Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Fracture, Tibia or Fibula


Related Terms

  • Broken Leg
  • Leg Fracture

Differential Diagnosis

Specialists

  • Emergency Medicine Physician
  • Orthopedic (Orthopaedic) Surgeon
  • Physical Therapist
  • Vascular Surgeon

Factors Influencing Duration

The severity of the fracture (i.e., open or closed, simple or comminuted, stable or displaced) and the treatment required (i.e., closed reduction and a cast versus surgery and internal/external fixation) will affect disability. The age of the individual and any comorbid conditions and/or complications may also affect disability. Individuals with uncomplicated fractures who are employed in sedentary jobs may return to work after about a week, but individuals with complicated fractures employed in jobs requiring physical labor or mobility may need 3 to 6 months for complete healing.

Medical Codes

ICD-9-CM:
823.00 - Closed Fracture of Upper End of Tibia Alone
823.01 - Closed Fracture of Upper End of Fibula Alone
823.02 - Closed Fracture of Upper End of Fibula with Tibia
823.10 - Open Fracture of Upper End of Tibia Alone
823.11 - Open Fracture of Upper End of Fibula Alone
823.12 - Open Fracture of Upper End of Fibula with Tibia
823.20 - Closed Fracture of Shaft of Tibia Alone
823.21 - Closed Fracture of Shaft of Fibula Alone
823.22 - Closed Fracture of Shaft of Fibula with Tibia
823.30 - Open Fracture of Shaft of Tibia Alone
823.31 - Open Fracture of Shaft of Fibula Alone
823.32 - Open Fracture of Shaft of Fibula with Tibia
823.80 - Closed Fracture of Tibia Alone, Unspecified Part
823.81 - Closed Fracture of Fibula Alone, Unspecified Part
823.82 - Closed Fracture of Fibula with Tibia, Unspecified Part
823.90 - Open Fracture of Tibia Alone, Unspecified Part
823.91 - Open Fracture of Fibula Alone, Unspecified Part
823.92 - Open Fracture of Fibula with Tibia, Unspecified Part

Overview

© Reed Group
A fracture of the tibia or fibula is a fracture of one of the two bones of the lower leg. This fracture can occur anywhere between the knee and ankle. The tibia is the most commonly fractured long bone. Only the tibia bears weight, but fracture of the tibia is often associated with fracture of the fibula because force is transmitted via the interosseous membrane that connects the two bones. Isolated fracture of the proximal or mid-shaft portions of the fibula is uncommon.

If the fracture is caused by a direct blow, the bone may fracture in several places (a comminuted or segmental fracture), and a break in the skin (open fracture) is more likely. A spiral fracture is most common in toddlers (ages 1 to 3 years) and is usually caused by a twisting force from a fall or from abuse. Fractures can also result from low-energy trauma such as stress fractures or from repetitive impact as in jogging. Fractures from low-energy trauma are often stable and minimally displaced. A high-energy injury (direct blow, gunshot wound, motor vehicle accident) is more likely to cause trauma to the surrounding soft tissues (muscle, ligaments, blood vessels, and nerves).

Incidence and Prevalence: The tibia is the most frequently fractured of the long bones (Norvell) and is the bone most commonly fractured in motor vehicle accidents. The highest incidence of tibial fractures in adults is among males aged 15 to 19 years (Poduval). Tibial fractures are a common lower extremity stress fracture, representing approximately one-half of all stress fractures in children and adults. Stress fractures of the tibia are especially common in sports involving running and jumping. Approximately 10% of stress fractures in adults occur in the fibula (Sanderlin).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Individuals at risk of tibia and/or fibula fractures are those who work at heights or participate in high-risk sports. Participants in repetitive impact sports, such as jogging, are at higher risk of stress fractures than the general population. Individuals afflicted with thinning of the bone (osteoporosis) are also at a higher risk of tibia and/or fibula fractures.

Source: Medical Disability Advisor



Diagnosis

History: A complete medical history is obtained, including prior fractures or orthopedic surgery, medical conditions (especially any underlying bone disease, neoplasia, arthritis), medications taken, allergies, and occupation. A description of the mechanism of injury, including the magnitude, location and direction of impact, is helpful. The individual may report recent trauma, such as a motor vehicle accident, a sports injury, or a severe fall. The individual may also report severe pain, inability to bear weight on the leg, and changes in sensation. Walking may be possible if only the fibula is fractured.

In the case of stress fractures, the individual may report recent changes in physical activity level, athletic training intensity, or training surfaces. Pain may worsen with weight-bearing activity and decrease with rest.

Physical exam: The exam may reveal swelling (edema), bruising (ecchymosis), and tenderness at the fracture site. There may be swelling and decreased range of motion at the knee or ankle, depending on the location of the fracture. If the fracture is displaced, a deformity may be noted. A break in the skin occurs with open fractures. A careful and thorough examination of the nerves, blood vessels, and muscles of the leg is important.

Tests: Plain x-rays will usually establish the diagnosis of a tibia and/or fibula fracture. X-rays of the knee or ankle may also be needed, depending on the location of the fracture. CT scan and MRI are rarely needed, unless the fracture extends into the knee joint. Because plain film radiographs usually do not show stress fractures until 2 to 8 weeks after the fracture has occurred, a bone scan is sometimes used to detect a stress fracture in the earliest stages. A triple phase nuclear medicine bone scan is often used to confirm the diagnosis. An arteriogram may be done if a problem with blood circulation (vascular compromise) is suspected. A complete blood count (CBC), blood typing, coagulation profiles, and electrocardiogram (ECG) are part of routine preparation for surgery. The necessity of other laboratory studies depends on the extent of injury and comorbid conditions.

Source: Medical Disability Advisor



Treatment

Many treatments are available, depending on the location and severity of the fracture(s). For uncomplicated fractures, closed reduction and a cast may be the only treatment required.

Compound or displaced fractures may require pins placed externally (external fixation devices), or surgery for open reduction, internal fixation (ORIF) with pins, plates, screws, or intramedullary rods placed longitudinally within the shaft of the bone. The treatment of open fractures begins with thorough irrigation under pressure, followed by surgical removal of dead tissue (open débridement). Surgical incisions may be closed with sutures. Other wounds may be left open for 48 hours and then closed with sutures, and drains left in place, or the wound may be left open to heal on its own. Bone grafting may be done early or late in the course of treatment. Medications include analgesics for pain and antibiotics and a tetanus shot (tetanus prophylaxis) for open fractures.

Source: Medical Disability Advisor



Prognosis

In general, the probability of complete healing of an uncomplicated tibial or fibular fracture is good. However, the outcome depends on the location, severity of the fracture, and extent of soft tissue injury, along with the presence of any complications. The tibia is the most common fracture to remain unhealed (nonunion) (Norvell). Prognosis is good for isolated fibula fractures.

Source: Medical Disability Advisor



Rehabilitation

The rehabilitation will be determined by the severity, location and type of fracture, how the fracture is stabilized (operative, nonoperative) and the length of immobilization. Simple midshaft tibial stress fractures may be immobilized with an orthotic boot (Dugan) or pneumatic brace during rehabilitation (Rome).

The goal of rehabilitation is to decrease pain and restore full function to the lower limb. Modalities such as heat and cold can be used to control pain and edema (Braddom). Rehabilitation emphasizes restoring full range of motion, strength, proprioception, and endurance of all adjacent joints while maintaining independence in all activities of daily living, if not contraindicated by the stability of the fracture. Gait training using appropriate assistive devices is indicated to promote independent ambulation. The individual may progress from walker to crutches to cane based on ability and weight bearing status. If casted, range of motion exercises of the adjacent joints may be beneficial unless contraindicated based on fracture stability. After cast removal, range of motion, proprioceptive activities, and strengthening exercises of the involved limb should be started (Bucholz). Exercise intensity and difficulty should be progressed until full function is achieved, and the individual should be instructed in a home exercise program to be performed independently.

If operatively managed, the protocol of rehabilitation will be guided by the treating physician.

Bone healing may occur within 6 to 16 weeks; however, return of full bone strength and the ability of the bone to sustain a heavy load may take up to a year (Chapman). Once healing has occurred, the individual may resume activities of daily living. It is important to instruct the individual not to overload the fracture site until the bone has regained its full strength. The resumption of heavy work and sports should be guided by the treating physician.

FREQUENCY OF REHABILITATION VISITS
Nonsurgical
SpecialistFracture, Tibia or Fibula
Physical TherapistUp to 20 visits within 8 weeks
Surgical
SpecialistFracture, Tibia or Fibula
Physical TherapistUp to 16 visits within 8 weeks
Note on Nonsurgical Guidelines: Rehabilitation may not begin until tissue healing, about 6 to 8 weeks after the fracture.
The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Source: Medical Disability Advisor



Complications

Possible complications include delayed union or nonunion, misalignment of the bone fragments (malunion), and leg shortening in the case of a seriously comminuted fracture. Skin loss due to the thinness of the skin over the tibia, infection in the bone (osteomyelitis), joint stiffness, or loss of knee motion are other complications. If the fracture involves the knee or ankle joint, traumatic arthritis may occur. Other complications include compartment syndrome; injury to the common or deep peroneal nerves, which may cause foot drop (typically with fibular fractures); and injury to the popliteal artery (especially with upper tibial fractures). Complex regional pain syndrome and fat embolism may also occur. Amputation may be necessary if there is massive damage to or infection of soft tissues in the leg.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Prolonged standing and walking will be temporarily limited. The individual will not be able to engage in physical activity that requires leg strength and exertion, such as lifting or heavy construction. The individual may be unable to drive a motor vehicle or operate heavy machinery until adequate lower extremity muscle control is regained. Accommodations should be made at the work site to allow periodic elevation of the injured leg. Prescribed medications may include painkillers (analgesics) with sedating qualities that can affect dexterity, alertness, and cognitive function. Work requirements and drug policies may have to be reviewed to accommodate this use.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Did individual present with symptoms consistent with a fracture of the tibia or fibula?
  • Was the fracture confirmed on x-ray?
  • Was CT scan or MRI done to assess fractures extending into the knee joint?
  • If a stress fracture was suspected, had enough time elapsed for the x-ray to show the fracture (2-8 weeks)?
  • Was a bone scan necessary to rule out a stress fracture?
  • If the diagnosis was uncertain, were other conditions with similar symptoms ruled out?

Regarding treatment:

  • Was the treatment appropriate for the type of fracture?
  • Was individual's pain adequately controlled?
  • If not, were alternative interventions tried, such as TENS, relaxation, visualization, or adjustments to analgesic dose?
  • Was surgery required? In cases of open fractures, was surgery initiated within 12 hours of injury? Did the fracture require extensive internal or external fixation?
  • Did individual participate in and comply with physical therapy as recommended?
  • Did individual return to activity too early?
  • Would the individual benefit from consultation with a specialist (orthopedic surgeon, vascular surgeon, or physiatrist)?

Regarding prognosis:

  • Does individual have any conditions that may affect ability to recover?
  • Did individual experience any complications that may influence length of disability?

Source: Medical Disability Advisor



References

Cited

Braddom, Randolph L. Physical Medicine and Rehabilitation. 3rd ed. Philadelphia: W.B. Saunders, 2006.

Bucholz, Robert, and James D. Heckman. Rockwood and Green's Fractures in Adults. 6th ed. Philadelphia: Lippincott, Williams & Wilkins, 2005.

Chapman, Michael W. Chapman's Orthopaedic Surgery. 3rd ed. Philadelphia: Lippincott, Williams & Wilkins, 2001.

Dugan, Sheila. "Chapter 70 - Stress Fractures." Essentials of Physical Medicine and Rehabilitation. Eds. Walter R. Frontera, Julie K. Silver, and Thomas Rizzo. 2nd ed. Philadelphia: Saunders, Elsevier, 2008.

Norvell, Jeffrey G., and Mark Steele. "Fracture, Tibia and Fibula." eMedicine. Eds. Michelle Ervin, et al. 11 Mar. 2008. Medscape. 18 Mar. 2009 <http://emedicine.medscape.com/article/826304-overview.>.

Poduval, Murali, and Kale Satischandra. "Diaphyseal Tibial Fractures." eMedicine. Eds. Pillip J. Marone, et al. 7 Apr. 2008. Medscape. 18 Mar. 2009 <http://emedicine.medscape.com/article/1248857-overview>.

Rome, K., H. Handoll, and R. Ashford, eds. "Interventions for preventing and treating stress fractures and stress reactions of bone of the lower limbs in young adults." Cochrane Database of Systematic Reviews. 4th ed. John. Wiley & Sons, 1999.

Sanderlin, B. W., and R. F. Raspa. "Common Stress Fractures." American Family Physician 68 8 (2003): 1527-1532. MD Consult. 15 Oct. 2003. Elsevier, Inc. 9 Jan. 2009 <http://home.mdconsult.com/das/journal/view/42041380-2/N/14136601?sid=311685796&source=MI>.

General

Konowalchuk, Brian, et al. "Tibial Shaft Fractures." eMedicine. Eds. Charles T. Mehlman, et al. 22 Feb. 2005. Medscape. 18 Mar. 2009 <http://emedicine.medscape.com/article/1249984-overview>.

Source: Medical Disability Advisor






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