What is the treatment for a tibial (tibia) fracture?

Treatment of Tibial Fractures

For hemodynamically stable patients without severe visceral injuries, perform early definitive osteosynthesis of tibial shaft fractures within 24 hours to reduce respiratory complications and systemic morbidity. 1

Initial Assessment and Imaging

Immediate Evaluation

• Obtain anteroposterior, lateral, and mortise radiographic views to confirm fracture location (proximal tibia, tibial shaft, distal tibia) and document displacement (>2mm is significant). 2
• Assess for vascular injury with CT angiography if any of the following are present: externalised arterial bleeding, injury near major vascular axis, non-expanding hematoma, isolated neurological deficit, or ankle-brachial index <0.9. 1
• Evaluate for compartment syndrome, which remains the most significant early complication—suspect with pain out of proportion to injury or increasing narcotic requirements. 3

Advanced Imaging

• Order CT for tibial plateau fractures to characterize severity (100% sensitivity vs 83% for radiographs alone) and measure articular depression—depression >11mm predicts lateral meniscus tear and ACL avulsion. 4
• Consider MRI after CT if articular depression >11mm, clinical suspicion of meniscal/ligamentous injury, or surgical planning is needed. 4
• Remember that approximately 10% of tibial fractures are only visible on follow-up radiographs, so repeat imaging is justified for persistent symptoms despite normal initial films. 2, 5

Surgical Timing Algorithm

Stable Patients (No Shock, No Severe Visceral Injuries, No Respiratory Failure)

Proceed with early definitive osteosynthesis within 24 hours. 1

• This approach specifically reduces respiratory complications including ARDS and fat embolism syndrome in tibial shaft fractures. 1
• Early fixation decreases both local and systemic complications when physiologic stability is maintained. 1

Unstable Patients (Shock, Severe Visceral Injuries, or Respiratory Failure)

Use damage control orthopaedics with temporary stabilization followed by delayed definitive surgery. 1

• Apply external fixator or skeletal traction initially for femoral and tibial shaft fractures. 1
• Delay definitive osteosynthesis to avoid "second hit" phenomenon—the surgery-induced inflammatory trigger that causes massive blood loss, lactic acidosis, hypothermia, and multiple organ failure. 1
• Perform safe definitive osteosynthesis as early as possible once circulatory status, respiratory function, and coagulation are stabilized. 1

Specific Fracture Management

Tibial Shaft Fractures

• Use reamed intramedullary nailing as the primary surgical technique—this achieves consolidation in most cases with mean healing time of 175 days (faster for transverse fractures at 122 days). 6
• For fractures with intact fibula, locked nailing is particularly important as these have higher rates of varus malunion and non-union with conservative treatment. 6
• Encourage immediate weight bearing postoperatively to promote healing. 6
• Consider dynamization with fibulotomy if delayed consolidation occurs. 6

Tibial Plateau Fractures

• Conservative management is appropriate for non-displaced fractures. 7
• Surgery is required for displaced fractures to restore articular congruity, mechanical alignment, and ligamentous stability, and to permit early mobilization. 7
• Surgical management achieves excellent medium-term functional outcomes with at least half of patients returning to original physical activity levels. 7

Open Fractures

• Perform serial wound debridements, wet-to-dry dressing changes, and wound-site compression. 8
• Apply split-thickness skin grafts as needed for wound closure. 8
• All fractures can heal without bone grafting when properly managed with external fixation and compression techniques. 8

Critical Pitfalls to Avoid

• Never assume normal initial radiographs rule out fracture—document plan for follow-up imaging at 1-2 weeks if symptoms persist. 2, 5
• Do not perform early definitive surgery on unstable polytrauma patients—the surgical "second hit" can precipitate multiple organ failure through massive blood loss, coagulopathy, and inflammatory mediator release. 1
• Monitor closely for compartment syndrome—perform secondary aponeurectomy immediately if suspected, as this complication occurs with both conservative and surgical management. 6, 3
• Document inflammatory markers and fever if infection is in differential, and record explicit follow-up plan to detect late displacement. 2

Postoperative Considerations

• Expect pain at nail insertion site (reported by 50% of patients, typically rated 1-2 on 10-point scale), which usually resolves after nail removal. 6
• Active knee and ankle mobility should be normal at final follow-up. 6
• Most patients feel cure is achieved by 5 months postoperatively. 6
• Risk factors for poor outcomes include postoperative arthritis, bicondylar and comminuted fractures, meniscal removal, instability, malalignment, and articular incongruity. 7