Abstract
In the adult population, tibial shaft fractures make up a significant portion of both closed and open long bone fractures. These injuries are often associated with high-energy trauma and have considerable financial impact on healthcare resources. Hence, it is crucial that these injuries are appropriately managed to provide optimal patient outcomes. The OTA/AO classification is frequently used to describe these fractures and are used in conjunction with the Gustilo–Anderson classification when open fractures are present. Along with conventional radiographs, modern imaging techniques such as computed tomography should be considered given their associations with intra-articular fractures. Primary treatment strategies aim to minimize further insult to soft tissues surrounding the fracture, prevent and/or recognize compartment syndrome, re-establish limb alignment and allow for early mobilization. Closed fractures may be treated conservatively or surgically, while open fractures require surgical intervention, sometimes in multiple stages. Postoperative care, including rehabilitation and weight-bearing guidelines, depends on injury severity and fracture type. Although scoring systems for fracture healing exist, specific validated functional outcome measures for tibial fractures are lacking. This review is aims to re-visit basic concepts and provide updates in the management of tibial shaft fractures.
Introduction
Tibial shaft fractures are one of the most common long bone fractures in adults. These fractures can be described as a break in the tibia that occurs along the bone between the knee and ankle joint. They can be further subdivided into closed with the skin and soft tissues intact, or open with direct communication between the fractured bone and the external environment. A recent paper published noted that the incidence of tibial shaft fractures at a level I trauma centre was 12.08 per 100,000 patients per year with the highest incidence of open fractures at 42.1%. Furthermore, the average age of patients with this injury was 39.61 with a male to female ratio of 2.125. Reflecting the demographics above, these fractures are mostly caused by high energy trauma including vehicle collisions (commonest cause), sports injuries and falls from height. Given the high incidence, there is a considerable financial impact on healthcare resources. Current literature reported that the average length of admission was 15.12 days with an estimated average cost of £8279 when surgery (intra-medullary nail) was indicated. These costs were increased to £14,756 when post-surgical infections occurred with an increased length of stay, rate of re-admissions and re-operation.
The paper is aimed at the trainees preparing for final professional exams by re-visiting basic concepts, provide an update in practices for the treatment of tibial shaft fractures.
Classification
The OTA/AO classification is most widely used to describe tibial shaft fractures as it is a comprehensive descriptive tool which is also able to grade the severity of injury and provide a correlation with scores of impairment, functional performance and self-reported health status. This classification consists of five parts which includes the bone involved, segment of bone where the fracture was present (proximal, midshaft, or distal), type of fracture (simple, wedge or comminuted), fracture pattern (spiral, oblique, transverse), and certain features unique to each bone.
However, as this classification does not take soft tissue injury into account, it is often used in conjunction with the Gustilo–Anderson classification to grade severity of open fractures intra-operatively:
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Type I: Wound laceration less than 1 cm which is clean
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Type II: Wound laceration more than 1 cm without extensive soft tissue damage, flaps or avulsions
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Type IIIA: Adequate soft tissue coverage of fractured bone despite extensive soft tissue laceration or flaps, or high-energy trauma regardless of size of wound
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Type IIIB: Extensive soft tissue injury with stripping of bone periosteum and exposed bone
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Type IIIC: Significant soft tissue injury with arterial injury present requiring repair.
The Tscherne classification for closed fractures is also useful to help categorize skin lesions and help in preoperative planning as the condition of soft tissues is vital in deciding surgical timing and outcome: ,
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Grade C0: Low energy with limited soft tissue damage
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Grade C1: Mild to moderate energy with superficial soft tissue abrasion or contusion
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Grade C2: High energy with deep abrasions; impending compartment syndrome
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Grade C3: High energy with extensive soft tissue contusion; myonecrosis; degloving; vascular injury; compartment syndrome.
Another notable classification previously noted in the literature was the Ellis classification which took both morphology and soft tissues into consideration, and graded tibial fractures into mild, moderate and severe.
Diagnostics
Once the appropriate clinical evaluation of the fracture has been conducted, the relevant radiological imaging is required to aid the diagnosis. Conventional radiographs (including anterior-posterior and lateral planes) of the whole of the tibia and fibula, along with both the knee and ankle joints should be taken. This allows for proper evaluation of the fracture configuration such as degree of angulation, displacement and any further extension of the fracture/isolated fracture in the ankle joint.
Furthermore, specific fracture configurations are at risk of having associated intra-articular extensions. Spiral tibial fracture subtypes of the AO/OTA classification were significantly associated with a posterior malleolar fracture, and non-spiral and distal tibial shaft fractures were associated with intra-articular fractures. Hence, a low threshold for preoperative computed tomography (CT) is often recommended to help identify this, as almost of a third of intra-articular extensions are un-displaced and missed on plain radiographs.
Therapies/treatment options
The main goals of treatment are to minimize and prevent further insult to the soft tissues and skin surrounding the fracture, prevent and/or recognize compartment syndrome, restore limb alignment, early weight-bearing and early mobilization. The management of these fractures can be broadly categorized into either ‘open’ or ‘closed’ ( Figure 1 ). Other approaches to management subdivide these fractures depending on the level of energy transmitted through the fracture or the displacement of the fracture.

Closed fractures can be managed conservatively with a cast and functional bracing, or with surgery which may involve an intramedullary nail, plate fixation or external fixator. Open fractures are an absolute indication for surgery, which can involve single or multiple stages (see below). Other absolute indications for surgery include compartment syndrome or neurovascular injury. Relative indications for surgery include failure of conservative management, high-energy injuries with comminution, segmental fractures, multiple fractures in the same limb or polytrauma patients where stabilization of limbs is a life-saving measure.
Conservative management
Minimally displaced and closed tibial shaft fractures can be managed in a long leg cast. This is applied from the upper thigh to metatarsal neck with 10–20° of flexion in the knee and the neutral position of the ankle. After reduction and application of cast, plain radiographs are required. To prevent malunion, the reduced fracture should have less than 5° of varus–valgus angulation, less than 10° of anterior–posterior angulation, more than 50% cortical apposition, less than 1 cm of shortening and less than 10–20° of flexion and less than 10° of rotational malalignment.
The process of wedging can also be utilized post-application of leg cast by making a transverse cut in the plaster for correction of minor degrees of angulation.
Repeat plain radiographs are taken at 2 weeks to check position. Changing to a below knee cast or Sarmiento (patella tendon bearing cast) can be considered around 4–6 weeks post-injury or when signs of bony union are identified.
Surgical management
External fixation: external fixators help stabilize and support tibial shaft fractures through the placement of 5 mm or 6 mm (in diameter) pins or transfixion wires perpendicularly into the tibia and attaching them to a rigid rods or frames outside the body.
This modality of fixation is may be considered in the closed and isolated tibial shaft fractures but are associated with increased risks of pin track, deep infection/osteomyelitis and malunion. Furthermore, this fixation device can only control cyclical movement at the fracture site by dynamization. This infers inferior bone healing compared to other surgical modalities and has been supported by other studies.
On the other hand, external fixators have been shown to be the treatment of choice particularly when significant soft tissue compromise is present or in the polytrauma patient where damage control orthopaedics is needed. These devices can be applied in a short time frame with minimal physiological insult and can provide fracture stability and alignment. This surgical option also means there are no metal implants across the fracture site with less vascular damage to a tibia that may already be compromised. More often than not, external fixators are used as a temporizing measure prior to definitive fixation with a plate or intramedullary nail.
External fixators fall can be subdivided into three broad categories, each with their own unique mechanical properties that affect the stability of the fracture and bone healing.
Unilateral/uniplanar fixators have asymmetrical mechanical properties with resistance to flexion in the plane of the screws but relatively flexible when stressed perpendicular to that plane. This leads to cantilever bending at the fracture leading to high shear and torque. Because of this, patients are not allowed to immediately weight-bear. They are useful for temporary fixation in the diaphyseal region. Common pitfalls often lead to insufficient rigidity of the construct which include pins that are placed far from the fracture, non-optimally sized pins selected, using a single rod (unstacked) device or placing the bars too far from the skin. Some fixators also incorporate a telescoping piston in the body of the fixator to enable the load-sharing construct which promotes micromotion at the fracture site, also known as dynamization, to promote bone healing.
Mulitplanar fixators on the other hand have improved axial and sagittal stability. Perpendicular linkage between the rods helps to control each plane of deformation which consequently leads to reduced shear and torque at the fracture site. However, dynamization and control micromotion cannot be reliably achieved because multiple connecting rods are seldom completely parallel to each other or the tibial shaft.
Circular frames have been increasingly used in limb reconstruction and non-union surgery. As a result of this, they have been increasingly used as the definitive modality of fixation for tibial shaft fractures particularly in high energy open tibia fractures with bone loss and/or soft tissue loss. Transosseous wires are tensioned onto interconnected rings which help to secure and align bone fragments. This allows for controlled compression, along with decreased shear and increased micromotion. The stiffness of the frame can be altered by repositioning or removing connecting rods, hence allowing for increased load transfer onto the bone as the fracture heals. Despite the benefits and potential role in treating tibial shaft fractures, these devices remain a tool for subspecialist limb reconstruction trauma surgeons and are unlikely to gain widespread use.
Intramedullary nailing: for closed unstable fractures or where contraindications are present for conservative management, intramedullary nailing is the treatment of choice. This involves performing a closed reduction of the fracture under intra-operative radiographic guidance. The proximal end of the tibia is then exposed and a guidewire passed through the fracture site. An appropriately sized nail is then selected and placed. Following this, transverse locking screws are placed proximally and distally. The benefits of intramedullary stabilization of tibial fractures are an insertion point that is distant from the traumatized soft tissues around the fracture site, a mechanical advantage of being positioned in the centre of axis when loadbearing and the lack of a requirement for precise reduction of individual fracture fragments.
With regards to exposure of the proximal tibia to identify the entry point of the intramedullary nail, either a supra-patella or infra-patella approach can be utilized. A recent meta-analysis involving 1196 patients reported that a supra-patella approach had significantly better patient-reported outcome measures (PROMs), increased accuracy in reduction by degrees of angulation at the fracture site and decreased intraoperative time. However, it was noted that most of the studies analysed were level-III studies and hence diminish the certainty of the conclusions made. Furthermore, there had been some discussion that a transverse rather than longitudinal incision when performing the supra-patella approach could reduce the risk of infra-patella nerve injury. This was proven significant in a randomized control trial with 136 patients, but no significant difference was noted in anterior knee pain and functional outcomes.
The decision to ream the intramedullary canal prior to nail placement has also been a topic of debate. Previous literature had suggested that there was benefit in performing reamed intramedullary nailing as it reduced rates of non-union and implant failure. In addition to this, a previous Cochrane review had reported ‘moderate’ quality evidence to suggest there was no significant difference in the rate of re-operations but reported a lower incidence of implant failure when reaming was conducted. However, a more recent systematic review published noted that non-union rates with and without reaming were statistically insignificant in 87.5% of studies but more than 78% of these findings were statistically fragile.
Plate fixation: another method of internal fixation is the application of a plate and screws construct. This approach is often indicated in metaphyseal fractures. These fractures are distal tibial or proximal third fractures where an intramedullary nail would be unable to cross the fracture site and have adequate locking both proximally and distally. Plate fixation may also be considered in the paediatric population as passing an intramedullary nail through a growing physis may lead to premature growth arrest.
This approach was previously avoided due to the risk of exposing the fracture site, leading to significant soft tissue and periosteal damage which was associated with increased infection and delayed bony union. Furthermore, biomechanical studies have shown that a locked medial plate system used for tibial shaft fractures had significantly lower interfragmentary movement under torsional loading conditions compared to intramedullary nails. However, given that intramedullary nails have significant rate of malalignment (5–58%) when managing distal and proximal tibial shaft fractures, the advancement of plating with minimally invasive percutaneous plate osteosynthesis (MIPPO) may have an added advantage in these fracture configurations.
MIPPO plates are placed along the anterolateral aspect of the fracture site via proximal and distal ‘access incisions’. The plate is then fixed to the bone only at the levels of these incisions. The placement of the plate in the submuscular plane helps to reduce injury to the surrounding soft tissues around the fracture site compared to conventional plating systems. This technique also allows for a more favourable biomechanical environment for fracture healing. These advancements have meant that plating devices are now considered as a viable option and alternative for closed tibial shaft fixation. A recent study showed there was no statistical significance in terms of complications between MIPPO and intramedullary nailing but have suggested that this could be due to the small samples sizes.
Management of open tibial shaft fractures
Patients with open tibial shaft fractures are often associated with high energy mechanisms and hence are associated with significant life-threatening injuries. It is important that these patients are assessed and resuscitated as per the Advanced Trauma Life Support protocol, prioritizing life before limb. This includes checking for catastrophic haemorrhage along with C-spine immobilization and assessing the status of the patient’s airway, breathing, circulation, disability and exposure. The appropriate resuscitative interventions must be taken at each step when indicated. Any external haemorrhage requires immediate control either by applying direct pressure or, as a final resort, applying a tourniquet with a clear documentation of exact time this was applied. Once haemodynamic stability is achieved in these patients, the open fractures should be addressed urgently as per the British Orthopaedic Association Standard for Trauma and Orthopaedics (BOAST) for open fracture guidelines (BOAST 4). Patients for whom an initial trauma CT is indicated should have the inclusion of the affected limb as well as angiography. It is important to identify any neurovascular injury early by performing a thorough peripheral nerve and vascular examination of the affected limb. Furthermore, it would be prudent to maintain a degree of suspicion towards compartment syndrome as this can be easily missed the acute setting. Gross contaminants should be removed but further washout in the emergency department is contraindicated due to concerns of pushing contaminants deeper into open wounds. Other aspects of open fracture management include clinical photography of the open wound, sealing the wound with a saline soaked gauze along with an adhesive film dressing, along with aligning and splinting of the fracture. Repeat orthogonal plain radiographs should be taken including both the joints above and below the fracture site. In terms of prescriptions, the patient should have adequate analgesia as per the World Health Organization pain ladder, antibiotics as per local microbiology protocols or broad-spectrum antibiotics, and tetanus prophylaxis. It can be assumed that all open fractures are tetanus-prone and hence should have prophylaxis prescribed as follows:
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Patients with unknown immunity or no previous immunization:
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Dose of the tetanus vaccine along with a dose of tetanus immunoglobulin at a different site is required.
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Patients with incomplete immunization:
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Reinforcing dose of the tetanus vaccine along with a dose of tetanus immunoglobulin at a different site is required.
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Patients with complete immunization (previously completed five doses of tetanus vaccine at the recommended intervals):
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Dose of tetanus vaccine is not required. However, if there is a heavily contaminated wound present, a dose of tetanus immunoglobulin would be required.
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In the UK, the current consensus for open fractures between the British Orthopaedic Association (BOA) and the British Association of Plastics, Reconstructive and Aesthetic Surgeons (BAPRAS) is for joint management of the patient. Hence, these patients should be taken directly or transferred to a specialist centre that can provide orthoplastics care to facilitate a stepwise and disciplined management approach.
With regards to open fractures and where significant soft tissue compromise is present, there is currently no consensus on the best method of obtaining and maintaining alignment and stability in the tibia for this subset of patients. Intramedullary nails, external fixators, or external fixation followed by intramedullary nailing or plates have previously been proposed. The management sequence of using an external fixator initially and followed by delayed reamed intramedullary nailing has been advocated particularly in Gustilo–Anderson Type 3 open fractures where definitive soft-tissue cover is not feasible, as well as in polytrauma patients. Unfortunately, the risk factors leading to infection and non-union when managing fractures in this sequence are not clear and the optimal time for conversion from external fixator to intramedullary nailing is currently unknown. A major component of this is understanding and knowing the time interval during which the host’s defence mechanisms can eradicate any residual bacteria around the pin sites and hence prevent further metalwork infection after definitive surgery an intramedullary nail or other internal fixation device. A systematic review with 96 patients who had a two-stage procedure where they were initially treated with external fixation and proceeded to have a reamed intramedullary nail noted 92% union rate at a mean time of 38.5 weeks. The mean time for the patients undergoing the second procedure was 26 days, when they were deemed to have complete healing of the pin track and normal erythrocyte sedimentation rate on monitoring bloods. However, it was reported that the rate of deep infection was 17%, with 2.5% progressing into chronic osteomyelitis.
It was previously thought that the decision for primary or delayed wound closure of open fractures should be guided by the Gustilo–Anderson classification. Historically, it was noted that grade 3 open fractures had significantly higher rates of infection on primary closure. However, it was then understood that bacteria in cultures before lavage and debridement did not correlate with bacteria identified in cases of a postoperative infection which lead to the suspicion this was caused by nosocomial infections. As there is now a clear correlation between rates of infection and non-union with a delay in soft tissue closure, it is now recommended that definitive soft tissue coverage should be achieved within 72 hours of injury or if possible during the initial surgical debridement. When local and free flaps are indicated for soft tissue coverage, the ‘fix and flap’ approach, where definitive fracture fixation occurs in the same surgical session as soft tissue coverage, is recommended.
When soft-tissue coverage is feasible and a single stage operation can be conducted, external fixators have been compared to intramedullary nails as a definitive fixation option as this would prevent a second operation for removal and exchange of fixation and would have positive implications in terms of cost effectiveness and patient morbidity. A recent meta-analysis comparing the two modalities of fixation in the context of a single stage definitive procedure noted that intramedullary nailing was recommended over external fixation in patients with Gustilo–Anderson Type 1 to 3a open tibial fractures due to reduced risk of superficial infection and malunion. However, subgroup analysis comparing intramedullary nails to circular external fixators did not show any significant difference in malunion due to their good mechanical stability and could potentially be used as an alternative to intramedullary nailing. It is also important to note that circular fixators do not confer a reduced rate of deep infection compared to intramedullary nails as a recent randomized control trial with 254 patients noted no significant difference. Nevertheless, circular frames are a favourable option in open tibial fractures with significant bone loss, contamination or multilevel fracture patterns.
Primary amputation
Considerations towards primary amputation are required particularly in severe open tibial fractures with extensive soft tissue injury and bone loss. Understandably, this treatment method may be difficult to be accepted by the patient and this decision should ideally involve multidisciplinary discussions which include clinicians from other specialties such as vascular and plastic surgery. Various predictive scoring systems such as the Predictive Salvage Index (PSI), mangled extremity severity score (MESS), Nerve injury, Ischaemia, Soft tissue injury, Skeletal injury, Shock & Age patient score (NISSA), Limb Salvage Index (LSI), and Hannover Fracture Scale (HFS) have been used to help clinicians decide between limb salvage or amputation. The LEAP study assessed the validity of usage of these scores. It found that although these scoring systems were quite useful in predicting limb salvage, they had low sensitivity and could not be accurate predictors of amputation. As the previous scoring systems mentioned above place a heavy emphasis on vascular deficit, they perform poorly in the absence of vascular injury. Hence, the Ganga Hospital Open Injury Severity Score (GHOISS) was proposed to assess open injuries without vascular deficit, looking mainly to address the need for assessment of Gustilo–Anderson Grade 3B injuries.
Although no optimal scoring systems currently exist, these scoring systems can be used to assist clinicians faced with challenging decision-making provided they are aware of the pitfalls of the scoring systems used. It is important to remember that the success of salvage strategies is not only dependant on the severity of limb injury, but also multiple other factors such as patient co-morbidities, facilities available and the expertise of the treating team.
BOA/BAPRAS have recommended that immediate amputation is indicated in the following:
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Incomplete amputations where there is almost complete severance of the affected limb from injury and the distal portion is subjected to significant trauma
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Extensive crush injury
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Limb avascularity with a warm ischaemia time of more than 4 hours.
Furthermore, BOA/BAPRAS have suggested that amputation be considered in less certain ‘grey areas’ which include the following:
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Limb ischaemia with clinical evidence of nerve dysfunction particularly absent plantar sensation
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Segmental loss of muscle involving three or more compartments, particularly when the posterior compartment is affected
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Segmental bone loss which exceeds one-third the length of the tibia
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Significant open foot injury accompanied by a tibial fracture.
Prognosis
The likelihood of non-union varies based on the location of the fracture along the tibial shaft. Fractures in the proximal third have a higher risk of non-union compared to midshaft fractures, primarily due to greater deforming forces and reduced soft tissue coverage. However, when managed and appropriately stabilized, the rates of non-union decrease, leading to favourable outcomes. Conservative treatment has a high success rate in achieving union, provided the alignment is maintained. However, the risk of displacement increases with oblique fracture patterns. In terms of amputation versus limb reconstruction, both approaches have been shown to result in comparable functional outcomes, as reported in the LEAP study.
Complications
Vascular injuries can be associated with tibial shaft fractures particularly when the proximal third is involved, as fracture fragments may damage the popliteal artery. It is therefore imperative that a neurovascular assessment is conducted in the initial management of these injuries. If present, these injuries are considered limb threatening and require emergency exploration and repair with vascular surgical input. Damage to one of the two major tibial vessels may also occur and go unnoticed if no critical limb ischaemia is present. It would be prudent to use a Doppler if distal pulses are not palpated and have a low threshold for a lower limb CT angiogram if there are any concerns of vascular injury without clear or obvious critical limb ischaemia.
Compartment syndrome is a known complication for both closed and open tibial shaft fractures, preoperatively and post-operatively. Without correct and timely diagnosis, this can lead to irreparable sequalae associated with significant morbidity. The diagnosis is based on clinical judgement when severe unremitting pain is present and worsens with passive stretching of the affected muscle compartment. Early diagnosis requires maintaining a high level of clinical suspicion, with a low threshold for performing serial assessment of the affected limb when suspected. In cases where the patient is obtunded due to head trauma or has sustained a spinal cord injury resulting in peripheral neurological deficit, increased firmness and pressure upon palpation of the muscle compartment may be the only detectable sign. Intracompartmental pressure (ICP) monitoring could be considered to support the diagnosis. This is conducted using a split-tip 20-gauge catheter introduced into the muscle compartment of the leg near the level of the fracture. As per the BOA standards for diagnosis and management of compartment syndrome (BOAST 10), a differential pressure of less than 30 mmHg suggest an increased risk and an absolute compartment pressure greater than 40 mmHg would be regarded as critical and warrant urgent surgical decompression. Swift management of compartment syndrome with a fasciotomies of all four compartments through two incisions is required. The incision wounds should be left open, and all patients should undergo a re-look in approximately 48 hours with early involvement of the plastic surgeons.
Infection is both a potential acute and late complication of tibial fractures. This is the most common complication in open tibial fracture injuries. The consequences of infection are well known and widely accepted. When present, it has a significant impact both in terms of clinical outcomes and on a healthcare service financially.
Tibial shaft fractures can also lead to various late complications, including malunion, delayed or non-union, deep vein thrombosis, pulmonary embolism, joint stiffness, osteoporosis and complex regional pain syndrome. Proximal third fractures are linked to malunion in valgus and procurvatum, while malrotation is associated with both proximal and distal third fractures. Percutanous plating is associated with wound breakdown and may cause irritation of the superficial peroneal nerve either proximally or distally. In contrast, intramedullary nailing is linked to knee pain, especially when the supra-patella approach is used, as mentioned earlier. Non-unions in closed tibial shaft fractures after intramedullary nailing is estimated to occur in up to 8% of patients. Dynamization of the nail has been reported to be an atraumatic and effective method to prevent non-unions. Hypertrophic non-unions require the biomechanical stability of the fracture to be addressed. Hence, this can be managed with augmentation plating or exchange nailing. On the other hand, atrophic non-unions require additional biological stimulation which can be achieved through bone grafting.
Delayed complications specific to open tibial shaft fractures include flap failure, bone loss, and an increased risk of delayed or non-union. Early prophylactic bone grafting is often considered when there is insufficient contact at the fracture site due to bone loss or comminution. A recent randomized control trial explored the use of a peptide fragment of parathyroid hormone (PTH) to promote bone healing and prevent non-union in these fractures. Patients received a novel PTH-based bone graft (KUR-113), showing significantly improved healing at 6 months in the intervention group. However, by 12 months, there was no difference in bony union, although the control group required more secondary interventions. The benefits of this adjunct remain uncertain, and cost considerations are necessary.
Postoperative care and rehabilitation
For patients with closed tibial shaft fractures treated conservatively in cast, the weight-bearing status depends on fracture stability. Patients with stable fractures are allowed to weight-bear as tolerated and typically progress to full weight-bearing within 2–3 weeks post-injury. Close follow-up with serial radiographs is essential to detect early displacement and assess bony union. In cases of isolated tibial fractures without fibula involvement or fractures with excessive comminution, 4–6 weeks of non-weightbearing is usually required.
For surgical fixation, whether using external fixators, plates, or intramedullary nailing, patients with length-stable extra-articular transverse shaft fractures should begin early weightbearing postoperatively to promote faster bone healing and reduce complication rates. Conversely, unstable or comminuted fractures should be considered for non-weightbearing for 6 weeks in the extra-articular cases and 12 weeks when the joint involvement is present.
Current evidence is inconclusive regarding early weight-bearing in high-risk patients, such as those susceptible to malunion, non-union, or the need for re-operation. Risk factors include fracture configuration as mentioned above, advanced age, smoking, alcohol use, diabetes, obesity, and open fractures. Consequently, the decision to extend non-weight-bearing for at least 6 weeks post-surgery should be carefully considered and balanced against the risks, especially in the geriatric population, where early mobilization is often recommended.
It is also crucial for patients on a non-weight-bearing regimen to receive chemical prophylaxis for venous thromboembolism. During rehabilitation, maintaining active knee and ankle range of motion is essential to prevent joint stiffness.
Functional outcomes
While surgical markers such as bony union, alignment, infection status, soft tissue healing, and revision surgery rates provide valuable insights into outcomes, these variables do not assess patient function. Functional outcomes are assessed by the ability of patients to perform specific activities. Although PROMs have become increasingly popular, their effectiveness in assessing recovery and outcomes following injury remains contentious. There is often a gap between clinical outcomes and what patients consider significant. A recent systematic review of outcome measurement in tibial fractures found that there is currently no validated functional outcome measure specifically for tibial fractures. For open fractures, BOA and BAPRAS have recommend the Enneking Score to evaluate limb function, along with several tools for assessing patient health status, including the Short Form 36 Questionnaire (SF-36), the Sickness Impact Profile (SIP), and the time to union.
Evaluation of consolidation
Fracture consolidation refers to the healing process that occurs once adequate fracture reduction has been achieved, progressing through inflammation, repair, and remodelling phases. Although various methods have been proposed for measuring fracture consolidation, the Radiological Union Scale for Tibial Fractures (RUST) is preferred due to its superior intra- and interobserver reliability. This method assesses callus formation using two plain radiographs taken from orthogonal views. Points ranging from 1 to 3 are assigned to each cortex based on the presence of callus and the visibility of the fracture line. An acute fracture scores a minimum of 4 points, while a fully healed fracture can score up to 12 points.
Conclusion
Tibial shaft fractures make up a significant portion of long bone injuries and open fractures. The OTA classification is currently the most comprehensive tool use to describe and classify these fractures but should be used in conjunction with the Gustilo–Anderson classification when an element of soft tissue compromise is present. With regards to radiographical investigations for diagnosis, modern adjuncts such as CT should be considered given the association with intra-articular extensions with these fractures. Despite the constant evolution and advancement in the management of tibial shaft fractures, further research is required to investigate the effectiveness of novel surgical techniques, formulate more specific scoring tools for clinical decision-making and functional outcomes that are validated for tibial shaft fractures.
References

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