What is the treatment for a fractured tibia in an adult with no significant medical history?

Treatment of Tibial Fractures in Adults

For most displaced or unstable tibial shaft fractures in adults, intramedullary nailing is the treatment of choice, offering superior biomechanical stability, faster healing, and better functional outcomes compared to casting or other methods. 1, 2

Initial Assessment and Stabilization

Immediate Evaluation

• Assess for compartment syndrome urgently - this is the most significant early complication requiring immediate fasciotomy if present, indicated by pain out of proportion to injury or increasing narcotic requirements 3
• Obtain high-quality imaging including AP and lateral radiographs to define fracture pattern, displacement, and comminution 2
• Evaluate soft tissue injury severity, as this significantly impacts treatment decisions and outcomes 2
• Check neurovascular status documenting pulses, sensation, and motor function 4

Timing of Definitive Treatment

• For hemodynamically stable patients without severe visceral injuries: perform definitive fixation within 24 hours to reduce local and systemic complications 5
• For polytrauma patients with shock, respiratory failure, or severe visceral injuries: use temporary external fixation initially, then convert to definitive fixation once stabilized (damage control orthopedics approach) 5

Surgical Treatment Algorithm

Indications for Surgical Stabilization (Absolute)

• Open tibial fractures 3, 2
• Tibial shaft fractures with ipsilateral femoral fractures (floating knee) 3
• Vascular injury requiring repair 2
• Compartment syndrome requiring fasciotomy 3
• Polytrauma patients requiring mobilization 5

Indications for Surgical Stabilization (Relative)

• Comminuted fractures 3
• Displaced fractures with intact fibula (prevents adequate reduction) 3
• Displaced fractures in adolescents 3
• Inability to maintain acceptable alignment with casting 1

Surgical Technique Selection

Intramedullary Nailing (Preferred Method)

• Use interlocking intramedullary nails for most unstable tibial shaft fractures - this provides superior biomechanical stability and is the treatment of choice 1, 2
• Advantages include faster mobilization, full range of motion, and solid bone union without hypertrophy 2
• Newer nail designs now accommodate proximal and distal metaphyseal fractures 1

Plate Osteosynthesis (Limited Indications)

• Metaphyseal fractures (proximal or distal) where nail fixation is technically challenging 1
• Distal tibial metaphyseal fractures - though evidence shows no clinically important difference between nailing and plating for function, pain, or complications 6
• Very rare indications for diaphyseal fractures 2

External Fixation

• Skeletally immature patients with unstable patterns 1
• Patients with unacceptably small intramedullary canals 1
• Temporary stabilization in polytrauma/damage control situations 5, 2
• Open fractures with severe soft tissue injury as definitive or temporary treatment 2

Conservative (Non-Surgical) Treatment

Indications for Casting

• Non-displaced or minimally displaced tibial shaft fractures 1, 2
• Patients with good compliance who can be monitored closely 2
• Stable fracture patterns where soft tissues can maintain alignment 3

Casting Technique

• Use either conventional 3-point molding or Sarmiento functional bracing technique 3
• Both depend on intact soft tissues to maintain bony alignment 3

Risks of Conservative Treatment

• Deep venous thrombosis 2
• Compartment syndrome 2
• Progressive soft tissue injury 2
• Chronic regional pain syndrome 2
• Malunion or delayed union 1

Postoperative Management

Immediate Postoperative Care

• Provide aggressive pain management to facilitate early mobilization 7
• Monitor for compartment syndrome even post-operatively 3
• Assess wound healing and watch for infection, particularly in open fractures 4
• Perform neurovascular checks regularly 4

Mobilization Protocol

• Begin early mobilization with weight-bearing as tolerated - this prevents recumbency complications and improves outcomes 5, 7
• Start physical therapy immediately once surgical stabilization is confirmed, including muscle strengthening and balance training 7
• For upper extremity involvement, begin finger motion immediately to prevent edema and stiffness 7

Radiographic Monitoring

• Obtain immediate postoperative radiographs to confirm reduction and hardware position 7
• Schedule serial follow-up imaging to monitor fracture healing, detect loss of reduction, and identify hardware complications early 7
• Close monitoring is essential as inadequate follow-up can lead to delayed detection of complications 7

Key Complications to Monitor

• Compartment syndrome - highest priority complication requiring immediate recognition and treatment 3
• Infection (especially in open fractures) 2
• Malunion or nonunion 1
• Hardware failure 2
• Chronic pain 2
• Stiffness from delayed mobilization 7

Common Pitfalls to Avoid

• Inadequate pain control leads to poor outcomes - prioritize multimodal analgesia throughout healing 7
• Delayed mobilization results in stiffness - aggressive early range-of-motion is essential 7
• Missing compartment syndrome - maintain high index of suspicion with any increasing pain 3
• Choosing plate fixation for diaphyseal fractures when nailing is biomechanically superior 2
• Attempting definitive fixation in unstable polytrauma patients - use damage control principles 5