Tibial shaft fractures in adults

INTRODUCTION — Tibial fractures are common long-bone injuries typically caused by trauma. Open fractures generally occur from high-velocity trauma (eg, automobile collision). Closed injuries may occur from falls or sports-related trauma.

This topic will review issues related to tibial shaft fractures. Tibial shaft fractures in children and a general overview of tibial fractures in adults are presented separately. (See "Tibial and fibular shaft fractures in children" and "Overview of tibial fractures in adults".)

EPIDEMIOLOGY — Tibial fractures are common long-bone injuries, accounting for approximately 2 percent of all adult fractures [1]. The National Center for Health Statistics reports 492,000 tibial fractures per year in the United States. Greater than 70,000 hospitalizations, 800,000 office visits, and 500,000 hospital days have been attributed to tibial shaft fractures in the United States annually [2]. The presence of significant osteoporosis increases the risk for compound or more complex fractures associated with higher morbidity and mortality [3,4]. More severe tibia fractures stem from high-energy trauma, most often motor vehicle collisions (MVCs) [3,5,6].

In Europe, closed tibial fractures are often associated with football (soccer) [7,8]. Shin guards may provide some protection, but many players who sustain tibial fractures are using shin guards at the time of injury [9]. Skiing is another sport commonly associated with low-energy, often torsional, tibial fractures [3]. Males sustain sports-related tibial shaft fractures more often than females [10].

A large-scale study of tibial shaft fractures from a trauma databank found an incidence of 16.9/100,000 population with a bimodal distribution of peaks at ages 20 and 50 [11]. The risk is somewhat higher in males (males 21.5/100,000 and females 12.3/100,000 incidence per year) [10]. The mechanism of injury among older adults is primarily falls, while MVCs are the primary cause in younger age groups. Tibial shaft fractures sustained from significant trauma are often associated with additional injuries. In this series, 59.6 percent of patients had at least one associated injury. The most common associated injuries were additional fractures, but 16.7 percent of this cohort sustained injury to an internal organ.

Trauma registry studies from the Netherlands and Sweden report a similar incidence of tibial shaft fractures [12,13]. In the Netherlands, there has been a slight decrease in incidence (12 percent). Tibial shaft fractures among women increased with age, but among men, the incidence was greatest among younger individuals. Hospital stays vary depending on the percentage of fractures due to high-energy trauma (ie, MVCs). Men and older patients have longer lengths of stay. Mean years lived with disability in both males and females was 4.5 and declined linearly with age.

CLINICAL ANATOMY — The tibia is the major weight-bearing bone of the lower leg (figure 1 and figure 2). The proximal portion of the bone, the tibial plateau, forms the lower surface of the knee joint (figure 3 and picture 1). The tibial shaft bridges the distance to the distal tibia, which contributes the superior articular surface of the ankle joint at the tibiotalar articulation as well as the medial malleolus. Another key bony landmark is the tibial tuberosity, which sits several centimeters below the joint line and the inferior patellar pole and serves as the attachment site for the patellar tendon [14].

A strong fibrous structure, the interosseous membrane, or syndesmosis (figure 4), connects the tibia and fibula along the length of the two bones. Proximally, this structure, reinforced by strong anterior and posterior ligaments, forms a synovial joint, the proximal tibiofibular articulation. Distally, the interosseous membrane and three ligaments (the anterior, posterior, and transverse tibiofibular ligaments) stabilize the superior ankle joint.

Another fibrous structure, the crural fascia, surrounds the bones and muscles of the lower leg. Fascial extensions and the interosseous membrane separate the muscles, nerves, and vessels of the lower leg into four distinct compartments (figure 5). Three of these, the anterior, posterior, and deep posterior compartments, all border the tibia and can be compromised by tibial injury.

Nerves and vessels lie within the anterior and the deep posterior compartments, and trauma that causes significant swelling in these compartments can result in neurovascular compromise. The key blood supply of the tibia arises from periosteal vessels and the nutrient artery. The nutrient artery originates from the posterior tibial artery and enters the posterolateral cortex at the middle third of the tibial shaft near the origin of the soleus muscle (figure 6). Fractures in this region potentially compromise this blood supply.

The periosteal vessels provide a less vulnerable circulation as they derive an abundant blood supply from the anterior tibial artery, which travels down along the interosseous membrane. Vascular compromise can arise proximally, from marked effusion of the knee joint or trauma that affects the popliteal artery before it branches into the anterior and posterior tibial arteries or at the level of the anterior tibial artery as it branches off the popliteal artery and passes through a gap in the interosseous membrane [14].

The tibial nerve and several branches provide the key innervation to the muscles of the lower leg and foot (figure 7 and figure 8). Nerve roots arise from L4 through S3. The posterior tibial nerve parallels the course of the posterior tibial artery and courses through the deep posterior compartment. In the popliteal space, branches of the tibial nerve provide innervation to the posterior compartment and to the popliteus muscle. The deep fibular (peroneal) nerve branches and follows the course of the anterior tibial artery providing innervation to muscles in the anterior lower leg.

MECHANISM OF INJURY — Three types of forces lead to most tibial shaft fractures: low energy, high energy, and rotational. Low-energy forces, such as those involved in sporting injuries or falls from standing, generally lead to fracture in the distal tibial shaft. Fractures of the thicker proximal shaft typically arise from high-energy impact, as occurs with motor vehicle collisions (MVCs). Tibial fractures from high-energy trauma are associated with higher complication rates [15]. Rotational forces lead to oblique, spiral, or distal fractures.

Direct trauma leads to transverse and comminuted fractures with the extent of comminution roughly proportional to the magnitude of force. Fractures from direct blows typically affect the anterior medial tibia, in part because of the lack of soft tissue protection.

Classifications of tibial fractures based upon specific aspects of the bone injury or by the degree of associated soft tissue injury are used to guide orthopedic decision-making and help to predict outcomes [2]. The classification schemes for tibial shaft fractures used by orthopedists are beyond the scope of this topic but were discussed in a 2003 review of treatment of closed tibial fractures [2], to which the interested reader is referred.

SYMPTOMS AND EXAMINATION FINDINGS — Tibial shaft fractures result in localized swelling, pain, and the inability to bear weight. Significantly displaced fractures can produce a shift in the alignment or gross malalignment of the lower leg. Open fractures are common, and overlying skin should be carefully examined for small lacerations.

Severe fractures from high-velocity trauma can be associated with neurovascular injury. Therefore, it is important to examine distal pulses and lower extremity motor and sensory function. (See "The detailed neurologic examination in adults".)

Displaced tibial shaft fractures and those with considerable soft tissue trauma are at increased risk for developing acute compartment syndrome (ACS), a limb-threatening complication. Symptoms and signs of ACS can include increasing and unrelenting pain, tense swelling, and pain with passive flexion and extension of the toes. (See "Acute compartment syndrome of the extremities" and 'Complications' below.)

DIAGNOSTIC IMAGING — Plain radiographs to assess tibial shaft fracture include anteroposterior (AP) and lateral views. Plain radiographs are generally thought to be highly sensitive and specific for typical tibial shaft fractures, but high-quality studies supporting this assertion are lacking. Plain radiographs are less sensitive for detecting subtle metaphyseal fractures, stress fractures, and insufficiency fractures.

The AP and lateral radiographs obtained should include the entire length of the lower leg from knee to ankle. Radiolucent splinting prevents additional injury and allows proper positioning to best visualize fractures.

As noted above, the orthopedic literature describes numerous fracture classification systems and radiographic grading criteria that are beyond the scope of this topic. However, radiographic findings that are important for initial evaluation include:

●Location of the fracture

●Separation or overlap of fracture fragments (distinguishes displaced from nondisplaced fractures)

●Fracture pattern (eg, transverse, oblique, comminuted)

●Degree of angulation

●Presence of malrotation

These radiographic features help to determine whether conservative or operative treatment is preferred (figure 9 and image 1). Significant malrotation, malalignment (angulation), and displacement for tibial shaft fractures are defined as follows:

●Malrotated fractures have ≥10 degrees of rotation in any plane

●Malaligned fractures are angulated ≥10 degrees

●Displaced fractures have ≥5 mm of displacement

Instructions for assessing and describing fractures on plain radiographs are provided separately. (See "General principles of fracture management: Bone healing and fracture description".)

Given the risk for posterior malleolar fracture associated with tibial fractures involving the distal third of the shaft and spiral fractures of the tibia, we suggest obtaining computed tomography (CT) in this setting to avoid missed injuries. (See 'Complications' below.)

Research into the use of ultrasound to diagnose long bone fractures is ongoing. (See "Overview of tibial fractures in adults", section on 'Diagnostic imaging'.)

DIAGNOSIS — Definitive diagnosis of a tibial shaft fracture is made by plain radiograph.

DIFFERENTIAL DIAGNOSIS — The presentation and diagnosis of tibia fractures resulting from high-energy trauma is straightforward. However, the presentation of tibia fractures caused by low-energy trauma may be similar to a number of other conditions. In the large majority of cases, a history of trauma combined with clinical findings of significant pain, focal tenderness, and an inability to ambulate will prompt the clinician to obtain plain radiographs and diagnose the tibia fracture. However, similarities in the initial presentation may cause confusion in some instances. Conditions to consider in the setting of low-energy trauma include the following:

●Medial tibial stress syndrome ("shin splints") ‒ Medial tibial stress syndrome is relatively common among runners, who present with a gradual increase in pain that is present diffusely most often along the posterior medial border of the tibia extending from the middle to the distal third of the shaft. Typically, there is no history of acute trauma, no focal tenderness, and no difficulty with simple ambulation. The key distinguishing feature beyond history and examination is the absence of any radiographic abnormality. (See "Running injuries of the lower extremities: Patient evaluation and common conditions", section on 'Medial tibial stress syndrome (shin splints) and tibial stress fractures'.)

●Tibial stress fracture ‒ Patients with a stress fracture of the tibial shaft develop pain gradually over several weeks that occurs only during activity (eg, running), but a sudden increase in pain may prompt them to seek medical attention. Typically, there is no history of acute trauma, and while there may be some pain, there is no difficulty with simple ambulation. Radiographs are often unremarkable but may reveal a stress fracture. When positive, the radiograph findings of a stress fracture are more subtle and often focal, which help to distinguish them from a traumatic fracture. (See "Stress fractures of the tibia and fibula".)

●Insufficiency fracture due to osteoporosis or other bone disease ‒ Insufficiency fractures can occur without trauma but manifest similar clinical findings (eg, focal tenderness, inability to ambulate) and are diagnosed by plain radiograph. Management is likely to be more complex than similar fractures in the absence of underlying bone disease. A key radiographic feature suggesting insufficiency fracture is relative osteopenia along the entire tibia. (See "Clinical manifestations, diagnosis, and evaluation of osteoporosis in postmenopausal women".)

●Microtrabecular fracture ("bone bruise") ‒ Microtrabecular fractures, or bone bruises, frequently occur in conjunction with anterior cruciate ligament (ACL) injuries but also with posterior cruciate ligament (PCL), meniscus, and other intra-articular injuries. These fractures typically occur on the femoral condyles or on the medial or lateral tibial plateaus. Rarely, these lesions, which are seen only with magnetic resonance imaging (MRI), develop on the tibial shaft and cause symptoms classically associated with a tibial fracture, including pain and inability to bear weight. If such lesions are found in the shaft of the tibia, clinicians should assess the patient for metabolic bone disease [16]. The absence of cortical change on radiograph or MRI, combined with the presence of bone marrow edema on MRI, is diagnostic.

●Subperiosteal hematoma ‒ Blunt trauma, particularly along the course of the anterior tibial artery, can lead to a significant hematoma with enough pain to mimic fracture. Pseudo-aneurysm of the tibial artery occurs in rare situations of blunt trauma and may cause delayed pain and swelling. While all contact sports pose a risk, snowboarding and alpine sports are performed at high velocity, and contusions to the tibia and lower extremity are among the most common injuries sustained [17,18]. Soft tissue swelling, pain, and tightness may suggest fracture, but radiographs are unremarkable. Musculoskeletal ultrasound can confirm the presence of hematoma.

●Bone tumor ‒ Tumors in long bones generally become symptomatic over months. However, pain frequently begins after an injury, may wax and wane, and persists at night in some cases. Systemic symptoms such as fever, weight loss, and malaise are often absent. Examination often reveals focal tenderness and a soft tissue mass. The proximal tibial shaft is a relatively common site for osteosarcoma. Some tumors present as pathologic fractures following trauma. Diagnosis is made by radiograph. (See "Osteosarcoma: Epidemiology, pathology, clinical presentation, and diagnosis" and "Nonmalignant bone lesions in children and adolescents".)

●Acute compartment syndrome ‒ Acute compartment syndrome (ACS) most often develops soon after significant trauma, particularly involving long bone fractures, but nontraumatic conditions may play a role. Important clues to the development of ACS include rapid progression of symptoms and signs over a few hours and the presence of multiple findings consistent with the diagnosis in a patient at risk. Notable findings include pain out of proportion to apparent injury, pain with passive stretch of muscles in the affected compartment, and a tense compartment with a firm "wood-like" feeling. (See "Acute compartment syndrome of the extremities".)

INDICATIONS FOR ORTHOPEDIC REFERRAL — Most physicians refer traumatic tibial fractures to orthopedists for definitive care. Rare exceptions to this would be minor, non-displaced fractures. Physicians managing such fractures must be proficient in the application and management of long leg casts.

Emergency (ie, immediate) surgical referral is required for open (compound) fractures, fractures with evidence of neurovascular injury or compartment syndrome, and fractures associated with dislocation of the knee or ankle (which must be reduced immediately). Time to operative intervention correlates with the risk of infection in open tibial fractures: a delay greater than six hours increases the risk [19]. Urgent referral (within a day or two of injury) is needed for severely comminuted fractures and markedly displaced fractures (assuming there is no neurovascular compromise). (See "Acute compartment syndrome of the extremities" and "Knee (tibiofemoral) dislocation and reduction".)

Orthopedists do not agree on how much displacement is acceptable or when to proceed with intramedullary nailing. Early assessment by the orthopedist helps to determine the treatment strategy.

INITIAL TREATMENT — Initial treatment is focused on symptom relief and preventing further injury. Stabilization of the fracture is accomplished with a long leg, posterior splint. Ice, elevation, and light compression minimize swelling and, along with analgesics, help to control pain (issues surrounding the use of nonsteroidal antiinflammatory drugs [NSAIDs] with fractures are reviewed separately). These treatments continue for 48 to 72 hours, or until definitive management begins. Close monitoring during the initial treatment phase must allow clinicians or caretakers to detect any emerging compartment syndrome or change in neurovascular status. (See "Nonselective NSAIDs: Overview of adverse effects", section on 'Possible effect on fracture healing'.)

In addition to adequate protein and calcium intake, vitamin D supplementation is a reasonable intervention to help ensure proper fracture healing [20]. Research demonstrates that vitamin D levels fall during the early weeks of tibial fracture healing. As vitamin D plays a role in the mineralization and formation of callus, many physicians prefer to supplement vitamin D during the healing phase. (See "General principles of definitive fracture management", section on 'Adjunctive therapy for fracture healing'.)

DEFINITIVE TREATMENT — Closed, well-aligned, nondisplaced tibial shaft fractures may be definitively treated with a long leg cast. Optimal management of displaced tibial shaft fractures has not been definitively determined, but intramedullary nailing is common [21].

According to a 10-year retrospective study from a single United States trauma center of closed, nondisplaced tibial shaft fractures initially managed with casting (n = 334), 38 percent of patients with these injuries were ultimately suitable candidates for nonoperative treatment [22]. Among patients initially treated conservatively in this cohort, 70 percent were switched to surgical management. Key reasons for transitioning to surgery included difficulty maintaining alignment and intolerance of long leg casting.

Long leg casting — In order to effectively protect the tibia following fracture, a long leg cast is applied that incorporates the knee and ankle joint, thus preventing excess motion above and below the fracture. The cast extends from the metatarsal heads to the upper thigh. The ankle is positioned in neutral with no dorsal or plantar flexion. Knee position allows up to 5 degrees of flexion. The steps for applying this type of cast are described below:

●Preparation and positioning – Lay out all the necessary equipment, including appropriately sized stockinette and casting material (picture 2). It is important to position the leg properly with the preferred angles for knee and ankle flexion and maintain these while the under layers and casting material are applied. Assistance is necessary. The first layer applied is the stockinette (picture 3).

●Application of padding – Next, apply the padding for the cast (eg, Webril) by rolling it onto the extremity from distal to proximal; each layer should overlap the preceding layer by about 50 percent (picture 4). Three or four layers of padding are used for the lower extremity. Add extra padding over any bony prominences (eg, medial and lateral malleoli), and avoid any folding of the padding material to prevent pressure sores from developing below the cast.

●Application of cast to lower leg – Once the padding is in place, apply the cast material, either fiberglass cast tape or plaster (picture 5). The cast material is applied to the lower leg first, moving distal to proximal and ensuring approximately a 50 percent overlap with the previous layer. Before the final layer is applied, fold the distal end of the stockinette back over the cast material and then add the final layer. Folding back the stockinette prevents the cast tape or plaster from touching the patient's skin. A total of 5 to 6 layers of fiberglass tape, or 8 to 12 layers of plaster, is applied.

●Application of cast to upper leg – Once the casting material applied to the lower leg has set (usually 5 to 10 minutes), apply casting material to the thigh (picture 6). Again, a 50 percent overlap of layers is appropriate, and before the final layer is applied, the stockinette should be folded back over the cast material at the proximal thigh and the final layer of casting material applied (picture 7). Once the casting material is applied, but before it sets, the clinician can use the flat surface of their palms to mold the cast to the contours of the bones.

This type of cast permits limited weight bearing to begin when clinically feasible. Plaster casts mold more closely to the leg and are preferred for the first few weeks of treatment. At the first cast change, a switch to fiberglass material allows the patient a much lighter cast and easier ambulation [2,23]. (See "General principles of definitive fracture management", section on 'Casting'.)

Operative versus nonoperative interventions — If long leg casting fails to achieve or maintain adequate reduction of tibial shaft fractures, the patient needs operative intervention.

It remains uncertain whether operative interventions, such as intramedullary nailing (image 2) or external fixation, result in better outcomes than closed management with casting [24-27]. A meta-analysis of studies that compared cast treatment versus open reduction and internal fixation or intramedullary nailing of closed tibial shaft fractures found insufficient evidence to support the superiority of any approach [24]. Another review that pooled data from prospective studies of cast versus operative treatment in 895 fractures was also inconclusive [25].

Operative treatment enables most patients to return to activity more quickly than casting. However, problems such as pain and functional limitations may persist, although data are conflicting. As examples, in a study of 223 patients who underwent intramedullary nailing, many experienced knee pain and difficulty returning to full activity or even performing activities of daily living even after six years [28]. However, a prospective observational study of intramedullary nailing reported that while significant problems persisted at one year, by five-year follow up, most patients reported satisfactory outcomes, and their quality of life was equal to that of the reference group [29].

Several trials involving cast braces have reported satisfactory outcomes, supporting the notion that conservative care is adequate for many tibial shaft fractures [26,30]. An observational study, performed in a resource-limited country, of 68 patients with tibial fractures treated alternately with cast bracing or intramedullary nailing reported no major differences in functional outcomes but lower treatment costs in the cast bracing group [31]. While commercial products made from synthetic materials are available, the traditional cast brace is made by covering the entire leg and foot with stockinette and then applying two plaster casts, one to the lower leg and one to the thigh (picture 8 and picture 9). These two casts are connected on the medial and lateral aspects of the knee by attaching two hinged medal braces to each plaster cast segment. This construct provides for some degree of knee flexion when patients begin progressive weight bearing (generally not for several weeks, depending upon the injury). Thus, cast bracing may offer advantages in areas with limited resources and less access to surgical services.

When comparing surgery and casting, the initial procedure cannot be considered in isolation, as a significant number of patients require additional surgery after the initial procedure. According to a study using data from the Swedish Fracture Registry, 37 percent of fractures treated operatively (majority with intramedullary nailing) underwent repeat operation [32].

The following observations may be pertinent to decision-making regarding management in an individual patient:

●Operative treatment leads to lower rates of nonunion or malunion.

●Operative treatment allows for earlier return to activity in most cases.

●Cast treatment entails a lower risk of superficial infection [33].

However, if long leg casting fails to achieve or maintain adequate reduction of tibial shaft fractures, the patient needs operative intervention.

FOLLOW-UP CARE — Loosening of the cast typically occurs as swelling decreases. Thus, the cast is likely to need changing every two to three weeks. Plaster casts mold more closely to the leg and are preferred for the first two to three weeks of treatment. Subsequently, a switch to lighter fiberglass material allows for easier ambulation [2].

The patient should remain non-weight bearing for the first one to two weeks in the long leg cast and then progress gradually to partial and then full weight bearing. Serial radiographs are obtained at weekly follow-up visits to identify any loss of reduction or change in position. After approximately four weeks, visits are extended to every two weeks, and these continue until evidence of satisfactory bone healing occurs, as demonstrated by callus formation and filling in of the fracture line on radiograph. Radiographic union scales are being developed to help clinicians determine the adequacy of healing, but further study is needed [34]. The author obtains radiographs at each follow-up visit until healing is evident. Thereafter, radiographs are obtained only if there is new trauma or new or unusual pain develops at the site.

Most nondisplaced tibial shaft fractures heal within 10 to 14 weeks. Definitive treatment entails four to six weeks of immobilization in a long leg cast. The cast is exchanged for a short leg walking brace (picture 10) when satisfactory bone healing is documented. Newer, lightweight walking appliances with air or other cushioned padding allow more aggressive rehabilitation once the patient progresses enough to use them.

Although prolonged absences from sedentary work are unnecessary, many patients with tibial shaft fractures experience persistent pain and have difficulty returning to full activity [35]. Clinicians should caution patients that healing takes time and that some symptoms may persist. (See 'Complications' below.)

COMPLICATIONS — Potential complications following tibial shaft fracture include the following:

Acute complications:

●Acute compartment syndrome (ACS; common; limb-threatening)

●Deep vein thrombosis (common; life-threatening)

●Infection (higher risk with open fracture or surgery)

●Loss of alignment

●Fat embolism (uncommon; life-threatening)

●Fibular (peroneal) nerve injury (uncommon; usually transient)

●Concomitant injury (eg, posterior malleolar fracture, talus injury)

Longer-term and chronic complications:

●Nonunion or malunion

●Knee pain

●Leg swelling

●Reduced ankle mobility

●Tibiofibular joint dislocation

●Thigh and calf muscle atrophy

●Osteoarthritis of knee or ankle

In the days following injury, patients with tibial shaft fractures are at relatively high risk of developing ACS, a limb-threatening complication. Patients must be monitored closely for signs of ACS during this period. Early symptoms of ACS include progressive pain out of proportion to the injury; signs include tense swollen compartments and pain with passive stretching of muscles within the affected compartment. A review of adult tibial shaft fractures reported a rate of ACS of 11.1 percent [36]. Motor vehicle crashes (MVCs), polytrauma, and a more complex fracture all increased the risk for ACS. (See "Acute compartment syndrome of the extremities", section on 'Clinical features'.)

Deep vein thrombosis frequently complicates tibial shaft fracture. As an example, in an observational study of 918 tibial shaft fractures treated with intramedullary nailing, 122 deep vein thromboses were identified by ultrasound prior to surgery [37]. This included 12.1 percent of isolated tibial shaft fractures and 18.8 percent of those associated with a concomitant fracture. Diabetes and older age were associated with increased risk. (See "Clinical presentation and diagnosis of the nonpregnant adult with suspected deep vein thrombosis of the lower extremity".)

Other potential short-term complications include infection, which occurs more frequently with open fractures and those requiring surgical fixation, and loss of alignment [33]. Possible longer-term complications include malunion and nonunion. Early weightbearing appears to reduce the risk of nonunion in surgically treated patients [38]. (See "General principles of fracture management: Early and late complications".)

Fat embolism syndrome occurs following high-energy trauma, particularly fractures to long bones or the pelvis. The condition can be life threatening. Common manifestations include signs of respiratory distress (including hypoxemia, dyspnea, and tachypnea) followed by neurologic abnormalities frequently involving confusion and depressed mental status. The condition can occur before or following surgical intervention. (See "Fat embolism syndrome", section on 'Clinical presentation'.)

Observational studies suggest that patients treated with intramedullary nailing regain function but often experience chronic sequelae, including knee pain, leg swelling, reduced ankle mobility, thigh and calf muscle atrophy, and osteoarthritis of the knee or ankle [39]. The percent of patients experiencing pain at 3 to 12 months following surgery ranges from approximately 40 to 65 percent, and pain may persist much longer [39-42]. Although most patients experience mild to moderate pain (in one small observational study, approximately 90 percent rated their pain as 1 to 5 on a 10-point visual analog scale), a substantial percentage experience more severe pain. Many patients also experience some degree of hyperalgesia. Most patients describe some degree of disability for several years [13,42].

According to multiple observational studies, posterior malleolar fractures are a relatively common complication of tibial shaft fractures, particularly spiral fractures of the distal third, where they may be present in as many as 70 percent of cases [43,44]. Up to 50 percent of posterior malleolar fractures remain occult (ie, not seen on plain radiograph), requiring computed tomography (CT) for diagnosis. Given the higher risk of posterior malleolar fracture in patients with tibial fractures involving the distal third of the shaft, we suggest obtaining a CT in this setting to avoid missed injuries [44]. (See 'Diagnostic imaging' above.)

Ankle pain affects over 10 percent of patients following tibial shaft fracture, and this may be due to a talus injury in many cases. In an observational study, 22 of 52 patients with tibial shaft fractures treated with intramedullary nailing were found to have talus lesions on magnetic resonance imaging (MRI), including osteochondritis dissecans, edema, and bone cysts, even though the fracture did not extend to the ankle joint [45]. Fractures of the distal third of the shaft, spiral fractures, and fractures with an associated lateral malleolus fracture showed higher risk for concomitant talar injury. (See "Osteochondritis dissecans (OCD): Clinical manifestations, evaluation, and diagnosis".)

Injury to the fibular (peroneal) nerve occurs more often with fractures managed surgically, but the resulting deficit is usually sensory and temporary [15]. Athletes recovering from tibial shaft fractures should be aware that calf atrophy can persist for years [46].

A small number of patients with tibial shaft fractures sustained from high-energy trauma also incur proximal tibiofibular joint dislocation, which may manifest as instability during recovery after surgical repair [47]. This uncommon problem may be overlooked and should be investigated in patients who experience feelings of instability in the area of the proximal tibiofibular joint during their recovery. Disruption of the distal tibiofibular joint can also occur. (See "Knee (tibiofemoral) dislocation and reduction".)

Cigarette smoking increases the risk of nonunion and malunion with all fracture types, but multiple observational studies report an association between smoking and impaired healing of tibial fractures in particular [48-51].

Patients with co-existing mental health disorders show higher rates of nonunion and other complications, and thus higher rates of revision surgery, following tibial shaft fracture [52].

RETURN TO SPORT OR WORK — Whether a patient can return to full activity depends upon the severity of the tibial fracture and concomitant injuries, the activity, and patient characteristics (eg, age, comorbidities). In general, if patient's occupations require minimal walking or standing, they can often return to work once they progress out of a long leg cast. For most athletes, cross-training in non-weight bearing activities begins at approximately four to six weeks following the injury.

Retrospective studies have examined the recovery time for tibial shaft fractures in soccer athletes. The following observations are illustrative:

●In a series of 50 consecutive adult soccer athletes with tibial shaft fractures, all reported good or excellent outcomes with treatment, but only 54 percent returned to competitive soccer [53].

●A retrospective review of 31 athletes with lower leg fractures found a significant delay in return to sport. For tibial fractures, the return time averaged 35 weeks, but if both tibia and fibula were fractured, the athletes needed 40 weeks.

Even though athletes rate outcomes highly, the severity of a tibial fracture indicates that they face a protracted recovery time before highly competitive activities can resume. A systematic review that included 16 studies but only three randomized trials reported greater delays and a lower rate of return to sport in those treated nonsurgically: 92 percent of athletes treated surgically returned to full sport compared with only 67 percent in the nonsurgical cohort [54].

Retrospective data on United States professional (American) football players with a tibial shaft fracture showed that greater than 90 percent returned to sport following intramedullary nailing [55]. While their performance remained impaired during the first year following injury, players returned to their baseline during the second year of recovery.

Prevention of tibial fractures in athletes is a worthy goal. However, a simple measure, shin guards, shows little effect on these injuries as 90 percent of soccer players experienced the injury while wearing them [9].

Although operative and nonoperative care leads to complete healing in the vast majority of tibial shaft fractures, residual symptoms are common. In a study of patients treated with intramedullary nailing or plate fixation, 61 of 64 (95 percent) returned to work, but 20 (31 percent) had to modify their work duties [56]. Residual ankle pain developed in 30 to 40 percent of patients, while knee pain developed in 20 to 30 percent.

For many patients who undergo surgery to treat a tibial shaft fracture, the injury has lifelong consequences. In a retrospective series of 223 patients with a mean follow-up of 7.9 years, 60 percent reported limitations in their activity and 44 percent reported chronic knee pain, leading to a drop in quality-of-life scores [42]. Particularly worrisome is that younger patients (18 to 34 years) reported the most difficulties.

ADDITIONAL INFORMATION — Several UpToDate topics provide additional information about fractures, including the physiology of fracture healing, how to describe radiographs of fractures to consultants, acute and definitive fracture care (including how to make a cast), and the complications associated with fractures. These topics can be accessed using the links below:

●(See "General principles of fracture management: Bone healing and fracture description".)

●(See "General principles of fracture management: Fracture patterns and description in children".)

●(See "General principles of definitive fracture management".)

●(See "General principles of acute fracture management".)

●(See "General principles of fracture management: Early and late complications".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Lower extremity (excluding hip) fractures in adults" and "Society guideline links: Acute pain management".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Lower leg fracture (The Basics)" and "Patient education: How to use crutches (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Mechanism of injury – Midshaft tibia fractures typically occur as a result of high-energy injuries (eg, motor vehicle crash [MVC], pedestrian-vehicle collision). Low-energy injuries more often lead to distal tibial fractures, while rotational injuries (foot planted and leg twists) cause spiral, oblique, or distal fractures. Diagnosis is made by plain radiograph. (See 'Epidemiology' above and 'Mechanism of injury' above and 'Diagnostic imaging' above.)

The presentation of tibia fractures caused by low-energy trauma may be similar to a number of other conditions. These are described in the text. In most such cases, radiographs allow the clinician to distinguish a fracture from alternative diagnoses. (See 'Differential diagnosis' above.)

●Indications for referral – Most physicians refer traumatic tibial shaft fractures to an orthopedist for definitive management. Fractures with comminution, significant angulation, or significant displacement must be referred. Significant malrotation, malalignment (angulation), and displacement for tibial shaft fractures are defined as follows:

•Malrotated fractures have ≥10 degrees of rotation in any plane

•Malaligned fractures are angulated ≥10 degrees

•Displaced fractures have ≥5 mm of displacement (see 'Indications for orthopedic referral' above)

●Emergency referral – Immediate surgical referral is required for all open fractures, fractures associated with neurovascular injury or suspected acute compartment syndrome (ACS), and fractures associated with dislocation of the knee or ankle.

●Complications – Tibial shaft fractures carry a relatively high risk for ACS, a potentially limb-threatening complication, and deep vein thrombosis. Other possible acute complications include infection, loss of alignment, fat embolism, fibular (peroneal) nerve injury, and concomitant injury (eg, posterior malleolar fracture). (See 'Complications' above and "Acute compartment syndrome of the extremities" and "Clinical presentation and diagnosis of the nonpregnant adult with suspected deep vein thrombosis of the lower extremity".)

●Initial management – Management of acute fracture includes use of a posterior long leg splint, analgesia, light compression, analgesics, and non-weight bearing status with crutches. Supplementation with vitamin D is a reasonable intervention. (See 'Initial treatment' above.)

●Nonsurgical management – Minor, nondisplaced, well-aligned tibial shaft fractures may be managed conservatively by physicians who are skilled at the application of a long leg cast and with monitoring for complications such as neurovascular injury and ACS. (See 'Definitive treatment' above.)

The initial splint is exchanged for a long leg cast after 48 to 72 hours once acute swelling has subsided. A plaster cast is preferred at the initial exchange. The plaster cast may be exchanged for a lighter-weight fiberglass cast after two to three weeks.

If radiographic healing is progressing normally six weeks following the initial injury, the long leg cast is exchanged for a short leg walking cast or a commercial cushioned lower-leg walking splint. Cigarette smoking increases the risk of nonunion, malunion, and delayed fracture healing. (See 'Follow-up care' above and 'Complications' above.)

●Prognosis – Prognosis varies depending on the severity of the fracture, concomitant injury, and other factors (eg, age, comorbidities). Long-term follow-up of tibial shaft fractures suggests that many patients experience some limitation of activity and often develop chronic knee or ankle pain. This does not seem related to the type of treatment.