformity of the foot.
 
4. In open fracture, the bone stump may break through the skin, and sometimes it may withdraw. Corresponding signs may appear when complicated by injury of nerves and blood vessels.
 
5. X-ray film can confirm the location and displacement of fracture.

Treatment:   
The therapeutic principle for the fracture of shafts of tibia and fibula is mainly to restore the length of the leg and its weight-bearing function. So, the key point is to treat fracture of tibia. Angulation and displacement in the fracture site should be corrected. Only splintage is needed for fracture with no displacement until it heals. Stable fracture with displacement such as transverse type may be treated by manipulative reduction and splintage. Unstable fracture such as comminuted and oblique types may be treated by manipulative reduction and splintage combined with transcalcaneal traction. For open fracture, a thorough debridement should be applied so as to make it change into the closed type as soon as possible. In the cases complicated by compartment syndrome of fascia, the deep fasciae should be incised for complete decompression.

Reduction:
Adequate analgesia and anesthesia should be first given. The patient takes a horizontal position with the knee bent to 200 to 300. One assistant nooses the popliteal fossa of the injured limb with his elbow, and the other assistant holds forefoot and heel, letting the leg rest in horizontal position, then the two assistants do counter-traction. For the case of spiral displacement, the distal assistant rotates the foot inward or outward to correct the displacement. The operator stands by the side of the injured limb for applying manipulation. For the fracture with anterior or posterior displacement, manipulation of lifting upward and pressing downward should be adopted. For the fracture with left or right lateral displacement, the pressing reposition manipulation should be adopted.

For the spiral or long oblique fracture with separation displacement, the operator may use his two hands to do counter pressing and squeezing manipulation. For the fracture with displacement of the two bones drawn near, bone-separating manipulation may be taken. Finally, the operator feels with his thumb and index finger the site of fracture along the crest of tibia. If a smooth sensation under the fingers can be felt, it shows that the fracture has been reduced. For the unstable fracture, transcalcaneal traction may first be applied, then the manipulative reduction. But the weight for traction should not be too powerful for fear that it should result in separation of the fracture ends due to hypertraction, which influences the healing of fracture.

Fixation:  
Fixation area is covered with a cotton cushion, then fixed with 5 pieces of moulding splints, which are respectively put on the anteromedial, anterolateral, medial, lateral and posterior sides of the leg, and wrapped with 4 to 6 pieces of stripes. Splint should exceed the knee joint for fracture of upper part, exceed the ankle joint for fracture of lower part, and free both the knee and ankle joints for fracture of middle part (see Fig.23). The fixation duration is 6 to 8 weeks for adults and 4 to 6 weeks for children.
 
Functional exercise:
After reduction and fixation, the injured limb may be lifted to a proper level with a pad under it, and active motion should be prescribed to interphalangeal joints of the foot. Within 7 to 10 days after the injury, special attention should be paid for blood circulation in the limb and effect of splintage. Generally speaking, two weeks after fixation, the patient with stable fracture can practice lifting his thigh and flexing his knee joint, and 3 to 4 weeks later he may be permitted to walk on a pair of crutches under the guide of doctor. It is not advisable for the patient with unstable fracture to practice walking early.

According to the condition of growth of callus revealed through roendgenographic evidence, the traction can be maintained for 3 or 4 weeks after injury. Then small splints may be applied for protection to practice flexing and extending knee and ankle joints on the bed. The patient is allowed to practice walking on crutches 5 to 6 weeks after fixation. If the pain of the affected limb has ceased and the limb has regained strength, walking on single crutch and progresrive partial weight-bearing practice may be started. The splintage may usually be removed after 7 to 8 weeks if there is roendgenographic evidence of satisfactory union of the fracture.

Herbal therapy  
Internal treatment based on syndrome differentiation  

1. In the early stage  
Main symptoms and signs:
Painful swelling of the leg with ecchymoses, loss of functional mobility, abdominal distension and fullness, constipation, brownish urine, dry mouth and foul breath.
 
Therapeutic methods:
Promoting blood flow to remove the stasis, subduing the swelling to check pain, and eliminating the accumulation by purgation.
   
Recipe and herbs:
Modified Fuyuan Huoxue Decoction and Dacheng Decoction. Specifically, Zhidahuang (Radix et Rhizoma Rhei Praeparata )20g, Zhike (Fructus Citri Aurantii)20 g, Dangguiwei (Extremitas Radix Angelicae Sinensis )15 g, Chaihu (Radix Bupleuri)12 g, Tianhuafen (Radix Trichosanthis)12 g, Poxiao (Natrii Sulfas) (to be taken following its infusion with the hot decoction)10 g, Sumu ( Lignum Sappan)10 g, Chenpi ( Pericarpium Citri Reticulatae )10 g, ttoupo ( Cortex Magnoliae Officinalis )10 g, Honghua ( Flos Carthmi )10g, Chuanshanjia ( Squama Manitis Pentadactylae)10 g, Taoren (Semen Persicae)6 g and Gancao (Radix Glycyrrhizae )3 g.
 
2. In the middle stage
Main symptoms and signs:
Relieved swelling and pain in the shank, delayed growth of callus.
   
Therapeutic method:
Promoting reunion of tendons and bones.

Recipe and herbs:
Modified Xugu Huoxue Decoction. Specifically, Dangguiwei (Extremitas Radix Angelicae Sinensis )10 g, Chishaoyao ( Radix Paeniae Rubrae )10 g, Shengdihuang ( Radix Rehmanniae )15 g, Huainiuxi (Radix Achyranthis Bidentatae)10 g, Zhechong (Eupolyphaga seu Steleophaga)15 g, Gusuibu ( Rhizoma Drynarii )20g, Duanzirantong ( Pyritum Carcinatum) (to be decocted first)20 g, Xuduan (RadixDipsaci)20 g, Luodeda (Herba Centellae)10g, Ruxiang (Gummi Olibanum)10 g, Moyao (Myrrha)10 g and Gancao (Radix Glycyrrhizae)5 g.

3. In the late stage  
Main symptoms and signs:
Delayed union of fractured bone, muscular atrophy, general lassitude, and rigidity of the joint.

Therapeutic methods:
Replenishing qi and blood, and strengthening tendons and bones.
 
Recipe and herbs:
Modified Shiquan Dabu Decoction. The herbs see the treatment of fracture of neck of femur in the late stage.