High-yield overview

Most Common Long Bone Fracture | 25% Open | Compartment Syndrome

2%Of all fractures

25%Are open fractures

5-10%Non-union rate

6hDebridement window for severe open

MANAGEMENT APPROACH

Closed stable

PatternLow-energy, minimal displacement

TreatmentCast vs IM nail

Closed unstable

PatternHigh-energy, rotational instability

TreatmentIM nail preferred

Open fracture

PatternGustilo-Anderson classification

TreatmentIM nail + debridement protocol

Segmental

PatternHigh-energy, bone devitalization risk

TreatmentIM nail, consider ex fix

Critical Must-Knows

IM nail is treatment of choice for most tibial shaft fractures (closed or open)
Compartment syndrome: high risk in tibial fractures - maintain vigilance for 24-48 hours
Open fractures: Gustilo-Anderson classification guides antibiotics and soft tissue coverage timing
Acceptable alignment: 5° varus/valgus, 10° AP angulation, 10° rotation, 10mm shortening
Anterior knee pain after nailing is common (20-50%) - discuss with patients

Clinical Pearls

"
25% of tibial shaft fractures are open - highest rate of any long bone
"
Suprapatellar nailing reduces anterior knee pain compared to infrapatellar
"
Compartment syndrome can occur in closed fractures - maintain high index of suspicion
"
Non-union more common in smokers, high-energy, and open fractures

Clinical Imaging

Imaging Gallery

Percutaneous injection of platelet-rich plasma (PRP) on the craniomedial aspect of the tibial shaft fracture site. The injection was to the cranial edge ofthe palpable plate. — Percutaneous injection of platelet-rich plasma (PRP) on the craniomedial aspect of the tibial shaft fracture site. The injection was to the cranial edCredit: Open-i / NIH via Open-i (NIH) (Open Access (CC BY))

Anteroposterior and lateral X-ray images showing a middle one-third tibial shaft fracture with an associated fibular fracture and a healed tibial fracture treated with intramedullary nailing. — Anteroposterior and lateral X-ray images showing a middle one-third tibial shaft fracture with an associated fibular fracture and a healed tibial fracCredit: Uzun M et al. via Adv Orthop via Open-i (NIH) (Open Access (CC BY))

Stance position. Solid lines were marked on the skin, and dashed lines have been added to the photograph to identify the tibial angle and the calcaneal stance. — Stance position. Solid lines were marked on the skin, and dashed lines have been added to the photograph to identify the tibial angle and the calcaneaCredit: Uzun M et al. via Adv Orthop via Open-i (NIH) (Open Access (CC BY))

Clinical images showing the crus heel relationship.Credit: Uzun M et al. via Adv Orthop via Open-i (NIH) (Open Access (CC BY))

Comprehensive Gustilo IIIB open tibial shaft fracture management series — Gustilo IIIB open tibial shaft fracture case demonstrating complete management pathway: (a) severe open wound with bone exposure, (b) pre-operative X-ray showing comminuted fracture pattern, (c) external fixator application with wound access, (d) post-operative stabilization X-ray, (e) healed soft tissues, (f) flap coverage, (g,h) final functional and radiographic outcome with IM nail.Credit: PMC - CC BY 4.0

Critical Tibial Shaft Fracture Exam Points

Open Fracture Risk

25% of tibial fractures are open - highest of any long bone due to subcutaneous anteromedial border. Gustilo-Anderson classification guides treatment. IV antibiotics within 1 hour.

Compartment Syndrome

Tibial fractures have highest compartment syndrome risk. 4 compartments at risk. Pain out of proportion + pain on passive stretch. Fasciotomy within 6 hours of symptom onset.

IM Nail = Gold Standard

Reamed locked IM nail is treatment of choice for most tibial shaft fractures. Better union rates than unreamed or plates. Acceptable for open fractures (Gustilo I-IIIA).

Acceptable Alignment

5-5-10-10 rule: 5° varus/valgus, 5° (debatable, up to 10°) AP, 10° rotation, 10mm shortening. Greater malalignment leads to abnormal joint loading.

Quick Decision Guide

Fracture Type	Key Feature	Treatment	Pearl
Closed, stable, isolated	Low energy, minimally displaced	Cast vs IM nail	Cast if patient preference and reliable
Closed, unstable/displaced	High energy, spiral, segmental	Reamed locked IM nail	Gold standard treatment
Open Gustilo I-IIIA	Open wound, varying contamination	Debridement + IM nail (primary or staged)	IV Abx within 1 hour
Open Gustilo IIIB-IIIC	Soft tissue loss, vascular injury	Ex fix initially, then nail/coverage	Needs plastic surgery for soft tissue
Compartment syndrome suspected	Pain out of proportion, tense	Emergency 4-compartment fasciotomy	Don't wait for diagnosis - act

Mnemonic

5 PsCompartment Syndrome 5 Ps

P	Pain Out of proportion, pain on passive stretch (EARLY)
P	Pressure Compartment feels tense (EARLY)
P	Paresthesias Numbness/tingling (getting late)
P	Paralysis Weakness (LATE - irreversible changes)
P	Pulselessness Absent pulses (VERY LATE - limb threatened)

P	Pain Out of proportion, pain on passive stretch (EARLY)	P	Paralysis Weakness (LATE - irreversible changes)
P	Pressure Compartment feels tense (EARLY)	P	Pulselessness Absent pulses (VERY LATE - limb threatened)
P	Paresthesias Numbness/tingling (getting late)

Hook:The first 2 Ps (Pain, Pressure) are EARLY signs - don't wait for the other 3!

Mnemonic

ALPDTibial Compartments

A	Anterior Tibialis anterior, EHL, EDL, deep peroneal nerve
L	Lateral Peroneus longus/brevis, superficial peroneal nerve
P	Posterior Deep Tibialis posterior, FHL, FDL, posterior tibial nerve/artery
D	Posterior Superficial Gastrocnemius, soleus, sural nerve

A	Anterior Tibialis anterior, EHL, EDL, deep peroneal nerve	P	Posterior Deep Tibialis posterior, FHL, FDL, posterior tibial nerve/artery
L	Lateral Peroneus longus/brevis, superficial peroneal nerve	D	Posterior Superficial Gastrocnemius, soleus, sural nerve

Hook:ALPD - All 4 compartments need decompression in fasciotomy!

Mnemonic

GAPOpen Fracture Antibiotics

G	Gustilo I-II Cephalosporin (cefazolin 2g IV)
A	Add aminoglycoside Gustilo III - add gentamicin for Gram negatives
P	Penicillin Farm contamination - add penicillin for Clostridium

G	Gustilo I-II Cephalosporin (cefazolin 2g IV)
A	Add aminoglycoside Gustilo III - add gentamicin for Gram negatives
P	Penicillin Farm contamination - add penicillin for Clostridium

Hook:GAP in coverage needs to be closed - step up antibiotics as contamination increases!

Mnemonic

5-5-10-10Acceptable Alignment

5	5° varus/valgus Coronal plane
5	5-10° AP angulation Sagittal plane
10	10° rotation Very difficult to assess
10	10mm shortening Especially with an intact fibula

5	5° varus/valgus Coronal plane	10	10° rotation Very difficult to assess
5	5-10° AP angulation Sagittal plane	10	10mm shortening Especially with an intact fibula

Hook:5-5-10-10: Think of it as the acceptable range for tibial shaft alignment!

Overview and Epidemiology

Why This Topic Matters

Tibial shaft fractures are the most common long bone fracture and have the highest rate of open injuries. The examiner will test knowledge of compartment syndrome, open fracture management, and technical aspects of nailing.

Demographics

Bimodal: Young males (high-energy) and elderly females (low-energy)
Male:Female 3:1 in young adults
20-30 years peak in males
Over 60 years peak in females (osteoporotic)

Mechanism

High-energy: MVA, motorcycle, pedestrian
Sports: Skiing, football (rotational)
Low-energy: Falls in elderly
Direct blow or twisting mechanism

Anatomy

Key Anatomical Concept

The tibia has minimal soft tissue coverage anteromedially - the subcutaneous border. This explains the high open fracture rate. The four compartments of the leg are at risk for compartment syndrome with any tibial fracture.

Tibial Anatomy

Proximal Tibia

Tibial plateau (covered elsewhere)
Tibial tubercle: Patellar tendon insertion
Gerdy's tubercle: ITB insertion
Proximal fibula: Safe zone for nailing

Shaft

Triangular cross-section
Anteromedial surface subcutaneous
Interosseous membrane to fibula
Nutrient artery enters posterolaterally
Minimum diameter at isthmus (mid-junction lower third)

Classification Systems

Gustilo-Anderson Open Fracture Classification

Type	Wound	Contamination	Soft Tissue	Treatment
I	Under 1cm	Clean	Minimal damage	Abx, debride, primary IM nail
II	1-10cm	Moderate	Moderate crush	Abx, debride, IM nail
IIIA	Over 10cm	High	Adequate coverage possible	Abx, serial debride, nail or ex fix
IIIB	Over 10cm	High	Requires flap/graft	Ex fix, plastic surgery, later nail
IIIC	Over 10cm	High	Vascular injury needing repair	Vascular repair, ex fix, ?amputation

Automatic Type III

The following are automatic Gustilo Type III regardless of wound size: (1) High-energy mechanism, (2) Farm contamination, (3) Segmental fracture, (4) Vascular injury, (5) Delayed presentation over 8 hours.

Clinical Assessment

History

Mechanism: High vs low energy (critical)
Time since injury (open fracture timing)
Environment (farm = contaminated)
Ambulatory status before injury
Smoking status (non-union risk)

Examination

Skin: Open wound? Skin tenting? Blisters?
Compartments: Tense? Pain on passive stretch?
Neurovascular: Deep peroneal, posterior tibial pulses
Knee and ankle examination (associated injuries)
Deformity: Shortening, angulation

Compartment Syndrome Assessment

Pain out of proportion to injury and pain on passive stretch are the EARLY signs. Do NOT wait for paralysis or pulselessness - these are late and indicate irreversible damage. If in doubt, measure pressures or perform fasciotomy.

Compartment Pressure Thresholds

Absolute pressure over 30mmHg or delta pressure (DBP - compartment pressure) under 30mmHg are indications for fasciotomy. Clinical diagnosis is paramount - if in doubt, decompress.

Differential Diagnosis & Mimics

Distinguishing Tibial Shaft Fracture from Mimics

Condition	Distinguishing Feature	Key Investigation	Pitfall
Tibial shaft fracture	Acute trauma, deformity, point tenderness over diaphysis	AP/lateral X-ray including knee and ankle	Always image joints above and below
Compartment syndrome (with/without fracture)	Pain out of proportion, pain on passive stretch, tense compartment	Clinical; compartment pressures if equivocal	Can occur with closed or even minimally displaced fractures
Tibial stress fracture	Insidious activity-related pain, athlete/runner, no acute trauma	MRI or bone scan (X-ray often normal early)	Anterior cortex 'dreaded black line' is high-risk for completion
Maisonneuve injury	Proximal fibula fracture with ankle pain/instability	Full-length tibia-fibula and ankle X-rays	Missed if leg not fully imaged
Pathological fracture	Low-energy mechanism, prior pain, lytic/sclerotic lesion	X-ray, MRI, staging if malignancy suspected	Do not nail a possible primary bone tumour before staging/biopsy
Tibial plateau / pilon fracture	Articular involvement at knee or ankle	CT with reconstructions	Intra-articular extension changes fixation strategy

Never Nail Before Excluding Pathology

In a low-energy tibial fracture with antecedent pain or a suspicious lesion, exclude a pathological (especially primary malignant) cause before reaming and nailing - intramedullary instrumentation can disseminate tumour and compromise limb salvage. Stage and biopsy first if in doubt.

Areas of Controversy & Uncertainty

Open Debridement Timing

The historical "6-hour rule" is not strongly supported by evidence (Harley 2002). Current consensus prioritises early antibiotics and thorough debridement over a rigid clock, with urgency driven by contamination and physiology.

Suprapatellar vs Infrapatellar

Suprapatellar nailing reduces knee pain and eases proximal-fracture reduction, but concerns remain about intra-articular debris and patellofemoral cartilage. Long-term comparative data are still limited.

Fibula Fixation

Whether to fix the fibula in distal third tibial fractures is debated - it can aid alignment but may over-constrain and is not routinely required.

Routine Fasciotomy / Pressure Monitoring

Continuous compartment pressure monitoring is not universally adopted; over-reliance on numbers risks both missed and unnecessary fasciotomies. Serial clinical assessment remains central.

Investigations

Imaging Protocol

ImmediateX-rays

AP and Lateral of tibia including knee and ankle joints. Assess fracture pattern, displacement, fibula fracture, joint involvement.

If NeededCT Scan

If articular extension suspected (plateau or plafond). 3D reconstructions for complex patterns.

Vascular ConcernCT Angiography

If diminished pulses, expanding hematoma, or Gustilo IIIC suspected. Do not delay surgery for this.

Fibula Fracture Implications

Intact fibula may cause varus malalignment - consider fibula osteotomy if difficulty achieving reduction. Fibula fracture at same level suggests higher energy. Proximal fibula fracture - check for ankle instability (Maisonneuve pattern).

Radiographic Example

Management Algorithm

Open Fracture Protocol

Within 1 hour: IV antibiotics (cefazolin ± gentamicin). Within 6 hours: Debridement for Gustilo III. Photograph wound, cover with saline-soaked gauze, splint. Do not explore in ED.

Intramedullary Nailing

IM Nail Technique

PositioningStep 1

Supine on radiolucent table. Knee flexed for infrapatellar or semi-extended for suprapatellar approach. Bump under knee.

Entry PointStep 2

Infrapatellar: Split patellar tendon, entry at anterior tibial cortex, in line with canal. Suprapatellar: Through quads tendon, knee semi-extended.

Canal PreparationStep 3

Pass guidewire across fracture. Ream sequentially (over-ream by 1-1.5mm for reaming debris compaction).

Nail InsertionStep 4

Insert appropriately sized nail. Check rotation clinically and fluoroscopically. Avoid distraction at fracture.

LockingStep 5

Distal locking first (usually 2 screws). Proximal locking. Consider blocking/Poller screws for metaphyseal fractures.

Reamed vs Unreamed

Reamed preferred for most fractures
Better union rates (SPRINT trial)
Unreamed acceptable for open fractures
Reaming provides autograft effect

Approach Comparison

Suprapatellar: Less knee pain, easier in obese
Infrapatellar: Traditional, may have more knee pain
Study shows similar outcomes
Surgeon preference

Surgical Technique

Intramedullary Nailing - Gold Standard

Intramedullary nail reaming technique for tibial shaft fracture — Intraoperative photograph demonstrating manual T-handle reaming technique for tibial intramedullary nailing. Sequential reaming creates space for nail insertion and generates autologous bone graft from the reaming debris (RIA effect).Credit: PMC - CC BY 4.0

Intramedullary nailing with fluoroscopic guidance — Intraoperative setup for tibial IM nailing: (a) patient positioning with knee flexed over bolster and C-arm access, (b) serial fluoroscopic images showing guidewire passage, reaming, nail insertion, and interlocking screw placement.Credit: PMC - CC BY 4.0

Patient Positioning:

Supine on radiolucent table
Knee flexed over triangle or padded bolster (90 degrees)
Ensure adequate C-arm access for AP and lateral views

Entry Point:

Infrapatellar (transtendinous or paratendinous)
Suprapatellar approach reduces anterior knee pain
Entry point at tibial plateau, slightly medial to lateral tibial spine

Reduction Techniques:

Blocking (Poller) screws for coronal/sagittal deformity
Fracture table with skeletal traction for difficult reductions
Percutaneous clamps for temporary stabilization

Nail Insertion:

Guide wire across fracture, confirm position on AP and lateral
Ream 1-1.5mm larger than nail diameter
Insert nail with rotational alignment corrected

Interlocking:

Proximal and distal interlocking screws
Static locking for unstable fractures
Consider end caps to facilitate later removal

Meticulous technique ensures optimal alignment and stable fixation.

Compartment Syndrome Management

Time is Muscle

Fasciotomy within 6 hours of symptom onset to prevent irreversible muscle necrosis. After 8 hours, myonecrosis begins. Volkmann's contracture is the end result of missed compartment syndrome.

Fasciotomy Technique

DecisionStep 1

Clinical diagnosis confirmed or high suspicion. Do not delay for pressure measurements if clinical picture clear.

IncisionsStep 2

Two-incision technique: Anterolateral incision releases anterior and lateral compartments. Posteromedial incision releases deep and superficial posterior compartments.

DecompressionStep 3

All four compartments must be released. Extend incisions if muscle bulging persists. Assess muscle viability (4 Cs: color, contractility, consistency, capacity to bleed).

Wound ManagementStep 4

Leave wounds open, loose dressing. Return to OR in 48-72 hours for reassessment. Delayed primary closure, skin graft, or VAC therapy.

4 Cs of Muscle Viability

Color (pink, not grey/black), Contractility (twitches when stimulated), Consistency (firm, not mushy), Capacity to bleed (should bleed when cut). Debride non-viable muscle.

Complications

Reamer-Irrigator-Aspirator bone grafting for tibial nonunion — Complex open tibial shaft fracture with bone loss requiring RIA (Reamer-Irrigator-Aspirator) bone grafting: (A) severe open wound with soft tissue damage, (B) pre-operative X-rays showing bone loss, (C) external fixator stabilization, (D) CT showing defect, (E) post bone grafting and soft tissue coverage.Credit: PMC - CC BY 4.0

Complication	Incidence	Risk Factors	Management
Compartment syndrome	5-10%	High-energy, crush, young males	Emergency 4-compartment fasciotomy
Non-union	5-10%	Open fracture, smoking, infection	Exchange nail, bone graft, plate
Malunion	5-15%	Inadequate fixation, poor reduction	Osteotomy and correction
Infection	1-5% closed, higher open	Open fracture, soft tissue damage	Washout, antibiotics, ? hardware removal
Anterior knee pain	20-50%	Infrapatellar approach, prominent hardware	Hardware removal, rarely severe
Hardware failure	Rare	Early weight bearing, non-union	Revision fixation

Postoperative Care

Immediate Postoperative (Days 0-14)

Wound Management:

Check surgical wounds at 48 hours
Incision care for fasciotomy wounds if performed
Negative pressure wound therapy for significant soft tissue defects

DVT Prophylaxis:

Chemical prophylaxis for 4-6 weeks
LMWH preferred (enoxaparin 40mg daily)
Mechanical prophylaxis with TED stockings

Weight-Bearing Status:

Most nailed tibias: weight-bearing as tolerated immediately
Unstable or comminuted patterns: touch weight-bearing for 6 weeks
Plate fixation: non-weight-bearing for 6-8 weeks typically

Physiotherapy:

Early range of motion for ankle and knee
Edema management
Gait training with appropriate aids

Early mobilization reduces complications and optimizes recovery.

Outcomes and Prognosis

Union Rates

Outcomes by Injury Pattern

Pattern	Union Rate	Time to Union	Key Factors
Closed fracture + IMN	95-98%	16-20 weeks	Gold standard treatment
Open Grade I-II	85-95%	20-26 weeks	Soft tissue management critical
Open Grade IIIA	80-90%	24-32 weeks	Higher complication rate
Open Grade IIIB/C	70-85%	Variable	High risk complications, may need flap

Prognostic Factors

Favorable Factors

Simple fracture pattern, Adequate soft tissue coverage, Non-smoker, Young patient, Good bone quality, Early stable fixation

Unfavorable Factors

Comminuted or segmental pattern, Open fracture (higher grades), Smoker, Elderly patient, Diabetes or peripheral vascular disease, Infection

Functional Outcomes

Most patients achieve good to excellent functional outcomes after tibial shaft fractures treated with IMN. Return to pre-injury activity levels is expected in the majority of cases, though high-energy injuries and open fractures have more variable outcomes. Anterior knee pain affects 20-50% of patients following infrapatellar nailing approaches.

Radiographic Healing Examples

Healed tibial shaft fracture with intramedullary nail — AP and lateral radiographs demonstrating healed tibial shaft fracture with intramedullary nail in situ. Note complete union with bridging callus, satisfactory alignment, and proximal/distal interlocking screws maintaining rotational stability.Credit: PMC - CC BY 4.0

Evidence Base and Key Trials

SPRINT Trial - Reamed vs Unreamed Tibial Nailing

Study to Prospectively Evaluate Reamed Intramedullary Nails in Tibial Fractures (Bhandari M, Guyatt G, Tornetta P, et al.) • J Bone Joint Surg Am (2008)

Key Findings:

Multicentre blinded RCT - 1319 adults randomised, 1226 (93%) completed 1-year follow-up
Closed fractures: reamed nailing reduced the primary composite event (11% vs 17%; RR 0.67, 95% CI 0.47-0.96, p=0.03), largely driven by less dynamisation
Open fractures: no significant difference (RR 1.27, 95% CI 0.91-1.78, p=0.16)
Delaying reoperation for nonunion to at least 6 months substantially reduced reoperation

Clinical Implication: Use reamed nailing for closed tibial shaft fractures. For open fractures either technique is acceptable; avoid early reoperation for presumed nonunion.

Limitation: Composite outcome heavily influenced by dynamisation; open-fracture subgroup not the primary comparison.

Verify on PubMed (PMID 19047701)

Nail vs Plate - Extra-articular Proximal Tibia

Meena RC, Meena UK, Gupta GL, Gahlot N, Gaba S • J Orthop Traumatol (2015)

Key Findings:

Prospective RCT of 58 closed extra-articular proximal tibial fractures - MIPO plating vs intramedullary nailing
Nailing had significantly shorter hospital stay (p=0.035) and union time (p=0.004)
No difference in infection, knee range of motion, malunion or nonunion
Both implants provided rigid fixation preventing secondary collapse

Clinical Implication: Both nailing and locked plating are valid for metaphyseal-diaphyseal tibial fractures; nailing may offer faster recovery where a stable construct is achievable.

Limitation: Single-centre, modest sample size; proximal third only, not generalisable to all shaft levels.

Verify on PubMed (PMID 25588847)

Exam Viva Scenarios

Use these scenarios to practise clinical reasoning and management decisions

CLINICAL SCENARIOStandard

Scenario 1: Closed Displaced Tibial Shaft Fracture

CLINICAL PROMPT

"A 35-year-old motorcyclist presents after an accident with a closed, displaced mid-shaft tibial fracture with an intact fibula. He has no other injuries. X-rays show 15° of valgus angulation and 2cm overlap. Neurovascular exam is normal. How would you manage this patient?"

PRACTICAL APPROACH

This is a closed displaced tibial shaft fracture with significant angulation and shortening - clearly outside acceptable alignment parameters and requires operative fixation. My management would be: First, complete assessment - confirm this is isolated (full secondary survey), check skin for impending open wounds, and **assess compartments** carefully given the mechanism. I would examine for pain on passive stretch and tense compartments. Second, I would splint the leg in a well-padded long leg backslab and provide analgesia. Third, this patient needs **reamed locked intramedullary nailing** - the gold standard treatment. My operative plan: supine positioning, either suprapatellar or infrapatellar approach based on preference, reaming to 1-1.5mm above final nail size. Blocking/Poller screws are unlikely to be needed for a mid-shaft fracture but I would position them if having difficulty with reduction or if the fracture is more proximal/distal. I would lock distally first (2 screws), then proximally. The intact fibula may cause varus if I'm not careful - I would check alignment carefully before completing proximal locking. Post-operatively, weight bearing as tolerated with crutches, thromboprophylaxis, and follow-up at 2, 6, and 12 weeks with X-rays.

KEY CLINICAL POINTS

Clearly needs surgery - angulation and shortening outside acceptable limits

Reamed locked IM nail is gold standard for closed tibial shaft

Check compartments before and after surgery

Intact fibula may cause varus - monitor alignment

Weight bearing as tolerated post-op

COMMON PITFALLS

Attempting non-operative with this degree of displacement

Not assessing for compartment syndrome

Not recognizing intact fibula may complicate reduction

Unreamed nailing when reamed is better for closed fractures

FURTHER QUESTIONS

"What if he develops increasing pain 12 hours post-operatively?"

"What are acceptable alignment parameters for tibial shaft?"

"Describe blocking screw technique"

CLINICAL SCENARIOChallenging

Scenario 2: Gustilo IIIB Open Fracture

CLINICAL PROMPT

"A 25-year-old pedestrian hit by a car presents with an open tibial fracture. There is a 15cm wound on the anterolateral leg with exposed bone and significant soft tissue stripping. There is no active bleeding and dorsalis pedis pulse is palpable. What is your management?"

PRACTICAL APPROACH

This is a Gustilo IIIB open tibial fracture - a severe injury requiring a systematic multidisciplinary approach. The wound is over 10cm with significant soft tissue stripping and will likely require flap coverage. My immediate management follows open fracture protocol: First, **IV antibiotics within 1 hour** - cefazolin 2g plus gentamicin for Gustilo III. Add penicillin if farm contamination. Second, **tetanus prophylaxis** if not up to date. Third, photograph the wound for documentation, then cover with saline-soaked gauze and apply a well-padded splint. No exploration in ED. Fourth, contact the plastic surgery team early - this will need soft tissue coverage. For operative management, I would proceed to theatre urgently (within 6 hours for Gustilo III). Debridement principles: extend wound to fully assess zone of injury, remove all non-viable tissue (using 4 Cs), copious low-pressure saline irrigation (per FLOW trial), and stabilization. For stabilization, I would use a **spanning external fixator** initially in this IIIB scenario to allow soft tissue access and resuscitation. I would plan for repeat debridement at 48-72 hours, with definitive fixation (likely IM nail) and soft tissue coverage (free flap) within 7-10 days ideally. The 'fix and flap within 72 hours' principle has been shown to improve outcomes in IIIB injuries.

KEY CLINICAL POINTS

Gustilo IIIB = requires flap/graft coverage, multidisciplinary

Antibiotics within 1 hour - cephalosporin + aminoglycoside

External fixator initially for soft tissue access

Serial debridement at 48-72 hours

Fix and flap ideally within 72 hours to 7 days

COMMON PITFALLS

Delayed antibiotics - must be given immediately

Primary nailing of IIIB - better to ex fix initially

Single debridement - serial debridement needed

Not involving plastic surgery early

FURTHER QUESTIONS

"What if the posterior tibial pulse is absent?"

"When would you convert the ex fix to a nail?"

"What are the antibiotic recommendations for open fractures?"

CLINICAL SCENARIOCritical

Scenario 3: Suspected Compartment Syndrome

CLINICAL PROMPT

"You are called to the ward 8 hours post-operatively for a 28-year-old man who had IM nailing of a closed tibial shaft fracture. The nurses report he is in severe pain despite IV morphine. His leg is in a backslab. On examination, he has severe pain on passive toe extension, the anterior compartment feels tense, and he reports tingling over the first web space. What is your management?"

PRACTICAL APPROACH

This clinical picture is highly concerning for **compartment syndrome**, which is an orthopaedic emergency. The triad of pain out of proportion (not controlled by morphine), pain on passive stretch (toe extension), and tense compartment with neurological symptoms (first web space paresthesias = deep peroneal nerve) is classic for anterior compartment syndrome. I would not delay for compartment pressure measurements - the clinical diagnosis is sufficient. My immediate actions: First, **remove the backslab completely** (cut both sides and remove entirely - splitting alone is not sufficient). Second, remove any constrictive dressings. Third, hold the limb at heart level (not elevated). Fourth, reassess after 30 minutes - if no dramatic improvement, proceed directly to theatre. Given the severity of his symptoms and the fact we are now 8 hours post-op, I would proceed to **emergency four-compartment fasciotomy**. I would use the two-incision technique: anterolateral incision to decompress anterior and lateral compartments, posteromedial incision for superficial and deep posterior compartments. All four compartments must be released. I would assess muscle viability (4 Cs) and debride any frankly necrotic muscle. Wounds would be left open with loose dressings, and I would plan return to OR in 48-72 hours for assessment, washout, and consideration of delayed primary closure or skin grafting.

KEY CLINICAL POINTS

Clinical diagnosis is sufficient - do not delay for pressure measurements

Remove ALL constrictive dressings immediately

Four-compartment fasciotomy required - two-incision technique

Time is muscle - irreversible damage after 6-8 hours of ischemia

Leave wounds open, return to OR in 48-72 hours

COMMON PITFALLS

Waiting for compartment pressure measurements

Only splitting the cast (must remove entirely)

Only releasing the anterior compartment

Closing the fasciotomy wounds primarily

FURTHER QUESTIONS

"What are the pressure thresholds for fasciotomy?"

"What is the consequence of missed compartment syndrome?"

"How would you manage the open wounds?"

MCQ Practice Points

Epidemiology Question

Q: What percentage of tibial shaft fractures are open? A: 25% - the highest rate of any long bone. This is due to the subcutaneous anteromedial border of the tibia with minimal soft tissue coverage.

Compartment Question

Q: What is the earliest clinical sign of anterior compartment syndrome in the leg? A: Pain on passive plantarflexion of the toes and first web space sensory changes (deep peroneal nerve distribution). Do not wait for paralysis or pulselessness.

Fixation Question

Q: What did the SPRINT trial show regarding reamed vs unreamed tibial nailing? A: Reamed nailing had lower re-operation rates for closed tibial shaft fractures. For open fractures, there was no significant difference. Reamed nailing is now standard for closed fractures.

Antibiotic Question

Q: What antibiotic regimen is recommended for Gustilo Type III open fractures? A: Cephalosporin (cefazolin 2g) PLUS aminoglycoside (gentamicin). Add penicillin if farm contamination is present to cover Clostridium species.

Alignment Question

Q: What are the acceptable alignment parameters for tibial shaft fractures? A: The 5-5-10-10 rule: 5° varus/valgus, 5-10° AP angulation, 10° rotation, 10mm shortening. Greater malalignment leads to abnormal joint loading and poor outcomes.

Irrigation Question

Q: What did the FLOW trial show about open fracture wound irrigation? A: Low-pressure saline irrigation is as effective as high-pressure. Soap provided no benefit and may actually increase complications. Simple saline irrigation is recommended.

Guidelines, Registries & Global Practice

Global Epidemiology

Most common long bone fracture worldwide (~2% of all fractures)
Incidence roughly 17 per 100,000 person-years in high-income settings
Bimodal: young men (high-energy road traffic and sport) and older women (low-energy falls)
Road traffic injury is the dominant high-energy cause in low- and middle-income countries

Why Practice Varies

Plastic surgery availability dictates feasibility of early "fix and flap" for Gustilo IIIB
Implant access (modern nails vs external fixators) varies by resource setting
Transfer distance to a level 1 / orthoplastic centre affects debridement and coverage timing
Antibiotic stewardship and microbiology support differ regionally

Major Guidelines Side by Side

Body	Open Fracture Antibiotics	Debridement Timing	Soft-tissue Coverage
BOA / BAPRAS (BOAST Open Fractures, UK)	IV co-amoxiclav or cefuroxime within 1h; add Gram-negative cover for contamination	Within 12h (24h for solitary high-energy without contamination); immediate if marine/agricultural/sewage	Definitive coverage within 72h, ideally combined ortho-plastic 'fix and flap'
AAOS / EAST (USA)	First-generation cephalosporin within 1h; add aminoglycoside/Gram-negative cover for type III	Urgent but not strictly 6h; based on contamination and physiology	Early coverage; staged for severe contamination
AO Foundation	Early IV prophylaxis; escalate cover with Gustilo grade	Thorough debridement prioritised over a fixed clock	Reconstructive ladder; temporary ex-fix then definitive fixation + flap
WHO / limited-resource consensus	Earliest available IV antibiotic; tetanus prophylaxis	As soon as safe theatre access allows	External fixation when plastics unavailable; transfer for coverage

Registry & Outcome Data

Long-bone fracture registries (e.g. national hip/trauma databases) consistently show intramedullary nailing as the dominant diaphyseal construct
Open fracture databases (e.g. UK open-fracture audits aligned to BOAST) demonstrate lower deep-infection rates with combined orthoplastic care and timely coverage
Registry follow-up confirms higher reoperation in open and high-energy patterns, consistent with SPRINT findings

High- vs Limited-Resource Practice

High-resource: reamed locked nail, suprapatellar option, early free-flap coverage
Limited-resource: external fixation as definitive treatment more common; staged nailing if implants available
Damage-control orthopaedics principles apply universally in polytrauma
Compartment syndrome vigilance and fasciotomy thresholds are identical worldwide

Medicolegal & Documentation Themes (Global)

Key documentation: (1) Time of injury and time of first antibiotic dose for open fractures, (2) Serial compartment checks with times recorded, (3) Consent including anterior knee pain risk for nailing, (4) Smoking-cessation counselling documented. Missed compartment syndrome is among the most common sources of orthopaedic litigation in every jurisdiction.

TIBIAL SHAFT FRACTURES

Clinical summary

Key Facts

•Most common long bone fracture
•25% are open (highest rate)
•5-10% non-union rate
•IM nail = gold standard treatment

Compartment Syndrome

•5 Ps: Pain, Pressure, Paresthesias, Paralysis, Pulselessness
•First 2 Ps are EARLY - act on these
•Fasciotomy within 6 hours
•All 4 compartments must be released

Open Fracture Protocol

•Antibiotics within 1 hour
•Gustilo I-II: cefazolin
•Gustilo III: add gentamicin
•Farm: add penicillin

Fixation Choice

•IM nail: most tibial shaft fractures
•Reamed beats unreamed for closed (SPRINT)
•Ex fix: IIIB/IIIC initially
•Plate: metaphyseal, narrow canal

Acceptable Alignment (5-5-10-10)

•5° varus/valgus
•5-10° AP angulation
•10° rotation
•10mm shortening

Fracture Type

Key Feature

Treatment

Pearl

Closed, stable, isolated

Low energy, minimally displaced

Cast vs IM nail

Cast if patient preference and reliable

Closed, unstable/displaced

High energy, spiral, segmental

Reamed locked IM nail

Gold standard treatment

Open Gustilo I-IIIA

Open wound, varying contamination

Debridement + IM nail (primary or staged)

IV Abx within 1 hour

Open Gustilo IIIB-IIIC

Soft tissue loss, vascular injury

Ex fix initially, then nail/coverage

Needs plastic surgery for soft tissue

Compartment syndrome suspected

Pain out of proportion, tense

Emergency 4-compartment fasciotomy

Don't wait for diagnosis - act

Type

Wound

Contamination

Soft Tissue

Treatment

Under 1cm

Clean

Minimal damage

Abx, debride, primary IM nail

1-10cm

Moderate

Moderate crush

Abx, debride, IM nail

IIIA

Over 10cm

High

Adequate coverage possible

Abx, serial debride, nail or ex fix

IIIB

Over 10cm

High

Requires flap/graft

Ex fix, plastic surgery, later nail

IIIC

Over 10cm

High

Vascular injury needing repair

Vascular repair, ex fix, ?amputation

Condition

Distinguishing Feature

Key Investigation

Pitfall

Tibial shaft fracture

Acute trauma, deformity, point tenderness over diaphysis

AP/lateral X-ray including knee and ankle

Always image joints above and below

Compartment syndrome (with/without fracture)

Pain out of proportion, pain on passive stretch, tense compartment

Clinical; compartment pressures if equivocal

Can occur with closed or even minimally displaced fractures

Tibial stress fracture

Insidious activity-related pain, athlete/runner, no acute trauma

MRI or bone scan (X-ray often normal early)

Anterior cortex 'dreaded black line' is high-risk for completion

Maisonneuve injury

Proximal fibula fracture with ankle pain/instability

Full-length tibia-fibula and ankle X-rays

Missed if leg not fully imaged

Pathological fracture

Low-energy mechanism, prior pain, lytic/sclerotic lesion

X-ray, MRI, staging if malignancy suspected

Do not nail a possible primary bone tumour before staging/biopsy

Tibial plateau / pilon fracture

Articular involvement at knee or ankle

CT with reconstructions

Intra-articular extension changes fixation strategy

Complication

Incidence

Risk Factors

Management

Compartment syndrome

5-10%

High-energy, crush, young males

Emergency 4-compartment fasciotomy

Non-union

5-10%

Open fracture, smoking, infection

Exchange nail, bone graft, plate

Malunion

5-15%

Inadequate fixation, poor reduction

Osteotomy and correction

Infection

1-5% closed, higher open

Open fracture, soft tissue damage

Washout, antibiotics, ? hardware removal

Anterior knee pain

20-50%

Infrapatellar approach, prominent hardware

Hardware removal, rarely severe

Hardware failure

Rare

Early weight bearing, non-union

Revision fixation

Pattern

Union Rate

Time to Union

Key Factors

Closed fracture + IMN

95-98%

16-20 weeks

Gold standard treatment

Open Grade I-II

85-95%

20-26 weeks

Soft tissue management critical

Open Grade IIIA

80-90%

24-32 weeks

Higher complication rate

Open Grade IIIB/C

70-85%

Variable

High risk complications, may need flap

SPRINT Trial - Reamed vs Unreamed Tibial Nailing

Study to Prospectively Evaluate Reamed Intramedullary Nails in Tibial Fractures (Bhandari M, Guyatt G, Tornetta P, et al.) • J Bone Joint Surg Am (2008)

Key Findings:

Multicentre blinded RCT - 1319 adults randomised, 1226 (93%) completed 1-year follow-up
Closed fractures: reamed nailing reduced the primary composite event (11% vs 17%; RR 0.67, 95% CI 0.47-0.96, p=0.03), largely driven by less dynamisation
Open fractures: no significant difference (RR 1.27, 95% CI 0.91-1.78, p=0.16)
Delaying reoperation for nonunion to at least 6 months substantially reduced reoperation

Clinical Implication: Use reamed nailing for closed tibial shaft fractures. For open fractures either technique is acceptable; avoid early reoperation for presumed nonunion.

Limitation: Composite outcome heavily influenced by dynamisation; open-fracture subgroup not the primary comparison.

Verify on PubMed (PMID 19047701)

Nail vs Plate - Extra-articular Proximal Tibia

Meena RC, Meena UK, Gupta GL, Gahlot N, Gaba S • J Orthop Traumatol (2015)

Key Findings:

Prospective RCT of 58 closed extra-articular proximal tibial fractures - MIPO plating vs intramedullary nailing
Nailing had significantly shorter hospital stay (p=0.035) and union time (p=0.004)
No difference in infection, knee range of motion, malunion or nonunion
Both implants provided rigid fixation preventing secondary collapse

Clinical Implication: Both nailing and locked plating are valid for metaphyseal-diaphyseal tibial fractures; nailing may offer faster recovery where a stable construct is achievable.

Limitation: Single-centre, modest sample size; proximal third only, not generalisable to all shaft levels.

Verify on PubMed (PMID 25588847)

Body

Open Fracture Antibiotics

Debridement Timing

Soft-tissue Coverage

BOA / BAPRAS (BOAST Open Fractures, UK)

IV co-amoxiclav or cefuroxime within 1h; add Gram-negative cover for contamination

Within 12h (24h for solitary high-energy without contamination); immediate if marine/agricultural/sewage

Definitive coverage within 72h, ideally combined ortho-plastic 'fix and flap'

AAOS / EAST (USA)

First-generation cephalosporin within 1h; add aminoglycoside/Gram-negative cover for type III

Urgent but not strictly 6h; based on contamination and physiology

Early coverage; staged for severe contamination

AO Foundation

Early IV prophylaxis; escalate cover with Gustilo grade

Thorough debridement prioritised over a fixed clock

Reconstructive ladder; temporary ex-fix then definitive fixation + flap

WHO / limited-resource consensus

Earliest available IV antibiotic; tetanus prophylaxis

As soon as safe theatre access allows

External fixation when plastics unavailable; transfer for coverage

Compartment	Contents	Nerve	First Sign of Syndrome
Anterior	Tibialis anterior, EHL, EDL, peroneus tertius	Deep peroneal	Weak toe/ankle dorsiflexion, 1st web space numbness
Lateral	Peroneus longus and brevis	Superficial peroneal	Weak eversion, lateral leg numbness
Deep Posterior	Tibialis posterior, FHL, FDL, popliteus	Tibial nerve	Weak toe flexion, sole numbness
Superficial Posterior	Gastrocnemius, soleus, plantaris	Sural nerve	Weak plantarflexion, lateral foot numbness

Vessel	Course	Clinical Relevance
Nutrient artery	Enters posterolaterally, upper-middle third	Supplies inner 2/3 of cortex
Periosteal vessels	From surrounding muscles	Supplies outer 1/3 of cortex
Anterior tibial artery	Through interosseous membrane, anterior	At risk in proximal fractures
Posterior tibial artery	Posterior to deep compartment	Main blood supply to foot

Type	Description	Examples
42-A	Simple	A1: Spiral, A2: Oblique, A3: Transverse
42-B	Wedge	B1: Spiral wedge, B2: Bending wedge, B3: Fragmented wedge
42-C	Complex/Segmental	C1: Spiral, C2: Segmental, C3: Irregular

Indication	Reason	Plate Type
Metaphyseal-diaphyseal	Insufficient nail purchase	Locking plate (MIPO)
Narrow canal (pediatric)	Cannot accommodate nail	Plate or flexible nails
Associated knee/ankle arthroplasty	Protect prosthesis	Plate
Segmental bone loss	Distraction with nail difficult	Plate ± bone graft
Patient preference	Avoid knee pain	Rare indication

Compartment	Contents	Nerve	First Sign of Syndrome
Anterior	Tibialis anterior, EHL, EDL, peroneus tertius	Deep peroneal	Weak toe/ankle dorsiflexion, 1st web space numbness
Lateral	Peroneus longus and brevis	Superficial peroneal	Weak eversion, lateral leg numbness
Deep Posterior	Tibialis posterior, FHL, FDL, popliteus	Tibial nerve	Weak toe flexion, sole numbness
Superficial Posterior	Gastrocnemius, soleus, plantaris	Sural nerve	Weak plantarflexion, lateral foot numbness

Tibial Shaft Fractures

Tibial Shaft Fractures

MANAGEMENT APPROACH

Critical Must-Knows

Clinical Pearls

Clinical Imaging

Imaging Gallery

Critical Tibial Shaft Fracture Exam Points

Open Fracture Risk

Compartment Syndrome

IM Nail = Gold Standard

Acceptable Alignment

Quick Decision Guide

5 PsCompartment Syndrome 5 Ps

ALPDTibial Compartments

GAPOpen Fracture Antibiotics

5-5-10-10Acceptable Alignment

Overview and Epidemiology

Demographics

Mechanism

Anatomy

Key Anatomical Concept

Tibial Anatomy

Proximal Tibia

Shaft

Four Compartments of the Leg

Tibial Blood Supply

Segmental Fractures

Classification Systems

Gustilo-Anderson Open Fracture Classification

Automatic Type III

AO/OTA Classification

Clinical Assessment

History

Examination

Compartment Syndrome Assessment

Differential Diagnosis & Mimics

Distinguishing Tibial Shaft Fracture from Mimics

Never Nail Before Excluding Pathology

Areas of Controversy & Uncertainty

Open Debridement Timing

Suprapatellar vs Infrapatellar

Fibula Fixation

Routine Fasciotomy / Pressure Monitoring

Investigations

Imaging Protocol

Radiographic Example

Management Algorithm

Open Fracture Protocol

Intramedullary Nailing

IM Nail Technique

Reamed vs Unreamed

Approach Comparison

Plate Fixation Indications

External Fixation

Definitive Ex Fix

Temporary Ex Fix

Ex Fix to IM Nail Conversion

Conservative Management

Cast/Brace Protocol

Surgical Technique

Intramedullary Nailing - Gold Standard

Critical Technical Points

When IMN Not Suitable

Compartment Syndrome Management

Time is Muscle

Fasciotomy Technique

Complications

Postoperative Care

Immediate Postoperative (Days 0-14)

Weeks 2-12

3-12 Months and Beyond

Outcomes and Prognosis

Union Rates

Outcomes by Injury Pattern

Prognostic Factors

Favorable Factors

Unfavorable Factors

Functional Outcomes

Radiographic Healing Examples