Tibia Shaft Fractures

Authors: Ujash Sheth, Joshua Blomberg, Jan Szatkowski

Topic updated on 03/03/16 2:07pm

Introduction

Proximal third-tibia

Epidemiology

most

common long bone fx

account for

4% of all fx seen in the Medicare population

Mechanism
low

energy fx pattern

result of torsional injury

indirect trauma results in spiral fx

fibula fx at different level

Tscherne grade 0 / I soft tissue injury

high energy fx pattern

fractures

direct forces often result in wedge or short oblique fx and sometimes significant
comminution

fibula fx at same level

severe soft tissue injury

Tscherne II / III

open fx

Associated conditions

soft tissue injury (open wounds)critical to outcome

compartment syndrome

bone loss

ipsilateral skeletal injury

extension to the tibial plateau or plafond

posterior malleolar fracture

most commonly associated with spiral distal third tibia fracture

Classification
Gustilo-Anderson Classification of Open Tibia Fxs
Type I

Limited periosteal stripping, wound < 1 cm

Type II

Mild to moderate periosteal stripping, wound 1-10 cm in length

Type IIIA

Significant soft tissue injury (often evidenced by a segmental fracture or comminution),

significant periosteal stripping, no flap required

Type IIIB

Significant periosteal stripping and soft tissue injury, flap required due to inadequate soft
tissue coverage (STSG doesn't count). Treat proximal 1/3 fxs with gastrocnemius rotation flap,
middle 1/3 fxs with soleus rotation flap, distal 1/3 fxs with free flap.

Type IIIC

Significant soft tissue injury (often evidenced by a segmental fracture or comminution),

vascular injury requiring repair to maintain limb viability

For prognostic reasons, severly comminuted, contaminated barnyard injuries, close range shotgun/high velocity gunshot
injuries, and open fractures presenting over 24 hours from injury have all been later included in the grade III group.
Presentation

Symptoms
o

pain, inability to bear weight, deformity

Physical exam
o

inspection and palpation

deformity / angulation / malrotation

contusions

blisters

open wounds

compartments

palpation

pain

passive motion of toes

intracompartmental pressure measurement if indicated

neurologic

deep peroneal n.

superficial peroneal n.

sural n.

tibial n.

saphenous n.

pulse

dorsalis pedis

posterior tibial

Imaging

Radiographs

be sure to check contralateral side

recommended views

full length AP and lateral views of affected tibia

AP, lateral and oblique views of ipsilateral knee and ankle

CT
o

indications

intra-articular fracture extension or suspicion of joint involvement

CT ankle for spiral distal third tibia fracture

to exclude posterior malleolar fracture

Treatment of Closed Tibia Fractures

Nonoperative
o

closed reduction / cast immobilization

indications

Operative

< 5 degrees varus-valgus angulation

< 10 degrees anterior/posterior angulation

> 50% cortical apposition

< 1 cm shortening

< 10 degrees rotational malalignment

if displaced perform closed reduction under general anesthesia

certain patients who may be non-ambulatory (ie. paralyzed), or those unfit for
surgery

technique

closed low energy fxs with acceptable alignment

place in long leg cast and convert to functional brace at 4 weeks

outcomes

high success rate if acceptable alignment maintained

risk of shortening with oblique fracture patterns

risk of varus malunion with midshaft tibia fractures and an intact fibula

non-union occurs in 1.1% of patients treated with closed reduction

external fixation

indications

complications

pin tract infections common

outcomes

can be useful for proximal or distal metaphyseal fxs

higher incidence of malalignment compared to IM nailing

IM Nailing

indications

unacceptable alignment with closed reduction and casting

soft tissue injury that will not tolerate casting

segmental fx

comminuted fx

ipsilateral limb injury (i.e., floating knee)

polytrauma

bilateral tibia fx

morbid obesity

contraindications

pre-existing tibial shaft deformity that may preclude passage of IM nail

previous TKA or tibial plateau ORIF (not strict contraindication)

outcomes

IM nailing leads to (versus external fixation)

decreased malalignment

IM nailing leads to (versus closed treatment)

decrease time to union

decreased time to weight bearing

reamed vs. unreamed nails

reamed possibly superior to unreamed nails for treatment of closed tibia

fxs for decrease in future bone grafting or implant exchange (SPRINT

trial)

recent studies show no adverse effects of reaming (infection, nonunion)

reaming with use of a tourniquet is NOT associated with thermal necrosis

of the tibial shaft

percutaneous locking plate

indications

proximal tibia fractures with inadequate proximal fixation from IM nailing

distal tibia fractures with inadequate distal fixation from IM nail

complications

non-union

wound infection and dehiscence

long plates may place superficial peroneal nerve at risk

Treatment of Open Tibia Fractures

Operative
o

antibiotics, I&D

indications

all open fractures require an emergent I&D

timing of I&D

surgical debridement 6-8 hours after time of injury is preferred

grossly contaminated wounds are irrigated in emergency department

antibiotics

standard abx for open fractures (institution dependent)

cephalosporin given for 24-48 hours in Grade I,II, and IIIA open fractures

aminoglycoside added in Grade IIIB injuries

penicillin administered in farm injuries

minimal data to support this

minimal data to support this

tetanus prophylaxis

outcomes

early antibiotic administration is the most important factor in reducing infection

emergent and thorough surgical debridement is also an important factor

must remove all devitalized tissue including cortical bone

external fixation

indications

provisional external fixation an option for open fractures with staged IM nailing or
plating

falling out of favor in last decade

indicated in children with open physis

IM Nailing

indications

most open fx can be treated with IM nail within 24 hours

contraindicated in children with open physis (use flexible nail, plate, or external
fixation instead)

outcomes for open fxs

IM nailing vs. external fixation

no difference with respect to

infection rate

union rate

time to union

IM nailing superior with respect to

decreased malalignment

decreased secondary surgeries

shorter time to weight bearing

reamed nails vs. unreamed nails

reaming does not negatively affect union, infection, or need for additional
surgeries in open tibia fractures

gapping at the fracture site is greatest risk for non-union

rhBMP-2

transverse fx pattern and open fractures also at increased risk for

non-union

prior studies have shown use in open tibial shaft fractures

accelerate early fracture healing

decrease rate of hardware failure

decrease need for subsequent autologous bone-grafting

decrease need for secondary invasive procedures

decrease infection rate

recent studies have not fully supported the above findings and rhBMP-2
remains highly controversial

amputation

indications

no current scoring system to determine if an amputation should be performed

relative indications for amputation include

significant soft tissue trauma

warm ischemia > 6 hrs

severe ipsilateral foot trauma

outcomes

LEAP study

most important predictor of eventual amputation is the severity of

ipsilateral extremity soft tissue injury

most important predictor of infection other than early antibiotic

administration is transfer to definitive trauma center

study shows no significant difference in functional outcomes between

amputation and salvage

loss of plantar sensation is not an absolute indication for amputation

Technique

IM nailing of shaft fractures

o

preparation

anesthesia

general anesthesia recommended

positioning

patient positioned supine on radiolucent table

bring fluoro in from opposite, non-injured, side

bump placed under ipsilateral hip

leave full access to foot and ankle to help judge intraoperative length, rotation, and
alignment of extremity

tourniquet

tourniquet placed on proximal thigh

not typically inflated

use in patients with vascular injury or significant bleeding associated with

extensive soft tissue injuries

deflate during reaming or nail insertion (weak data to support this)

approach

options include

medial parapatellar

most common starting point

can lead to valgus malalignment when used to treat proximal fractures

lateral parapatellar

helps maintain reduction when nailing proximal 1/3 fractures

requires mobile patella

patellar tendon splitting

gives direct access to start point

can damage patellar tendon or lead to patella baja (minimal data to support
this)

semiextended medial or lateral parapatellar

used for proximal and distal tibial fractures

suprapatellar (transquadriceps tendon)

requires special instruments

can damage patellofemoral joint

starting point

medial parapatellar tendon approach with knee flexed

incision from inferior pole of patella to just above tibial tubercle

identify medial edge of patellar tendon, incise

peel fat pad off back of patellar tendon

starting guidewire is placed in line with medial aspect of lateral tibial spine
on AP radiograph, just below articular margin on lateral view

insert starting guide wire, ream

semiextended lateral or medial parapatellar approach

skin incision made along medial or lateral border of patella from superior
pole of patella to upper 1/3 of patellar tendon

knee should be in 5-30 degrees of flexion

choice to go medial or lateral is based of mobility of patella in either

direction

open retinaculum and joint capsule to level of synovium

free retropatellar fat pad from posterior surface of patellar tendon

identify starting point as mentioned previously

fracture reduction techniques

spanning external fixation (ie. traveling traction)

clamps

femoral distractor

small fragment plates/screws

intra-cortical screws

reaming

reamed nails superior to unreamed nails in closed fractures

be sure tourniquet is released

advance reamers slowly at high speed

overream by 1.0-1.5mm to facilitate nail insertion

confirm guide wire is appropriately placed prior to reaming

nail insertion

insert nail in slight external rotation to move distal interlocking screws anteriorly
decreasing risk of NVS injury

if nail does not pass, remove and ream 0.5-1.0mm more

locking screws

statically lock proximal and distally for rotational stability

no indication for dynamic locking acutely

number of interlocking screws is controversial

two proximal and two distal screws in presence of <50% cortical contact

consider 3 interlock screws in short segment of distal or proximal shaft fracture

Complications

Knee pain
o

>50% anterior knee pain with IM nailing

occurs with patellar tendon splitting and paratendon approach

pain relief unpredictable with nail removal

lateral radiograph is best radiographic views to make sure nail is not too proud
proximally

Malunion

high incidence of valgus and procurvatum (apex anterior) malalignment in proximal third
fractures

varus malunion leads to ipsilateral ankle pain and stiffness

chronic angular deformity is defined by the proximal and distal anatomical/mechanical axis
of each segment

center of rotation of angulation is intersection of proximal and distal axes

Nonunion
o

definition

delayed union if union at 6-9 mos.

nonunion if no healing after 9 mos.

treatment

nail dynamization if axially stable

exchange nailing if not axially stable

reamed exchange nailing most appropriate for aseptic, diaphyseal tibial

nonunions with less than 30% cortical bone loss.

consider revision with plating in metaphyseal nonunions

posterolateral bone grafting if significant bone loss

non-invasive techniques (electrical stimulation, US)

BMP-7 (OP-1) has been shown equivalent to autograft

often used in cases of recalcitrant non-unions

compression plating has been shown to have 92-96% union rate after open tibial
fractures initially treated with external fixation

Malrotation
o

most commonly occurs after IM nailing of distal 1/3 fractures

can assess tibial rotation by obtaining perfect lateral fluoroscopic image of knee, then
rotating c-arm 105-110 degrees to obtain mortise view of ipsilateral ankle

reduced risk with adjunctive fibular plating

Compartment syndrome
o

incidence 1-9%

diagnosis

high index of clinical suspicion

pain out of proportion

pain with passive stretch

compartment pressure within 30mm Hg of diastolic BP is most sensitive diagnostic

test

treatment

emergent four compartment fasciotomy

outcome

can occur in both closed and open tibia shaft fxs

failure to recognize and treat compartment syndrome is most common reason

for successful malpractice litigation against orthopaedic surgeons

prevention

increased compartment pressure found with

traction (calcaneal)

leg positioning

Nerve injury
o

LISS plate application without opening for distal screw fixation near plate holes 1113 putsuperficial peroneal nerve at risk of injury due to close proximity

saphenous nerve can be injured during placement of locking screws

transient peroneal nerve palsy can be seen after closed nailing

EHL weakness and 1st dorsal webspace decreased sensation

treated nonoperatively; variable recovery is expected

Tibia and Fibula Fracture

Background
Lower leg fractures include fractures of the tibia and fibula. Of these two bones, the tibia is the only weightbearing
bone. Fractures of the tibia generally are associated with fibula fracture, because the force is transmitted along the
interosseous membrane to the fibula.
The skin and subcutaneous tissue are very thin over the anterior and medial tibia and as a result of this, a significant
number of fractures to the lower leg are open. Even in closed fractures, the thin, soft tissue can become compromised.
In contrast, the fibula is well covered by soft tissue over most of its course with the exception of the lateral malleolus.
The tibia and fibula articulate at the proximal tibia-fibular syndesmosis.

Fractures of the tibia can involve the tibial plateau, tibial tubercle, tibial eminence, proximal tibia, tibial shaft, and tibial
plafond. See the image below.

Shown is an intra-articular fracture of the medial condyle of the tibial plateau.

For more information, see Medscape's Trauma Resource Center.

Epidemiology
Frequency
United States
Fractures of the tibia are the most common long bone fractures. The annual incidence of open fractures of long bones
is estimated to be 11.5 per 100,000 persons, with 40% occurring in the lower limb. [1] The most common fracture of the
lower limb occurs at the tibial diaphysis.[2] Isolated midshaft or proximal fibula fractures are uncommon.

Mortality/Morbidity
Limb loss may occur as a result of severe soft-tissue trauma, neurovascular compromise, popliteal artery injury,
compartment syndrome, or infection such as gangrene or osteomyelitis. Popliteal artery injury is a particularly serious
injury that threatens the limb and is easily overlooked.
The common peroneal nerve crosses the fibular neck. This nerve is susceptible to injury from a fibular neck fracture,
the pressure of a splint, or during surgical repair. This can result in foot drop and sensation abnormalities.
Delayed union, nonunion, and arthritis may occur. Among the long bones, the tibia is the most common site of fracture
nonunion.

Age
Toddler fracture (distal spiral fracture of the tibia) is most common in children aged 9 months to 3 years.
Cl

History
Mechanisms of injury for tibia-fibula fractures can be divided into 2 categories:

Low-energy injuries such as ground levels falls and athletic injuries

High-energy injuries such as motor vehicle injuries, pedestrians struck by motor vehicles, and gunshot wounds
Patient may report a history of direct (motor vehicle crash or axial loading) or indirect (twisting) trauma.
Patient may complain of pain, swelling, and inability to ambulate with tibia fracture.
Ambulation is possible with isolated fibula fracture.
Tibial plateau fractures occur from axial loading with valgus or varus forces, such as in a fall from a height or collision
with the bumper of a car. The lateral tibial plateau is fractured more frequently than the medial plateau.
Tibial tubercle fractures usually occur during jumping activities such as basketball, diving, football, and gymnastics.
This type of fracture is more common in adolescents than in adults.
Tibial eminence fractures occur with trauma to the distal femur while the knee is flexed such as falling off of a bicycle.
Another mechanism for this fracture is hyperextension. Tibial eminence avulsion fractures occur most often in children
aged 8-14 years but can occur in a skeletally mature patient.

Tibial shaft fractures usually present with a history of major trauma. An exception to this is a toddler's fracture, which is
a spiral fracture that occurs with minor trauma in children who are learning to walk.
Tibial plafond fractures refer to fractures involving the weightbearing surface of the distal tibia. This type of injury
usually results from high-energy axial loading but may result from lower-energy rotation forces.
Maisonneuve fractures are rare and considered unstable ankle injuries. This type of injury usually involves a pronationexternal rotation force.
Stress fractures of the tibia and fibula may occur as a result of repetitive submaximal stresses that may occur while
participating in athletics. The history may reveal some change in training routine.
Patients with osteoporosis may have a seemingly innocent mechanism of injury and still sustain fracture. [3]

Physical
When examining a patient for a lower leg fracture one should first examine the patient for edema, ecchymosis, and
point tenderness. Gross deformities should be noted and splinted. A careful neurovascular assessment should be
performed, and an emergent fracture reduction should be performed if neurovascular deficits are present.
A careful examination should be performed for open wounds. Open fractures require antibiotics and an emergent
orthopedic consultation.
Tibial plateau fractures often present with a knee effusion. Tenderness will be present along the medial or lateral tibial
plateau. Approximately 20% of tibial plateau fractures are associated with ligamentous injuries. See the images below.

Tibial plateau fractures. Line drawings of Schatzker types I, II, and III tibial plateau
fractures. Type I consists of a wedge fracture of the lateral tibial plateau, produced by low-force injuries. Type II combines the wedge
fracture of the lateral plateau with depression of the lateral plateau. Type III fractures are classified as those with depression of the
lateral plateau but no associated wedge fracture.

Tibial plateau fractures. Line drawings of Schatzker types IV, V, and VI tibial plateau
fractures. Type IV is similar to type I fracture, except that it involves the medial tibial plateau as opposed to the lateral plateau.
Greater force is required to produce this type of injury. Type V fractures are termed bicondylar and demonstrate wedge fractures of
both the medial and lateral tibial plateaus. Finally, type VI fractures consist of a type V fracture along with a fracture of the underlying
diaphysis and/or metaphysis.

Tibial tubercle fracture will have tenderness over the anterior tibia approximately 3 cm distal to the articular surface. In
more severe tibial tubercle fractures, full extension of the knee is not possible. The patella may be high riding.
Tibial eminence fracture may present with a knee effusion and pain and may represent an avulsion of the tibial
attachment of the anterior cruciate ligament.
Tibial shaft fractures are the most common long bone fracture and usually involve the fibula as well. Tibial fractures
present with localized pain, swelling, and deformity.
Maisonneuve fractures involve a fracture of the proximal fibula in association with a fractured medial malleolus (or
injured deltoid ligament) and diastasis of the distal tibiofibular syndesmosis. Patients present with proximal fibular pain
in addition to medial ankle pain. This is an unstable ankle injury.
Tibial plafond fractures will have tenderness along the distal tibial and may have severely decreased range of motion in
the ankle.

Causes
Causes include the following:

Direct forces such as those caused by falls and MVCs

Indirect or rotational forces

Prehospital Care
Address airway, breathing, and circulation.
Check and document neurovascular status.
Apply sterile dressing to open wounds.
Apply gentle traction to reduce gross deformities; splint the extremity.
Administer parenteral analgesics for an isolated extremity injury in a hemodynamically stable patient.

Emergency Department Care

Parenteral analgesia should be administered when appropriate. Although management of pain has improved, pain due
to long bone fractures is notably undertreated in the emergency department. [3]
Open fractures must be diagnosed and treated appropriately (also see Tibia Fractures, Open). Tetanus vaccination
should be updated, and appropriate antibiotics should be given in a timely manner. Some recommend antibiotics within
3 hours of the accident.[7] This should involve antistaphylococcal coverage and consideration of an aminoglycoside for
more severe wounds. Orthopedics should be consulted for emergent debridement and wound care. Fractures with
tissue at risk for opening should be protected to prevent further morbidity.
According to one study, delay of the first operative procedure beyond the day of admission appears to be associated
with a significantly increased probability of amputation in patients with open tibia fracture. In this study, data were
analyzed from the Nationwide Inpatient Sample, 2003 to 2009.[8]

Compartment syndrome
Compartment syndrome can develop in fractures of the lower leg.
Signs of compartment syndrome include crescendo symptoms, pain with passive movement of involved muscles,
paresthesias, and pallor, and a very late finding is pulselessness. Increased compartment pressure is present during
compartment syndrome; therefore, external palpation frequently aids in the diagnosis. However, a soft extremity on
palpation does not rule out compartment syndrome.
Serial examinations should be performed on patients with high-risk injuries or patients with equivocal symptoms.
If compartment syndrome is suspected, obtain an emergent orthopedic consult and measure compartment pressures.
Compartment syndrome must be treated promptly with an emergency surgical fasciotomy. If untreated, the increased
compartment pressures can cause ischemia and necrosis of the structures within that facial compartment and
permanent disability.[9, 10, 11, 12, 13, 14]
Risk factors for compartment syndrome of the lower leg include tibial diaphysis fracture, soft-tissue injury, and crush
injury.[9]
Open fractures in pediatric patients have a significantly increased risk of developing compartment syndrome. [9]
In one study, the authors ascertained whether all children under the age of 12 years with fractures of the tibia
warranted admission because of the risk of acute compartment syndrome. The mean age of the patients was 5.8
years. According to the authors, patients who have minimally displaced tibial fractures, whose pain is adequately
controlled, and who can safely be moved with parental supervision may be discharged from the emergency
department. None of the children younger than 12 years developed acute compartment syndrome; however, the
authors noted that certain features, such as a history of high-energy injury, displaced fractures, or coexisting fibular
fractures, should raise concern that compartment syndrome may occur and, thus, admission and observation may be
considered.[10]

Tibial plateau fracture

Immobilize nondisplaced fractures and have the patient remain nonweightbearing.
Obtain an orthopedic consultation for displaced (depressed) fractures, which require open reduction and internal
fixation. Articular depression of greater than 3 mm may be considered for surgery.
In a study of 158 patients with 162 tibial plateau fractures, the overall rate of compartment syndrome was 11%. Tibial
widening and femoral displacement were found to be significant associated factors. [15]
See the images below.

Type II tibial plateau fracture in a young active adult with good bone stock treated with percutaneous elevation
and cannulated cancellous screw fixation without bone grafting.

Type III tibial plateau fracture with central depression in an elderly person treated surgically using percutaneous
elevation, bone grafting, and cancellous screw fixation.

Tibial eminence fracture

For nondisplaced fractures (and stable knee joint), immobilize the knee.
Obtain an orthopedic consultation for an unstable knee, or displaced fracture for possible surgical fixation.

Tibial tubercle fracture

For nondisplaced fractures, immobilize the knee.
Obtain an orthopedic consultation for a displaced fracture to consider open reduction and internal fixation.
In one study of patients with tibial tubercle fractures, mean age at surgery was 14.6 years, and the most common
fracture reported was type III (50.6%). Compartment syndrome was present in 3.57% of cases. [16]

Proximal tibia fractures

Intra-articular fractures require reduction and internal fixation.
Other methods to surgically repair proximal tibia fractures include external fixation, plating, and intramedullary nailing.
Closed treatment involves reduction and the placement of a long leg cast. Intact extensor mechanisms can make it
difficult to maintain good fracture alignment.
Tibial shaft fractures that are closed may be treated with cast immobilization if alignment is good or with intramedullary
nailing.

Isolated midshaft or proximal fibula fracture

Immobilization in a long leg cast generally is not required. Recommend a few days without weightbearing activity until
swelling resolves, followed by weightbearing activity as tolerated.
Short leg walking cast usually is not required; however, some orthopedists may prefer a short leg walking cast or cam
walker with weight bearing.

Tibia and fibula stress fractures

The keystone of treating stress fractures is the temporary cessation of the offending activity.
Crutches may be used initially to allow the patient to be nonweight-bearing.

Consultations
Obtain emergent orthopedic consultation for open fractures. Consultation is also generally indicated for closed
fractures.
Emergent consultation is needed in suspected compartment syndrome.
Advise patient to obtain orthopedic follow-up care of isolated fibula fractures.

Femur Shaft Fractures (Broken Thighbone)

Your thighbone (femur) is the longest and strongest bone in your body. Because the femur is so strong, it usually takes a lot of force to break
it. Car crashes, for example, are the number one cause of femur fractures.
The long, straight part of the femur is called the femoral shaft. When there is a break anywhere along this length of bone, it is called a
femoral shaft fracture.

The femoral shaft runs from below the hip to where the bone begins to widen at the knee.

Types of Femoral Shaft Fractures

Femur fractures vary greatly, depending on the force that causes the break. The pieces of bone may line up correctly or be out of alignment
(displaced), and the fracture may be closed (skin intact) or open (the bone has punctured the skin).
Doctors describe fractures to each other using classification systems. Femur fractures are classified depending on:

The location of the fracture (the femoral shaft is divided into thirds: distal, middle, proximal)

The pattern of the fracture (for example, the bone can break in different directions, such as cross-wise, length-wise, or in the
middle)

Whether the skin and muscle above the bone is torn by the injury

The most common types of femoral shaft fractures include:

Transverse fracture. In this type of fracture, the break is a straight horizontal line going across the femoral shaft.
Oblique fracture. This type of fracture has an angled line across the shaft.
Spiral fracture. The fracture line encircles the shaft like the stripes on a candy cane. A twisting force to the thigh causes this type of fracture.
Comminuted fracture. In this type of fracture, the bone has broken into three or more pieces. In most cases, the number of bone fragments
corresponds with the amount of force required to break the bone.
Open fracture. If a bone breaks in such a way that bone fragments stick out through the skin or a wound penetrates down to the broken
bone, the fracture is called an open or compound fracture. Open fractures often involve much more damage to the surrounding muscles,
tendons, and ligaments. They have a higher risk for complications especially infections and take a longer time to heal.

Top of page

Cause
Femoral shaft fractures in young people are frequently due to some type of high-energy collision. The most common cause of femoral shaft
fracture is a motor vehicle or motorcycle crash. Being hit by a car as a pedestrian is another common cause, as are falls from heights and
gunshot wounds.
A lower-force incident, such as a fall from standing, may cause a femoral shaft fracture in an older person who has weaker bones.
Top of page

Symptoms
A femoral shaft fracture usually causes immediate, severe pain. You will not be able to put weight on the injured leg, and it may look
deformed shorter than the other leg and no longer straight.
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Doctor Examination
Medical History and Physical Examination
It is important that your doctor know the specifics of how you hurt your leg. For example, if you were in a car accident, it would help your
doctor to know how fast you were going, whether you were the driver or a passenger, whether you were wearing your seat belt, and if the
airbags went off. This information will help your doctor determine how you were hurt and whether you may be hurt somewhere else.
It is also important for your doctor to know whether you have other health conditions like high blood pressure, diabetes, asthma, or allergies.
Your doctor will also ask you about any medications you take.
After discussing your injury and medical history, your doctor will do a careful examination. He or she will assess your overall condition, and
then focus on your leg. Your doctor will look for:

An obvious deformity of the thigh/leg (an unusual angle, twisting, or shortening of the leg)

Breaks in the skin

Bruises

Bony pieces that may be pushing on the skin

After the visual inspection, your doctor will then feel along your thigh, leg, and foot looking for abnormalities and checking the tightness of the
skin and muscles around your thigh. He or she will also feel for pulses. If you are awake, your doctor will test for sensation and movement in
your leg and foot.

Imaging Tests
Other tests that will provide your doctor with more information about your injury include:

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 femur.

Computed tomography (CT) scan. If your doctor still needs more information after reviewing your x-rays, he or she may order a
CT scan. A CT scan shows a cross-sectional image of your limb. It can provide your doctor with valuable information about the
severity of the fracture. For example, sometimes the fracture lines can be very thin and hard to see on an x-ray. A CT scan can
help your doctor see the lines more clearly.

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Treatment
Nonsurgical Treatment
Most femoral shaft fractures require surgery to heal. It is unusual for femoral shaft fractures to be treated without surgery. Very young
children are sometimes treated with a cast. For more information on that, see Pediatric Thighbone (Femur) Fracture.

Surgical Treatment
Timing of surgery. If the skin around your fracture has not been broken, your doctor will wait until you are stable before doing surgery. Open
fractures, however, expose the fracture site to the environment. They urgently need to be cleansed and require immediate surgery to prevent
infection.
For the time between initial emergency care and your surgery, your doctor will place your leg either in a long-leg splint or in skeletal traction.
This is to keep your broken bones as aligned as possible and to maintain the length of your leg.
Skeletal traction is a pulley system of weights and counterweights that holds the broken pieces of bone together. It keeps your leg straight
and often helps to relieve pain.
External fixation. In this type of operation, metal pins or screws are placed into the bone above and below the fracture site. The pins and
screws are attached to a bar outside the skin. This device is a stabilizing frame that holds the bones in the proper position so they can heal.
External fixation is usually a temporary treatment for femur fractures. Because they are easily applied, external fixators are often put on when
a patient has multiple injuries and is not yet ready for a longer surgery to fix the fracture. An external fixator provides good, temporary stability
until the patient is healthy enough for the final surgery. In some cases, an external fixator is left on until the femur is fully healed, but this is
not common.

External fixation is often used to hold the bones together temporarily when the skin and muscles have been injured.
Intramedullary nailing. Currently, the method most surgeons use for treating femoral shaft fractures is intramedullary nailing. During this
procedure, a specially designed metal rod is inserted into the marrow canal of the femur. The rod passes across the fracture to keep it in
position.
An intramedullary nail can be inserted into the canal either at the hip or the knee through a small incision. It is screwed to the bone at both
ends. This keeps the nail and the bone in proper position during healing.
Intramedullary nails are usually made of titanium. They come in various lengths and diameters to fit most femur bones.

Intramedullary nailing provides strong, stable, full-length fixation.

Plates and screws. During this operation, the bone fragments are first repositioned (reduced) into their normal alignment. They are held
together with special screws and metal plates attached to the outer surface of the bone.
Plates and screws are often used when intramedullary nailing may not be possible, such as for fractures that extend into either the hip or
knee joints.

(Left) This x-ray shows a healed femur fracture treated with intramedullary nailing. (Right) In this x-ray, the femur fracture has been treated
with plates and screws.
Top of page

Recovery
Most femoral shaft fractures take 4 to 6 months to completely heal. Some take even longer, especially if the fracture was open or broken into
several pieces.

Weightbearing
Many doctors encourage leg motion early in the recovery period. It is very important to follow your doctor's instructions for putting weight on
your injured leg to avoid problems.
In some cases, doctors will allow patients to put as much weight as possible on the leg right after surgery. However, you may not be able to
put full weight on your leg until the fracture has started to heal. It is very important to follow your doctor's instructions carefully.
When you begin walking, you will most likely need to use crutches or a walker for support.

Physical Therapy
Because you will most likely lose muscle strength in the injured area, exercises during the healing process are important. Physical therapy
will help to restore normal muscle strength, joint motion, and flexibility.
A physical therapist will most likely begin teaching you specific exercises while you are still in the hospital. The therapist will also help you
learn how to use crutches or a walker.
Top of page

Complications
Complications from Femoral Shaft Fractures
Femoral shaft fractures can cause further injury and complications.

The ends of broken bones are often sharp and can cut or tear surrounding blood vessels or nerves.

Acute compartment syndrome may develop. This is a painful condition that occurs when pressure within the muscles builds to
dangerous levels. This pressure can decrease blood flow, which prevents nourishment and oxygen from reaching nerve and

muscle cells. Unless the pressure is relieved quickly, permanent disability may result. This is a surgical emergency. During the
procedure, your surgeon makes incisions in your skin and the muscle coverings to relieve the pressure.

Open fractures expose the bone to the outside environment. Even with good surgical cleaning of the bone and muscle, the bone
can become infected. Bone infection is difficult to treat and often requires multiple surgeries and long-term antibiotics.

Complications from Surgery

In addition to the risks of surgery in general, such as blood loss or problems related to anesthesia, complications of surgery may include:

Infection

Injury to nerves and blood vessels

Blood clots

Fat embolism (bone marrow enters the blood stream and can travel to the lungs; this can also happen from the fracture itself
without surgery)

Malalignment or the inability to correctly position the broken bone fragments

Delayed union or nonunion (when the fracture heals slower than usual or not at all)

Hardware irritation (sometimes the end of the nail or the screw can irritate the overlying muscles and tendons)

Bone fracture
A bone fracture (sometimes abbreviated FRX or Fx, Fx, or #) is a medical condition in which there is a damage in the
continuity of the bone. A bone fracture can be the result of high force impact or stress, or a minimal trauma injury as a result
of certain medical conditions that weaken the bones, such as osteoporosis, bone cancer, or osteogenesis imperfecta, where
the fracture is then properly termed a pathologic fracture.[1]
Although broken bone and bone break are common colloquialisms for a bone fracture, break is not a
formal orthopedic term.

Signs and symptoms[edit]

Although bone tissue itself contains no nociceptors, bone fracture is painful for several reasons:[2]

Breaking in the continuity of the periosteum, with or without similar discontinuity in endosteum, as both contain
multiple pain receptors.

Edema of nearby soft tissues caused by bleeding of torn periosteal blood vessels evokes pressure pain.

Muscle spasms trying to hold bone fragments in place. Sometimes also followed by cramping.

Damage to adjacent structures such as nerves or vessels, spinal cord and nerve roots (for spine fractures), or cranial
contents (for skull fractures) can cause other specific signs and symptoms.

Pathophysiology[edit]
Main article: Bone healing
The natural process of healing a fracture starts when the injured bone and surrounding tissues bleed, forming a
fracture hematoma. The blood coagulates to form a blood clotsituated between the broken fragments. Within a few
days, blood vessels grow into the jelly-like matrix of the blood clot. The new blood vessels bring phagocytes to the area,
which gradually remove the non-viable material. The blood vessels also bring fibroblasts in the walls of the vessels and these
multiply and produce collagen fibres. In this way the blood clot is replaced by a matrix of collagen. Collagen's rubbery
consistency allows bone fragments to move only a small amount unless severe or persistent force is applied.
At this stage, some of the fibroblasts begin to lay down bone matrix in the form of collagen monomers. These monomers
spontaneously assemble to form the bone matrix, for which bone crystals (calcium hydroxyapatite) are deposited in amongst,
in the form of insoluble crystals. This mineralization of the collagen matrix stiffens it and transforms it into bone. In fact,
bone is a mineralized collagen matrix; if the mineral is dissolved out of bone, it becomes rubbery. Healing bone callus is on
average sufficiently mineralized to show up on X-ray within 6 weeks in adults and less in children. This initial "woven" bone
does not have the strong mechanical properties of mature bone. By a process of remodeling, the woven bone is replaced by
mature "lamellar" bone. The whole process can take up to 18 months, but in adults the strength of the healing bone is usually
80% of normal by 3 months after the injury.
Several factors can help or hinder the bone healing process. For example, any form of nicotine hinders the process of bone
healing, and adequate nutrition (including calciumintake) will help the bone healing process. Weight-bearing stress on bone,
after the bone has healed sufficiently to bear the weight, also builds bone strength. Although there are theoretical concerns
about NSAIDs slowing the rate of healing, there is not enough evidence to warrant withholding the use of this type analgesic
in simple fractures.[3]

Effects of smoking[edit]
Smokers generally have lower bone density than non-smokers, so have a much higher risk of fractures. There is also
evidence that smoking delays bone healing. Some research indicates, for example, that it delays tibial shaft fracture healing
from a median healing time of 136 to 269 days.[4] This means that the fracture healing time was approximately doubled in
smokers. Although some other studies show less extreme effects, it is still shown that smoking delays fracture healing.

Diagnosis[edit]

Radiography to identify eventual fractures after a knee injury.

A bone fracture may be diagnosed based on the history given and the physical examination performed. Radiographic
imaging is often performed, to confirm the diagnosis. Under certain circumstances, radiographic examination of the nearby
joints is indicated in order to exclude dislocations and fracture-dislocations. In situations where projectional radiography alone
is insufficient, Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) may be indicated.

Classification[edit]
"Compound Fracture" redirects here. For the 2013 horror film, see Compound Fracture (film).

Compare healthy bone with different types of fractures:

(a) closed fracture
(b) open fracture
(c) transverse fracture
(d) spiral fracture
(e) comminuted fracture
(f) impacted fracture
(g) greenstick fracture
(h) oblique fracture

Open ankle fracture with luxation

In orthopedic medicine, fractures are classified in various ways. Historically they are named after the doctor who first
described the fracture conditions. However, there are more systematic classifications in place currently.

Mechanism[edit]

Traumatic fracture - This is a fracture due to sustained trauma. e.g.- Fractures caused by a fall, road traffic accident,
fight etc.

Pathologic fracture - A fracture through a bone which has been made weak by some underlying disease is called
pathological fracture. e.g.- a fracture through a bone weakened by metastasis. Osteoporosis is the most common cause
of pathological fracture.

Periprosthetic fracture - A fracture at the point of mechanical weakness at the end of an implant

Soft-tissue involvement[edit]

Closed fracture: are those in which the overlying skin is intact

Open fracture/Compound fracture: involve wounds that communicate with the fracture, or where
fracture hematoma is exposed, and may thus expose bone to contamination. Open injuries carry a higher risk
of infection.

Clean fracture

Contaminated fracture

Displacement[edit]

Non-displaced

Displaced

Translated

Angulated

Rotated

Shortened

Fracture pattern[edit]

Linear fracture: A fracture that is parallel to the bone's long axis.

Transverse fracture: A fracture that is at a right angle to the bone's long axis .

Oblique fracture: A fracture that is diagonal to a bone's long axis (more than 30).

Spiral fracture: A fracture where at least one part of the bone has been twisted.

Compression fracture/Wedge fracture: usually occurs in the vertebrae, for example when the front portion of
a vertebra in the spine collapses due to osteoporosis (a medical condition which causes bones to become brittle and
susceptible to fracture, with or without trauma).

Impacted fracture: A fracture caused when bone fragments are driven into each other.

Avulsion fracture: A fracture where a fragment of bone is separated from the main mass.

Fragments[edit]

Incomplete fracture: A fracture in which the bone fragments are still partially joined. In such cases, there is a crack in
the osseous tissue that does not completely traverse the width of the bone

Complete fracture: A fracture in which bone fragments separate completely.

Comminuted fracture: A fracture in which the bone has broken into several pieces.

Anatomical location[edit]
An anatomical classification may begin with specifying the involved body part, such as the head or arm, followed with more
specific localization. Fractures that have additional definition criteria than merely localization can often be classified as
subtypes of fractures that merely are, such as a Holstein-Lewis fracture being a subtype of a humerus fracture. However,

most typical examples in an orthopedic classification given in previous section cannot appropriately be classified into any
specific part of an anatomical classification, as they may apply to multiple anatomical fracture sites.

Skull fracture

Basilar skull fracture

Blowout fracture - a fracture of the walls or floor of the orbit

Mandibular fracture

Nasal fracture

Le Fort fracture of skull - facial fractures involving the maxillary bone and surrounding structures in a
usually bilateral and either horizontal, pyramidal or transverse way.
Spinal fracture

Cervical fracture

Fracture of C1, including Jefferson fracture

Fracture of C2, including Hangman's fracture

Flexion teardrop fracture - a fracture of the anteroinferior aspect of a cervical vertebral

Clay-shoveler fracture - fracture through the spinous process of a vertebra occurring at any of the
lower cervical or upper thoracic vertebrae

Burst fracture - in which a vertebra breaks from a high-energy axial load

Compression fracture - a collapse of a vertebra, often in the form of wedge fractures due to larger
compression anteriorly.

Chance fracture - compression injury to the anterior portion of a vertebral body with concomitant
distraction injury to posterior elements

Holdsworth fracture - an unstable fracture dislocation of the thoracolumbar junction of the spine

Rib fracture

Sternal fracture

Shoulder fracture

Clavicle fracture

Scapular fracture

Arm fracture

Humerus fracture (fracture of upper arm)

Supracondylar fracture
Holstein-Lewis fracture - a fracture of the distal third of the humerus resulting in entrapment of
the radial nerve.

Forearm fracture

Ulnar fracture

Monteggia fracture - a fracture of the proximal third of the ulna with the dislocation of
the head of the radius

Hume fracture - a fracture of the olecranon with an associated anterior dislocation of

the radial head

Radius fracture

Essex-Lopresti fracture - a fracture of the radial head with concomitant dislocation of

the distal radio-ulnar joint with disruption of the interosseous membrane.[5]

Distal radius fracture

Galeazzi fracture - a fracture of the radius with dislocation of the distal

radioulnar joint

Colles' fracture - a distal fracture of the radius with dorsal (posterior)

displacement of the wrist and hand

Smith's fracture - a distal fracture of the radius with volar (ventral) displacement
of the wrist and hand

Barton's fracture - an intra-articular fracture of the distal radius with dislocation

of the radiocarpal joint.

Hand fracture

Scaphoid fracture

Rolando fracture - a comminuted intra-articular fracture through the base of the first metacarpal bone

Bennett's fracture - a fracture of the base of the first metacarpal bone which extends into
the carpometacarpal (CMC) joint.[6]

Boxer's fracture - a fracture at the neck of a metacarpal

Pelvic fracture

Fracture of the hip bone

Duverney fracture - an isolated pelvic fracture involving only the iliac wing.

Femoral fracture

Hip fracture (anatomically a fracture of the femur bone and not the hip bone)

Patella fracture

Crus fracture

Tibia fracture

Pilon fracture

Tibial plateau fracture

Bumper fracture - a fracture of the lateral tibial plateau caused by a forced valgus applied to
the knee

Segond fracture - an avulsion fracture of the lateral tibial condyle

Gosselin fracture - a fractures of the tibial plafond into anterior and posterior fragments[7]

Toddler's fracture - an undisplaced and spiral fracture of the distal third to distal half of the tibia[8]

Fibular fracture

Maisonneuve fracture - a spiral fracture of the proximal third of the fibula associated with a tear of
the distal tibiofibular syndesmosis and the interosseous membrane.

Le Fort fracture of ankle - a vertical fracture of the antero-medial part of

the distal fibula with avulsion of the anterior tibiofibular ligament.[9]

Combined tibia and fibula fracture

Bosworth fracture - a fracture with an associated fixed posterior dislocation of the proximal fibular
fragment which becomes trapped behind the posterior tibial tubercle. The injury is caused by severe external
rotation of the ankle.[10]

Trimalleolar fracture - involving the lateral malleolus, medial malleolus and the distal posterior
aspect of the tibia

Bimalleolar fracture - involving the lateral malleolus and the medial malleolus.

Pott's fracture

Foot fracture

Lisfranc fracture - in which one or all of the metatarsals are displaced from the tarsus[11]

Jones fracture - a fracture of the proximal end of the fifth metatarsal

March fracture - a fracture of the distal third of one of the metatarsals occurring because of recurrent stress

Calcaneal fracture

OTA/AO classification[edit]
Main article: Mller AO Classification of fractures
The Orthopaedic Trauma Association Committee for Coding and Classification published its classification system[12] in 1996,
adopting a similar system to the 1987 AO Foundation system.[13] In 2007, they extended their system,[14] unifying the 2 systems
regarding wrist, hand, foot and ankle fractures.

Classifications named after people[edit]

Main category: Orthopedic classifications

"Denis classification" for spinal fractures[15]

"Frykman classification" for forearm fractures (fractures of radius and ulna)

"Gustilo open fracture classification"[16]

"Letournel and Judet Classification" for Acetabular fractures[17]

"Neer classification" for humerus fractures[18][19]

Seinsheimer classification, Evans-Jensen classification, Pipkin classification and Garden classification for hip
fractures

Treatment[edit]

X-ray showing the proximal portion of a fractured tibia with anintramedullary nail.

Proximal femur nail with locking and stabilisation screws for treatment of femur fractures of left thigh.

The surgical treatment ofmandibular angle fracture. Fixation of the bone fragments by the plates. The principles of osteosynthesis are
stability (immobility of the fragments that creates the conditions for bones coalescence) and functionality.

Treatment of bone fractures are broadly classified as surgical or conservative, the latter basically referring to any non-surgical
procedure, such as pain management, immobilization or other non-surgical stabilization. A similar classification
is open versus closed treatment, in which open treatment refers to any treatment in which the fracture site is surgically
opened, regardless of whether the fracture itself is anopen or closed fracture.

Pain management[edit]
In arm fractures in children, ibuprofen has been found to be as effective as a combination of acetaminophen and codeine.[20]

Immobilization[edit]
Since bone healing is a natural process which will most often occur, fracture treatment aims to ensure the best
possible function of the injured part after healing. Bone fractures are typically treated by restoring the fractured pieces of bone
to their natural positions (if necessary), and maintaining those positions while the bone heals. Often, aligning the bone,
called reduction, in good position and verifying the improved alignment with an X-ray is all that is needed. This process is
extremely painful without anesthesia, about as painful as breaking the bone itself. To this end, a fractured limb is usually
immobilized with a plaster or fiberglass cast or splint which holds the bones in position and immobilizes the joints above and
below the fracture. When the initial post-fracture edema or swelling goes down, the fracture may be placed in a removable
brace or orthosis. If being treated with surgery, surgical nails, screws, plates and wires are used to hold the fractured bone
together more directly. Alternatively, fractured bones may be treated by the Ilizarov method which is a form of external fixator.
Occasionally smaller bones, such as phalanges of the toes and fingers, may be treated without the cast, by buddy
wrapping them, which serves a similar function to making a cast. By allowing only limited movement, fixation helps preserve
anatomical alignment while enabling callus formation, towards the target of achieving union.
Splinting results in the same outcome as casting in children who have a distal radius fracture with little shifting.[21]

Surgery[edit]
Surgical methods of treating fractures have their own risks and benefits, but usually surgery is done only if conservative
treatment has failed, is very likely to fail, or likely to result in a poor functional outcome. With some fractures such as hip
fractures (usually caused by osteoporosis), surgery is offered routinely because non-operative treatment results in prolonged
immobilisation, which commonly results in complications including chest infections, pressure sores, deconditioning, deep vein
thrombosis (DVT) and pulmonary embolism, which are more dangerous than surgery. When a joint surface is damaged by
a fracture, surgery is also commonly recommended to make an accurate anatomical reduction and restore the smoothness of
the joint.
Infection is especially dangerous in bones, due to the recrudescent nature of bone infections. Bone tissue is
predominantly extracellular matrix, rather than living cells, and the few blood vessels needed to support this low metabolism
are only able to bring a limited number of immune cellsto an injury to fight infection. For this reason, open fractures
and osteotomies call for very careful antiseptic procedures and prophylacticantibiotics.
Occasionally bone grafting is used to treat a fracture.
Sometimes bones are reinforced with metal. These implants must be designed and installed with care. Stress
shielding occurs when plates or screws carry too large of a portion of the bone's load, causing atrophy. This problem is
reduced, but not eliminated, by the use of low-modulusmaterials, including titanium and its alloys. The heat generated by the
friction of installing hardware can easily accumulate and damage bone tissue, reducing the strength of the connections. If
dissimilar metals are installed in contact with one another (i.e., a titanium plate withcobalt-chromium alloy or stainless
steel screws), galvanic corrosion will result. The metal ions produced can damage the bone locally and may cause systemic
effects as well.
Electrical bone growth stimulation or osteostimulation has been attempted to speed or improve bone healing. Results
however do not support its effectiveness.[22]

Complications[edit]

An old fracture with nonunion of the fracture fragments.

Some fractures can lead to serious complications including a condition known as compartment syndrome. If not treated,
compartment syndrome can eventually require amputation of the affected limb. Other complications may include non-union,
where the fractured bone fails to heal or mal-union, where the fractured bone heals in a deformed manner.
Complications of fractures can be classified into three broad groups depending upon their time of occurrence. These are as
follows 1. Immediate complications - occurs at the time of the fracture.
2. Early complications - occurring in the initial few days after the fracture.
3. Late complications - occurring a long time after the fracture.

Immediate complications

Early complications

Late complications

Systemic

Hypovolaemic shock
ARDS - Adult respiratory distress
syndrome

Imperfect union of the

fracture

Fat embolism syndrome

Delayed union

Deep vein thrombosis

Non union

Pulmonary syndrome

Mal union

Aseptic traumatic fever

Cross union

Septicemia (in open fracture )

Crush syndrome

Systemic

Hypovolaemic shock

Others

Local

Injury to major vessels

Injury to muscles and
tendons

Injury to joints

Injury to viscera

Local

Infection

Compartment syndrome

Avascular necrosis

Shortening

Joint stiffness

Sudeck's dystrophy

Osteomyelitis

Ischaemic
contracture

Myositis ossificans

Osteoarthritis

PILOMATRIXOMA OF THE FOREARM: A CASE REPORT

INTRODUCTION
Pilomatrixoma, also known as pilomatricoma or calcifying epithelioma of Malherbe, is a benign neoplasm that
derives from hair follicle matrix cells. These lesions are typically found in the head and neck region, but also
occur in the upper extremities and are rarely reported in other sites. 1-7 The largest case series in the literature
includes 346 pilomatrixomas of which 15.3 percent were observed in the upper extremities. 8Despite the
frequency of presentation of this lesion in the upper extremities, discussion of this lesion is essentially limited to
the literature of otolaryngology, pathology, and dermatology.
We present a case of a forearm pilomatrixoma. Additionally, we discuss the clinical features and review the
literature regarding pilomatrixomas in the upper extremity.
Case Report

A 52-year-old woman presented with a 5 month history of insidious onset of an isolated right forearm mass,
located dorsally at the junction of middle and distal third of the forearm. The mass was painless, slowly
enlarging, and not associated with drainage. She denied any history of trauma, fever, chills, weight loss, fatigue,
numbness, or tingling.
Physical examination revealed a 1.0 by 1.0 cm, non-tender, firm mass over the radial aspect of the distal onethird of the right forearm. It was superficial and easily mobile. There was no tenderness noted in the region of the
first or second dorsal extensor tendon compartments. The neurovascular status of the right hand was noted to be
intact, and Tinel's sign over the mass was negative. There were no other palpable masses in the extremities, and
no epitrochlear or axillary adenopathy was present. Plain radiographs were unremarkable.
Excisional biopsy was performed under regional anesthesia. Grossly, the mass was white in appearance and well
circumscribed. Histopathology revealed a pilomatrixoma, and the histology is presented in figures 1 and and22.

Figure 1

Forearm pilomatrixoma involving deep dermis and subcutis (original magnification 40X). The tumor
is well-circumscribed with islands of basaloid cells (arrows) located both peripherally and centrally.
Most of the tumor, however, is composed of eosinophilic ...

Figure 2
Basaloid matrical germinative cells (far right and top center) blend into keratinized ghost cells
(original magnification 200X). Keratin debris elicits an inflammatory response including a mixture
of acute inflammatory cells (asterisks) and a foreign ...
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DISCUSSION
Pilomatrixoma, or calcifying epithelioma of Malherbe, is a benign skin neoplasm that arises from hair follicle
matrix cells. In 1880, Malherbe and Chenantais first described this lesion, referred to as the calcifying
epithelioma, though it was thought to derive from sebaceous glands. 9 The term pilomatrixoma was introduced in
a publication by Forbis and Helwig in 1961 to better convey the histological source. 10 These lesions are typically
found in the head and neck region, but they have also been described in various upper extremity locations. These
lesions present most commonly in children and young adults, and they are noted more commonly in females.
A rare malignant counterpart, pilomatrix carcinoma, has been described, and approximately 90 cases have been
reported in the literature. It is locally aggressive and can recur. In several cases, it has demonstrated metastases.
Many key features are similar between these benign and malignant counterparts; the primary differentiating
characteristics include a high mitotic rate with atypical mitoses, central necrosis, infiltration of the skin and soft
tissue, and invasion of blood and lymphatic vessels.11-12
In this patient's case, the definitive diagnosis was made only after histologic examination following excision of
the mass. Pilomatrixomas are often misdiagnosed on preoperative evaluation. In a series of 51 histologically
proven pilomatrixomas, Wells et al found that the referring diagnosis was incorrect in 94% of cases, and the
preoperative diagnosis was incorrect in 57 percent. 13 In a recent series of 346 pilomatrixomas, the preoperative
diagnosis was accurate and consistent with the pathological diagnosis of pilomatrixoma in only 28.9 percent of
cases.8 Finally, Kumaran et al. reported a correct preoperative clinical diagnosis in 46 percent following
retrospective review of 78 excised pilomatrixomas. 1 Incorrect preoperative diagnoses most commonly included
unidentified masses, as well as epidermoid cysts, sebaceous cysts, dermoid cysts, nonspecified cysts, and foreign
bodies.1,8
On presentation, as in this case, palpation of a superficial firm nodule that is not painful or tender is
characteristic; however, 32 percent in a series of 346 cases presented with pain and tenderness. 8 Most commonly,
the overlying skin is of normal color and texture; however, the examiner may observe the tent sign, consisting of
flattening of some portion or the entire surface of the tumor with angulation resembling the side of a tent, often
seen only by stretching the skin.14 This has been attributed to attachment of the tumor to the overlying epidermis,
and the associated bluish or reddish discoloration is due to the growth of blood vessels into the overlying
skin.6 Although pilomatrixomas are usually solitary, multiple lesions have been reported in association with
genetic disorders, such as myotonic dystrophy, Gardner syndrome, xeroderma pigmentosum, and basal cell nevus
syndrome.6,8-15
The histopathologic features of a pilomatrixoma include a well demarcated tumor which is often surrounded by a
connective tissue capsule. Generally, it is located in the dermal or subcutaneous layer. The tumor is composed of

islands of epithelial cells made up of varying amounts of uniform basaloid matrical cells and often shows cystic
change. Centrally, there is degeneration of these basaloid cells as the tumor matures. This is characterized by
formation of anucleated ghost (or shadow) cells due to the central unstained areas of these cells. 16 It is important
to note, however, that these ghost cells, though quite specific, are not unique to pilomatrixomas. There may be a
variably prominent inflammatory reaction.9 Foreign body giant cells, keratin debris, and central calcifications are
also characteristic. Calcification has been noted in 70 to 85 percent of cases. 7
Diagnostic imaging is generally not obtained in the evaluation of pilomatrixomas as they are usually superficial,
small, and well-circumscribed. Plain radiographs in this case were unremarkable, but pilomatrixomas may
demonstrate foci of calcification. Computed tomography (CT) demonstrates a sharply demarcated, subcutaneous
lesion of soft tissue density, with or without calcification. MRI may reveal a rim-enhancing lesion with small
areas of signal dropout which may be consistent with calcifications. 15Ultrasound demonstrates a well-defined
mass with inner echogenic foci and a peripheral hypoechoic rim or a completely echogenic mass with strong
posterior or acoustic shadowing in the subcutaneous layer.17
Wang et al. noted that 45 percent of cases of pilomatrixoma were incorrectly diagnosed by fine needle aspiration
cytology based on their review of multiple case reports and series. 16 Nevertheless, in their study as well as other
more recent studies, fine needle aspiration has been found to be quite accurate when two key components,
basaloid cells and ghost cells, are visualized, as this has been found to be specific for pilomatrixoma. 1
As performed in this case, management of pilomatrixomas typically involves marginal excision. Lesions on the
extremities may be left untreated unless they become large or symptomatic, however in many cases these are
excised for definitive diagnosis. If the tumor adheres to the dermis, the overlying skin may be excised. The
recurrence rate is low, ranging from 0 to 3 percent. 15 If a lesion recurs after excision or rapidly enlarges, it should
be excised due to malignant potential or possible misdiagnosis.
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REFERENCES
1. Kumaran N, Azmy A, Carachi R, Raine PA, Macfarlane JH, Howatson AG. Pilomatrixoma
accuracy of clinical diagnosis. J Pediatr Surg. 2006;41:17551758. [PubMed]
2. Marrogi AJ, Wick MR, Dehner LP. Pilomatrical neoplasms in children and young adults. Am J
Dermatopathol. 1992;14:8794. [PubMed]
3. Migirov L, Fridman E, Talmi YP. Pilomatrixoma of the retroauricular area and arm. J Pediatr
Surg.2002;37:E20. [PubMed]
4. Schweitzer WJ, Goldin HM, Bronson DM, Brody PE. Solitary hard nodule on the forearm.
Pilomatricoma. Arch Dermatol. 1989;125:828829. [PubMed]
5. Meyer RS, Sanchez AA, Bannykh G, Donthineni-Rao R, Botte MJ. Forearm mass in a 31-year-old
man.Clin Orthop. 2004;424:280286. [PubMed]
6. Wagner AM. A 12-year-old girl with an enlarging nontender nodule on the arm. Pediatr
Ann.2006;35:445447. [PubMed]