Proximal Tibia Fracture - Examination Documentation

Overview

History

• Low-energy (falls, twisting): typically lateral split plateau fractures - low risk of vascular or neurologic complications
• High-energy (motor vehicle collision, pedestrian struck, fall from height): bicondylar or comminuted fractures with high risk of compartment syndrome, vascular injury, and peroneal nerve injury
• Fatigue/stress fractures: common in older, obese patients with osteoporosis from compressive forces

• Diabetes mellitus
• Peripheral vascular disease
• Tobacco use (any form)
• Malignancy / chemotherapy
• Chronic steroid or immunotherapy use
• Anti-seizure medications
• Renal disease / nutritional deficits
• Activity level, employment, and mental status (relevant for surgical planning)

Inspection

Palpation

• Localized tenderness at tibial plateau (medial vs. lateral)
• Tibial tubercle tenderness (tibial tubercle fracture variant)
• Anterolateral soft tissue tenderness - possible Segond fracture
• Posterolateral corner hematoma - associated with anteromedial plateau fractures; indicates posterolateral corner injury with residual varus instability
• Effusion / hemarthrosis - common in intra-articular fractures
• Compartment tightness / firmness (anterior, lateral, superficial posterior, deep posterior compartments)

Neurovascular Examination (CRITICAL - must be documented)

Vascular Assessment

• Distal pulses: dorsalis pedis and posterior tibial - document presence, strength, symmetry
• Capillary refill of toes (normal < 2 seconds)
• Skin color and temperature compared to contralateral limb
• Ankle-Brachial Index (ABI) for high-energy injuries:
  • Normal ABI ≥ 0.9
  • ABI < 0.9 requires CT arteriogram and vascular surgery consult
  • Doppler-aided systolic pressure of injured vs. uninjured extremity (use upper limb as reference)
• Specific vascular risks by fracture type:
  • Popliteal artery: at risk with bicondylar/comminuted/subcondylar fractures
  • Anterior tibial artery: at risk with displaced lateral condyle fractures

Neurologic Assessment

• Peroneal nerve (most commonly injured - typically by stretch):
  • Sensation: dorsum of foot and first web space
  • Motor: dorsiflexion and eversion of foot (tibialis anterior, peronei)
  • Peroneal nerve injury twice as common in fracture-dislocation patterns
• Tibial nerve sensation (plantar foot) and motor (toe flexion)
• Saphenous nerve (medial leg/foot sensation)
• Sural nerve (lateral foot/heel sensation)
• Superficial peroneal nerve (dorsal foot)

Document sensory and motor function as a baseline at initial exam - repeat periodically during the first 24-48 hours.

Compartment Syndrome Assessment (SERIAL)

1. Pain out of proportion to injury
2. Pain with passive stretch of muscles in the affected compartment (hallmark sign)
3. Tense, firm compartments on palpation
4. Paresthesias / numbness in nerve distributions of affected compartments
5. Weakness of involved musculature
6. Pallor / pulselessness / paralysis - late findings indicating ischemia

• Indicated when physical exam is unreliable (unresponsive patient, altered consciousness, high-energy mechanism)
• Delta pressure (diastolic BP - compartment pressure) < 30 mmHg = fasciotomy threshold
• If diagnosis is clear clinically, fasciotomy may be performed without pressure measurement
• Repeat measurements as indicated by clinical progression

• High-energy fracture patterns
• Patients with altered sensorium
• Post-operative monitoring

Ligamentous Examination

Pain often limits examination accuracy; ligamentous assessment under anesthesia or post-reduction may be more reliable.

Deformity and Range of Motion

• Angular deformity (valgus / varus / recurvatum)
• Rotational malalignment
• Limb length discrepancy
• Active and passive knee ROM - document in degrees
• Ability to perform straight leg raise (assesses extensor mechanism integrity)
• Weight-bearing status

Associated Injury Screening

• Ipsilateral femur/hip fractures (floating knee)
• Ankle/foot injuries
• Fibular head fractures (indicate proximal tibiofibular joint instability or ligamentous injury)
• Spine fractures (axial loading mechanisms)
• Systemic trauma (per ATLS protocol for high-energy mechanisms)

Radiological Correlation (document exam findings before imaging)

• Plain films (AP, lateral, oblique): lipohemarthrosis (fat-fluid level) on cross-table lateral is pathognomonic of intra-articular fracture (marrow fat entering joint)
• CT: mandatory for operative planning; quantifies articular depression, comminution, and fracture pattern (degree of displacement underestimated on X-ray)
• MRI: for ligamentous and meniscal injuries when clinical exam is equivocal

Fracture Pattern Classification (Schatzker - for documentation reference)

Types IV-VI carry the highest risk of vascular injury, compartment syndrome, and peroneal nerve injury.

Documentation Template (Structured Note)

PROXIMAL TIBIA FRACTURE - PHYSICAL EXAMINATION

Date/Time:
Examiner:

HISTORY
  Mechanism: [fall / MVC / pedestrian / sports / other]
  Energy: [low / high]
  Time of injury:
  Relevant PMH: [diabetes / PVD / tobacco / steroids / renal / cancer / medications]
  
INSPECTION
  Side: [R / L]
  Deformity: [valgus / varus / rotational / shortening / none]
  Swelling: [mild / moderate / severe]
  Ecchymosis: [location]
  Skin: [intact / open wound / blisters / contusions] - describe size and location
  
PALPATION
  Tenderness: [medial plateau / lateral plateau / tibial tubercle / fibular head / other]
  Effusion: [present / absent] - size estimate
  Compartment firmness: [normal / increased] - anterior / lateral / posterior
  
NEUROVASCULAR
  Dorsalis pedis pulse: [present / absent / diminished] - right: ___ left: ___
  Posterior tibial pulse: [present / absent / diminished] - right: ___ left: ___
  Capillary refill: [< 2s / > 2s]
  Skin color/temperature: [normal / pale / mottled / cool]
  ABI (high-energy): [___] (normal ≥ 0.9)
  
  Sensation:
    Dorsum/first web space (peroneal): [normal / reduced / absent]
    Plantar (tibial): [normal / reduced / absent]
    Medial leg/foot (saphenous): [normal / reduced / absent]
    Lateral foot (sural): [normal / reduced / absent]
  
  Motor:
    Dorsiflexion (L4-5, peroneal): [5/5 / grade ___ /5]
    Plantar flexion (S1-2, tibial): [5/5 / grade ___ /5]
    Eversion (peroneal): [5/5 / grade ___ /5]
    Toe extension/flexion: [5/5 / grade ___ /5]
  
COMPARTMENTS
  Anterior: [soft / firm / tense]
  Lateral: [soft / firm / tense]
  Superficial posterior: [soft / firm / tense]
  Deep posterior: [soft / firm / tense]
  Pain with passive stretch: [yes / no]
  Compartment pressure (if measured): anterior: ___ mmHg, lateral: ___ mmHg, 
    posterior: ___ mmHg, delta P: ___
  
LIGAMENTOUS (document if performed / deferred due to pain)
  Valgus stress: [stable / lax ___°] - 0° and 30°
  Varus stress: [stable / lax ___°] - 0° and 30°
  Lachman: [negative / positive / not performed]
  Posterior drawer: [negative / positive / not performed]
  Segond fragment: [present on imaging / absent]
  
RANGE OF MOTION
  Flexion: ___ ° (active / passive)
  Extension: ___ ° (active / passive)
  Extension lag: [yes / no]
  SLR: [intact / unable]
  
ASSOCIATED INJURIES
  Ipsilateral extremity: [none / describe]
  Fibular head: [intact / tender / fracture]
  Distal neurovascular: as above
  
IMPRESSION
  Fracture pattern: [Schatzker type ___ / extra-articular / stress]
  Open vs. closed: [open / closed]
  Neurovascular status: [intact / compromised - describe]
  Compartment syndrome risk: [low / moderate / high / present]
  
PLAN
  Imaging ordered: [XR / CT / MRI / CT angio]
  Vascular surgery consult: [yes / no]
  Compartment pressure monitoring: [yes / no]
  Splint/immobilization: [applied / type]
  Serial exams planned: [q___hours]

Key Examination Priorities (Summary)

1. Neurovascular status first - ABI for high-energy injuries; CT arteriogram if ABI < 0.9
2. Compartment syndrome - serial exams mandatory for high-energy patterns (especially medial plateau/bicondylar)
3. Open wound identification - changes urgency and antibiotic management
4. Peroneal nerve - most commonly injured nerve; document at baseline
5. Soft tissue envelope - dictates surgical timing and approach
6. Ligamentous integrity - Segond fracture = ACL disruption until proven otherwise
7. Associated injuries - floating knee, ipsilateral hip/ankle, spine