Closed Tibial Fracture



Most common long bone fracture




Young patients / sports


Elderly / simple falls


MVA - often compound


Anatomical Classification



- proximal metaphysis


Shaft / Middle


Tibial Midshaft Fracture



- distal metaphysis


Tibial Fracture AP


Tscherne Soft Tissue Classification


Grade 0

- nil ST injury


Grade 1

- superficial abrasion / contusion

- ST injury from pressure from within


Grade 2

- deep contusion / abrasion

- due to direct trauma


Grade 3

- extensive contusion and crush

- subcutaneous tissue avulsion

- severe muscle injury




Acceptable alignment


No scientific data

- can probably accept a reasonable amount of deformity

- up to and including 10o without risk knee / ankle OA


Usually don't accept this


Operative v Non operative


Littenberg et al JBJS Am 1998

- meta-analysis of 19 papers

- non operative prevents infection

- ORIF more likely to result in union


Sarmiento 1000 patients closed treatment

- 60% lost to follow up

- non union rate 1.1%

- 10% short > 1 cm

- 5% > 8o varus

- comminution longer to unite

- intact fibula more rapid union but increased risk angular deformity


IMN v cast


Hooper et al JBJS 1998

- IMN more rapid union, less malunion and earlier RTW

- improved outcome when > 50% displacement or angulation > 10o


Puno et al Clin Orthop 1986

- 200 closed tibial fractures

- IMN union 98%, malunion 0%, infection 3%

- cast 90%, malunion 4%


Advantages cast

- no infection

- no knee pain

- no hardware to removed


Advantage IMN

- faster union

- reduced non union

- reduced malunion

- earlier ROM

- able to weight bear early


Non Operative Treatment / Plaster Cast




Low energy injury

Minimal ST injury

Stable fracture / minimal / acceptable displacement




Coronal < 5o

Sagittal < 10o

Rotation < 10o

Shortening < 1cm

> 50% apposition




Gavity assist over edge of bed

Application SL initially

Extend with knee slightly flexed


Union rate 




Tibial Shaft Fracture Non Operative Treatment BeforeTibial Shaft Fracture Non Operative Treatment After


Operative Treatment




1.  IM Nail

2.  Plate

3.  External Fixation


1.  IMN Nail


Tibial Midshaft Fracture IMN APTibial Midshaft Fracture IMN Post op


A.  IMN Tibial Shaft




Provides rotatory stability

- required with spiral / comminution / metaphyseal

- may not be necessary with transverse fractures




Larsen et al J Orthop Trauma 2004

- RCT of reamed v unreamed

- significantly longer time to union in unreamed



- reaming also bone grafts fracture site

- large nail provides greater stability


SPRINT trial JBJS Am 2008

- multicentred trial of over 1000 tibial IMN

- demonstrated a possible benefit for reaming


B.  IMN Proximal tibial fractures




High incidence malunion

- typically valgus 

- flexion / procurvatum

- posterior translation of distal segment


Proximal Tibial Fracture Poorly Nailed




Standard medial and anterior entry points

- mismatch to distal canal 

- canal becomes triangular

- pushes fracture into the above deformities


Surgical Points


1.  Change entry point

- match entry point to distal IM canal

- lateral and posterior

- in line with lateral tibial spine

- through or lateral to PT

- entry with knee semi-extended


2.  Blocking screws

- also lateral and posterior

- functionally narrow IM canal

- on concave side of deformity

- same positions as entry point

- posterior in proximal segment

- lateral in proximal segment


C.  IMN Distal tibial fractures


Distal Tibial FractureDistal Tibial Nail APDistal Tibial Nail Lateral




Distal tibial nails

- multiple distal screws

- some within 5 mm of end of nail

- usually 2 medial-lateral and 1 AP




Most important is to centre guide wire over talus

- in lateral and AP


1.  Use finger reduction tools and pass across fracture site

2.  Use temporary external fixator

3.  Pins in distal tibia / calcaneum to control distal fragment

4.  Plate fibula

5.  Blocking screws


2.  ORIF with plate



- metaphyseal / periarticular fractures

- tibial fractures in children


A.  Midshaft tibial ORIF


Tibial Midshaft PlateTibial Midshaft Plate Lateral



- poor skin / blood supply / muscle cover

- high risk of wound breakdown

- must strip bone to apply plate



- minimally invasive

- indirect reduction techniques





- excessive soft tissue stripping

- inability for fracture to compress


Distal Tibial ORIF Nonunion


B.  Distal Tibial ORIF



- too distal to nail



- may need initial external fixation

- hold reduction

- enable swelling to reduce

- ORIF as per tibial plafond fracture


Distal Tibial Fracture DisplacedDistal Tibial Fracture External FixationDistal Tibial Fracture ORIF


3.  External fixation




Contaminated wound

Vascular injury

Damage Control Orthopedics

Segmental bone loss - Ilizarov





- 4 or 5 mm half pin

- predrill to decrease thermal necrosis

- 2 near fracture and 2 far from cortex

- 2 bars / close to skin (2 cm)




Compartment syndrome


5 - 15 %

- pain from nerve ischaemia first symptom

- pain with passive stretch first sign


Normal compartment pressures

- > 30 mm Hg less than DBP

- < 30 mm Hg



- 3%


Delayed / non union


SPRINT trial JBJS Am 2008

- incidence of non union of 4%




Most common in proximal and distal tibial fracture


Anterior Knee Pain after IMN


Most common complication


Vaisto et al J Trauma 2008

- RCT of paratendinous v transtendinous nail insertion

- no difference in incidence of knee pain


Nail removal

- resolves in 1/2 after removal of nail

- improves in 1/4

- no improvement in 1/4