The soft-tissue envelope is the most important component in the evaluation and subsequent care of tibia fractures. One third of the tibia has no muscle cover and lies directly beneath the skin. Therefore, most open and closed tibia fractures are associated with an injury to the skin and subcutaneous tissues. The extent and location of swelling and bruising should be assessed first. Fracture blisters are a sign of massive soft-tissue swelling with pressure on the skin from inside and should be a warning to delay any intervention. Next, the skin must be assessed for intra-dermal swelling. When this occurs, the normal skin lines are lost and the skin appears shiny and smooth. Especially in distal tibia fractures, early surgery may not be safe. In case of massive swelling, intramedullary nailing must be delayed until the skin starts to wrinkle again. While waiting for the condition of the soft tissues to improve, the limb should be stabilized by splinting, traction, or preferably by temporary external fixation. Compartment syndrome occurs more often with tibia fractures than with other long-bone fractures [20]. Causes can be swelling, bleeding, ischemia, or rebound edema following restoration of vascularity (reperfusion injury). The anterior compartment is most commonly involved [21]. Any of the signs of compartment syndrome, including severe pain, pain with passive stretch, and localized loss of sensation require immediate action, either measurement of compartment pressure or operative release by fasciotomy. This release must be combined with appropriate fracture fixation.

The pulses must be assessed. A missing pulse in an otherwise healthy leg must raise suspicion of vascular damage, especially in a displaced fracture which involves the proximal tibia. In tibia fractures, nerve injuries are less common than arterial injuries, but neurological status of the limb must still be accurately assessed.

Radiographic imaging of the tibia is usually confined to standard anteroposterior and lateral images, which should include the knee and ankle joints.

Additional imaging is rarely required in fresh fractures and yet the imaging must be carried out in a proper way since standard radiographic methods used to image the tibia during intramedullary nail insertion may be subject to error [22]. Firstly, identifying the correct anteroposterior radiographic view of the proximal tibia by using simple limb rotation may be difficult for mechanically unstable and comminuted tibia fractures. Secondly, “parallax error” may cause incorrect apparent displacement or location of an object (such as a predetermined entry point) because of the difference in perspective between two radiographic points of view. Thirdly, “magnification error” can cause misleading assumptions regarding the actual size and distance between objects in the radiograph because of joint positioning problems and joint contracture (Fig. 22.2a, b). These effects can be minimized by proper, fixed positioning of the patient during radiographic preoperative assessment. This approach can help in reducing the stated difficulties, providing more accurate determination of the nail insertion point and angle and, thus, minimize limb malalignment and malunions [23].

The entry point for nail introduction should be monitored by an image intensifier in both planes before commencing the procedure. The particular location of the insertion point is a determining factor in postoperative tibia malalignment and malunion of proximal or segmental tibia fracture fixation cases. Eccentric nail insertion will result in a valgus or varus tilt of the proximal fragment.

The proximal nail entry point is not in line with the medullary canal in the sagittal plane, and so its exact position varies depending on the design and stiffness of the nail. The benefits of each type of nail should be considered carefully. In the coronal plane, the entry point must remain extraarticular and be centered over the medullary canal, if there is a short proximal fragment.

There is, however, contradictory evidence in the literature for what concerns the location of the ideal entry portal. Samuelson et al. [24] introduced nails to cadaveric bones in a retrograde fashion through the center of the tibial plafond towards proximally and identified the exit point of the nail at the tibia plateau, being the exact entry point to the canal center. They found that the optimal insertion point is approximately 8 mm medial from the anterior intercondylar tubercle, cautioning against the use of any kind of lateral insertion. To the contrary, both Lang et al. [2] and Freedman and Johnson [25] implicated their valgus malalignment results to medial nail entry points. Lembcke et al. [26] cautioned against eccentric approaches, noting that medial and lateral insertion points can cause valgus and varus deformities, respectively.

Carr et al. [27] measured the mechanical strains in the proximal tibial fracture fragment during intramedullary nail insertion. They compared the bursting strains generated by using the nail insertion site, recommended by the manufacturers of several types of commercially available nails with the strains generated by using the most proximal insertion site, just anterior to the tibia plateau in the midline. They found that the strain in the lateral cortex was significantly increased for the Lottes nail when using a distal starting point. Similarly, increases in anteromedial surface strains were noted for the Russell-Taylor nail when using a distal starting point. However, changes in nail insertion location had no effect when using the Grosse-Kempf nail. It follows that the geometry and mechanical rigidity of the nail is highly relevant for the choice of the optimal insertion site.

When operative stabilization of tibia shaft fractures in skeletally mature patients is indicated, intramedullary nailing through an infrapatellar entry portal is the standard of care. The entry point can be reached by retracting the patella tendon or splitting it. The approach used depends on the surgeons experience and preference [24, 28].

Intramedullary nailing of more proximal tibia fractures or extremely comminuted/segmental tibia fractures can be very challenging because of the need to perform the procedure with the knee flexed. To overcome this challenge, intramedullary nailing with the knee in a semiextended position has been proposed [29]. Proponents of the semiextended technique suggest that valgus and procurvatum malalignment have been more easily avoided when the knee is maintained in extension. In addition, by maintaining the knee in extension throughout the entirety of the case, anteroposterior and lateral imaging of the tibia is facilitated. Tornetta described a proximal medial arthrotomy to allow lateral subluxation of the patella [30], whereas Cole [21] described a suprapatellar approach using a midline quadriceps tendon insertion site to perform intramedullary nailing (Fig. 22.3a–d). The primary concern with this technique has been the potential for damage to the articular surface of the patellofemoral joint. If the patella and femoral trochlea are properly protected using a cannulated trocard, however, the articular surfaces should be protected from scuffing and subjected only to compressive pressures [29]. In proximal quarter fractures, a lateral parapatellar incision helps ensure a proper entry point and prevents fracture displacement during nail insertion [29].

Intramedullary nails are tubular, solid, or cannulated. Reamed and non-reamed nails are, in essence, similar implants which splint the bone from within; the difference lies in the technique of insertion. Intramedullary nails inserted with reaming are tubular and tend to be used with a large diameter. They have a long, proven record of success and are to be favored for closed fractures and nonunions. Intramedullary nails inserted without reaming are solid or cannulated and smaller in diameter (8–10 mm). They were originally introduced as a temporary and minimally invasive splint for open fractures, but proved to be useful for definitive fixation and became popular even for the treatment of closed fractures [31, 32].

The extent of reaming should be adjusted to ensure that the intramedullary nail will pass the isthmus easily and permit the insertion of a large enough nail to provide stability. In most cases, this means a nail with a diameter of 11–12 mm in acute fractures. In delayed unions or nonunions, even larger nails may be required for better stability [4].

Both nonunion [43, 44] and infection at the implant-bone interface [45, 46] may necessitate a second operation to promote fracture healing. Because of the risks and costs to the patient, and the costs to the health care system, reoperation represents an important adverse event from both individual and societal points of view. A meta-analysis of randomized controlled trials [47] suggested that reamed intramedullary nailing of distal femur and tibia fractures results in significantly fewer nonunions than non-reamed nailing (Fig. 22.6a–g). Evaluation of fracture subgroups further suggested a large treatment effect favoring reamed nails in femur fractures, but a less persuasive effect in tibia fractures.

Because the biology of open tibia fractures is different from that of closed fractures, the relative impact of reamed and non-reamed nailing may differ in these sub-populations. The significant soft tissue damage and stripping of the periosteum from the cortical bone, which is common in open fractures, has the potential to compromise blood supply to that region [48]; therefore, the preservation of endosteal, or intramedullary, blood supply may be more important. Opponents of reamed nailing believe that the disruption of endosteal blood supply, as a result of intramedullary reaming, increases the risk of nonunion for the open fracture. To clarify this issue, a second meta-analysis was conducted examining evidence regarding the treatment of open tibia fractures [49]. Two small randomized controlled trials that compared reamed and non-reamed nailing procedures were identified. There was a trend in favor of reamed nails in the risk of re-operation in comparison to non-reamed nails (Fig. 22.7a–e). The trends in favor of reamed nails in open tibia fractures are consistent with other findings [10].

Despite the results of these two meta-analyses, uncertainty about the optimal treatment for tibia fractures remains. Reasons for this uncertainty ensue:

A survey of a 20 % random sample of members of the Canadian Orthopaedic Association was conducted [50]. Of the 60 respondents who treat tibia fractures, 35 (58 %) indicated that they thought reamed nails were superior and 25 indicated (42 %) that they thought non-reamed nails were the same or better than reamed nails. For open tibia fractures: 31 (52 %) believed non-reamed nails were superior whereas 29 (48 %) believed reamed nails were the same or better. The results demonstrate a lack of predominant nail preference for both open and closed fractures. These findings were supported in a large international survey of surgeons [51]. Only a large randomized controlled trial would resolve the remaining, legitimate, scientific uncertainty, and the continuing controversy in the clinical community.