Background

Fractures of the tibia and the fibula are the subject of ongoing controversy and
discussion. Despite newer innovations in implants and external fixation devices,
tibial fractures essentially remain unresolved; they are among the most challenging fractures
to be treated by an orthopedic surgeon. These injuries are different and variable in presentation,
and their outcomes are unpredictable. The literature has traditionally included two schools of
thought regarding management of these injuries: operative and nonoperative therapy. Although
gray zones have been resolved, no consensus has been reached on the optimal management of
diaphyseal fractures of the tibia. This problem is predominantly attributed to the high
prevalence of concomitant closed and open soft-tissue injuries. Therefore, diaphyseal tibial
injuries are prone not only to infection and nonunion in the long term but also to significantly
increased morbidity caused by polytrauma and associated injuries in the acute setting. The
delayed unions and nonunions that occur in these fractures are themselves a separate problem
covered extensively in the literature and in academic forums. As Marvin Tile wrote: [1]
"We should reject the theories of the dogmatists who say that all tibial fractures should be
treated operatively or that all tibial fractures should be treated nonoperatively. It is time to
remove this kind of dogma from one's thinking and to individualize the treatment of these
fractures. The optimal treatment of a tibia fracture stems from an analysis of the natural history
of the fracture. A thorough assessment of the fracture type and pattern and then correlating it
with the natural history of a similar fracture type permits achievement of the best functional
outcomes for each individual patient." [1]
The ability to treat tibial shaft fracture by conservative or operative means depends on what is
often termed the natural history of the fracture. John Charnley hypothesized that the periosteal
hinge was the important factor in the management of fractures. Conservative management was
more likely to fail in fractures that had a residual fracture gap or an intact fibula than in others.
Some factors that influence the natural history of tibial fractures include the location and extent
of displacement, comminution, soft-tissue injury, and contamination. Another factor is
antecedent sepsis.
The Edwin Smith papyrus (an ancient Egyptian treatise on trauma surgery from the 17th
century BCE) contained references to the management of long-bone fractures with splints and
bandages. Hippocrates recommended the use of bandages and splints in his treatise on fractures;
he stressed the need to change these bandages frequently to accommodate changes in limb
swelling.
The advent of plaster and the design of functional casts revolutionized the management of tibial
fractures. [1, 2, 3, 4] Anthonius Mathijsen, Fedor Victor Krause, Pierre Delbet, and, more recently,
Augusto Sarmiento have considerably refined the indications and methods of conservative
management of tibial fractures. Understanding wound debridement and knowing Sir Joseph
Lister's work on antisepsis enabled surgeons to treat open diaphyseal tibial fractures with some
prospect of avoiding amputation.
Albin Lambotte first pioneered external fixation in the tibia, and Ernest William Hey Groves
introduced internal fixation with nails, which Gerhard Kntscher and J Otto Lottes later
popularized. The AO (Arbeitsgemeinschaft fr Osteosynthesefragen) school further refined the
practice of intramedullary nailing and interlocked nailing.
Anatomy
Knowledge of the relevant anatomy is essential for recognizing and planning
management of the soft-tissue injuries that are associated with diaphyseal tibial fractures. The
tibia is triangular in cross-section, with proximal and distal flares. It has three surfaces: medial,
lateral, and posterior. This bone is thinnest in cross-section at the junction of the middle and
lower thirds. The anteromedial border is subcutaneous throughout its length and is called the
shin. The broad and smooth medial surface is also subcutaneous throughout its length. The
nutrient artery to the tibia arises from the posterior tibial artery, which enters the tibia at the
posterolateral cortex distal to the origin of the soleus at the oblique line of the tibia. Inside the
medullary canal, it gives off three ascending branches and one descending branch, which form
the endosteal vascular tree. This, in turn, anastomoses with the periosteal vessels originating
from the anterior tibial artery. As it passes through a hiatus in the interosseous membrane, the
anterior tibial artery is particularly prone to injury in diaphyseal fractures of the tibia. The
peroneal artery has an anterior communicating branch to the anterior tibial artery. Hence, an
occlusion of the peroneal artery may exist, even in the presence of a dorsalis pedis pulse. The
distal third of the tibial shaft is supplied by the periosteal anastomoses around the ankle, with
branches entering the tibia through ligamentous attachments. A watershed zone may exist at
the junction of the middle and lower thirds of the tibial shaft. When the nutrient artery is
obstructed, reverse flow is established through the cortex. In such a situation, the periosteal
blood supply becomes more important. This situation emphasizes the importance of preserving
the periosteal attachments during fixation procedures. Tight osteofascial compartments
surround the tibia. The crural fascia divides the leg into four compartments; one of these is for
the weaker muscle group of extensors, and the other three serve the stronger flexor musculature.
The compartments of the leg are as follows:
 Anterior (extensors and dorsiflexors of the foot)
Lateral (strong everters and plantarflexors of the foot)
Superficial posterior (plantarflexors of the foot)
Deep posterior or medial (plantarflexors of the foot)
The septa are as follows:
Anterior septum, between the anterior and lateral compartments
Posterior septum, between the lateral and posterior compartments
Transverse septum, between the medial and posterior compartments
Interosseous membrane, between the anterior and middle compartments
Pathophysiology
The pathoanatomy of the fracture includes the location, morphology, and soft-tissue
status of the limb. Because of its subcutaneous location, the tibia is extremely prone to soft-
tissue injury and compounding (see the image below). This damage can occur at the time of
injury or at the time of surgery. Closed soft-tissue trauma can be significant and may go unre

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Diaphyseal fractures are slow to heal and are often unpredictable in terms of their
course to union. Trauma is greater with long, spiral fractures than with transverse and short
oblique fractures. The degree of trauma is further manifested in the extent of the comminution
and displacement, both of which are also indicative of extensive soft-tissue disruption. Soft-
tissue damage may be overt or may be a frank open injury. Ipsilateral limb fractures,
polytrauma, visceral injuries, and comorbid factors, such as the patient's general condition and
age, as well as coexistent arterial or nerve injuries, also markedly influence outcomes. Good
nonoperative management is preferred to bad operative management.
Etiology
The mechanism of a diaphyseal tibial injury can be direct or indirect. Direct
mechanisms of injury are high-energy fractures (road traffic accidents), penetrating injuries,
and three-point bending injuries. High-energy mechanisms produce transverse or comminuted
displaced diaphyseal injuries, with a higher incidence of compounding and soft-tissue
injury. [5, 6] Penetrating injuries (eg, gunshot wounds) may produce a variable pattern,
depending on the missile involved in the injury. Bending forces (eg, ski-boot injuries) produce
short, oblique, spiral fractures and sometimes a small butterfly fragment. On occasion, a highly
comminuted segmental pattern of injury may be observed. The prevalence of open and closed
soft-tissue injuries is high. Indirect mechanisms are primarily torsional, low-energy injuries,
which produce spiral, nondisplaced, minimally comminuted fractures with minimal soft-tissue
damage.
Epidemiology
United States and international statistics
Tibial fractures are among the most common lower limb injuries to be treated by an
orthopedic surgeon. In the early 1990s, tibial fractures accounted for 77,000 hospitalizations
per year. The incidence has increased to approximately 500,000 cases in the United States per
year. On average, almost 26 tibia fractures occur per 100,000 population per year. An
epidemiologic analysis of open long-bone fractures at the Edinburgh Orthopaedic Trauma unit
was performed over 6 years. [4] The authors also analyzed 2450 consecutive fractures of the
tibia and the fibula over 3 years. [7] Of these fractures, 21.3% were diaphyseal. The average age
of affected patients rises almost linearly as the injuries progress from AO type A to AO type C
(see Workup, Staging). The most common causes are road traffic accidents and sporting
injuries. Open fractures account for 23.5% of these fractures, with Gustilo grade 3 being the
most frequent of the 3 types. Only 8% were grade 3C, requiring vascular reconstruction.
Results of a later study of open fractures showed that the severity of injury represented by the
fracture index was correlated with the injury severity score for each fracture type and
location. [8] Approximately 21% of patients who present with open fractures have considerable
musculoskeletal injuries. Those with open femoral fractures tend to be most severely injured.
Patients with distal tibial fractures tend to have an injury severity score and a fracture index
that are lower than those of patients with diaphyseal tibial fractures. Most vascular
injuries occur in persons with diaphyseal fractures, and most of these persons eventually
undergo amputation.

Age- and sex-related demographics

The average age of those with a tibial fracture is approximately 37 years, with an
average of 31 years for men and 54 years for women. Data indicate a bimodal distribution, with
a preponderance in young men. In fact, the highest incidence of adult diaphyseal tibial fractures
is seen in male adolescents aged 15-19 years, in whom the incidence is approximately 109
cases per 100,000. The second peak, which appears after age 80 years, especially affects the
female population and is attributed to osteoporosis. However, a change in demographic
patterns can be expected with the institution of stringent gun control laws and better road safety
measures.
Prognosis
The outcome and prognosis of a diaphyseal tibial fracture depend on what Brumback
and Virkus and Tile called the "personality" of the fracture. Other factors include the location
of the fracture, the extent of comminution (which signifies the extent or energy of the trauma),
the degree of soft-tissue trauma, the presence of comorbid factors (eg, diabetes), and the
presence of polytrauma. Limb-threatening vascular and nerve injuries also substantially alter
the patient's prognosis. The outcomes vary and are universally worse with higher grades of
compounding and closed soft-tissue injuries. The method of treatment is also a contributory
factor. In the acute setting, distal vascular injuries are associated with an increased rate of
amputation and poorer results after limb salvage. Higher rates of nonunion, delayed union,
infection, and amputation are seen in patients with higher grades of soft-tissue and bony injury.
Predictors of secondary procedures in a tibial fracture are an open fracture, a transverse fracture,
and a postoperative fracture gap. Smoking and comorbid factors also increase the rate of
nonunions. Delayed union is reported in as many as 16-60% of low-energy injuries and 43-
100% of Gustilo type 3B injuries. When the use of external fixators is the primary management,
the rate of infection increases with conversion to intramedullary nails, irrespective of the care
taken before nailing, with respect to pin-track healing. The prevalence of delayed union and
nonunion is also high in fractures with extensive comminution or instability that are treated
using nonoperative methods. The rate of infection and soft-tissue breakdown is sufficiently
high with conventional plate techniques that they might be better avoided altogether. However,
early results with minimally invasive plate osteosynthesis and locked compression plates are
encouraging; the procedures are indicated in selected patientswith articular extension and
metaphyseal comminution. Long periods in a functional brace or cast uniformly gives rise to
severe hindfoot disabilities. Notably, however, these methods have yielded the best results in
patients with low-energy fractures. Intramedullary nailing is the benchmark in the treatment of
diaphyseal long-bone fractures. The results are consistent and predictable, and the
complications are easily manageable. Infection rates have been low in most series, with rates
of infection being higher in Gustilo grade 3 injuries than in others. In these cases, using an
unreamed nail may be judicious. All other fractures, including grade 1, grade 2, and low-grade
closed fractures with soft-tissue injury, can be treated with reamed nails. Unreamed nails are
best in Gustilo grade 3B injuries. Note, however, that the use of unreamed nails is associated
with a significant risk of implant failure. A Cochrane review on intramedullary nailing of the
tibia failed to find significant conclusive evidence in favor of either reamed or undreamed
nailing. However, reamed nailing appeared to have a lower risk of nonunion and implant failure
compared with unreamed nails. [9] The degree of reaming does not have any statistically
significant influence on the outcomes of nailing; however, more aggressively reamed tibias
tend to have faster healing times and faster return to function. [10] A French study of 28 cases
of isolated tibial fractures found intramedullary nailing to be a useful mode of treatment to
prevent nonunion and varus angulation in tibial fractures without fibular fractures.
Intramedullary nailing is the preferred first-intention mode of treatment in these injuries. [11]
A review of a about 323 cases of open tibial fractures treated in Singapore showed that there
was no difference in infection rates even if the fractures were operated on within 6 hours of
admission. The authors found complication rates to be much higher amongst multiply injured
patients. [12]

Management of high-grade open injuries of the tibia and the fibula

With the increase in incidence of high-velocity road traffic accidents, there has been an
increase in the incidence of open fractures of the tibia. Debridement is the mainstay of treatment
to manage the soft tissue injuries. However, stabilization of the bone is as important as the soft-
tissue management to ensure healing of the osteocutaneous injuries. These injuries are also
associated with greater incidence of vascular and nerve injuries, which may affect the
postoperative course and functional prognosis following injury. Traditionally, these fractures
were treated with wound debridement and external fixation followed by soft-tissue coverage
and bone reconstruction. The period of treatment would last from months to years. There is an
increasing trend to offer single-stage management of these injuries with internal fixation and
early flap coverage to improve functional results. Gopal et al described the acute management
of these fractures with the dictum of "fix and flap" using immediate intramedullary nailing and
early or immediate soft tissue coverage, with encouraging results. [13] They suggested
immediate or early referral to a suitable center equipped with plastic- and super-speciality
services as early as possible. In another paper analyzing the outcomes of open tibial fractures
over 9 years in Singapore, it was observed that the more severe injuries of the tibia were often
associated with polytrauma, increased hospital stays, and multiple reoperations. The severity
of polytrauma may determine feasibility of early surgery within 6 hours; the authors mention
no significant benefits of surgery within 6 hours in this subset of patients. [12] The special issues
incurred in addressing open tibial fractures sustained in combat were assessed and described in
a paper by Penn-Barwell et al. [14] The authors noted the need for aggressive prevention of
infection and the need for orthopedic plastic surgical management. They also noted the
tendency for poorer bony healing in this group of patients. They had an amputation rate of 13%.
They did not find a relationship between the mode of fixation and the final functional outcomes.
History and Physical Examination
Upon admission, a detailed patient history must be obtained to determine the nature of
the injury and to determine whether any other injuries are present. Clinical examination starts
with excluding life-threatening injuries and stabilizing all vital parameters. A comprehensive
screening to rule out pelvic, abdominal, chest, and head injuries is necessary. Thereafter,
attention should be given to the limb to immediately assess for limb-threatening vascular and
neurologic injuries. The patient should be assessed for compartment syndromes, closed soft-
tissue injury, and open wounds (see the image below). The extent of injury is roughly classified,
with the final assessment coming when the patient enters the operating suite. A bulky dressing
and an above-the-knee splint are applied, and radiographs are ordered.

Compound grade 3C injury with an extensive soft-tissue injury.

Laboratory Studies
Laboratory studies should include a workup for diabetes, neurologic conditions, and cardiac
conditions.
Imaging Studies
Radiographs of the affected limb should be obtained in at least two planes,
including anteroposterior (AP) and lateral. Additional oblique views are also occasionally
needed to determine the extent of the comminution and the fracture anatomy. Imaging the knee
and the ankle as part of the radiographic survey is mandatory. Additional radiographs may be
needed to assess for other injuries. (See the images below.)

Isolated tibial fracture without fibular fracture

Clinical and radiographic findings of a compound grade 2 injury.

Computed tomography (CT) or additional radiologic investigations have no role unless
articular extension is present and must be imaged.
Other Tests
When a fat embolism syndrome is suspected, it may be necessary to obtain an arterial
blood gas (ABG) analysis, a platelet count, a CT scan of the chest and/or brain, and a carotid
Doppler ultrasonogram. [1, 16, 17] The use of these investigations must be restricted to specific
indications only.
Diagnostic Procedures
A swab is collected from the muscle in all open, high-grade injuries. The authors culture
the swab to specifically rule out spore bearers. In the authors' emergency departments, all
patients with open wounds receive prophylactic immunization against tetanus and gas gangrene.
Staging
Numerous fracture classifications have been proposed over the past decades. Most of these
tend to be descriptive in nature and are based on the following criteria:
Open versus closed injury
Involvement of the proximal, middle, or distal thirds
Number and position of fragments, such as comminution or butterfly fragments
Transverse, spiral, or oblique fractures
Varus, valgus, anterior, or posterior angulation
Displacement or the percentage of cortical contact
Rotation
Associated injuries
The Orthopedic Trauma Association divides fractures into three types, each of which has three
subtypes, as follows:
Type A (simple) - A1, spiral; A2, oblique greater than 30; A3, transverse less than 30
Type B (wedge,butterfly fragment) - B1, spiral; B2, bending; B3, fragmented
Type C (complex or comminuted) - C1, spiral; C2, segmented; C3, irregular
Open fractures

Open fractures are classified with the system that Gustilo and Anderson proposed in 1976
and modified in 1984. [18] In this system, the grades are defined as follows:

Grade 1 - The skin opening is 1 cm or less; this injury is most likely due to an inside-out
mechanism; muscle contusion is minimal; the fracture pattern is transverse or short
oblique
Grade 2 - The skin laceration is greater than 1 cm, with extensive soft-tissue damage,
flaps, or avulsion; a minimal-to-moderate crushing component may be noted; the fracture
pattern is simple transverse or short oblique, with minimal comminution
Grade 3 - Extensive soft-tissue damage includes the muscle, skin, and neurovascular
structures; this is a high-velocity injury with a severe crushing component
Grade 3C - This is a vascular injury requiring repair
Grade 3B - This consists of extensive soft-tissue injury with periosteal stripping and bone
exposure; it is typically associated with massive contamination and inadequate bone
coverage; treatment requires flap advancement or a free flap
Grade 3A - This involves extensive soft-tissue laceration (10 cm) but adequate bone
coverage and includes segmental fractures and gunshot wounds
Owing to its importance in determining the prognosis, the Gustilo-Anderson system has gained
popular support. However, its main drawback has been the wide interobserver variation in its
implementation in clinical settings. The higher grades have complication rates that are
uniformly higher than those of the lower grades. (See the images below.)
Clinical and radiographic findings of a compound grade 2 injury.

Management of a grade 3 injury in an external fixator followed by delayed nailing using a

Kntscher-Herzog nail.
Rajasekharan reported that the Gustilo-Anderson classification of the grade 3 fracture is a little
too generalized and is associated with high interobserver and intraobserver variability. [8] Type
3B injuries have a wide spectrum of injuries, with major complications being common.
Accordingly, Rajasekharan proposed a trauma score for grade 3B open fractures, which was
devised to assess injury to the following three components:
Covering tissues
Musculotendinous units
Bone
Severity in each category was assessed on a scale of 1-5. Seven comorbid factors known to
influence the prognosis were each given a score of 2; these scores were then summed.
Rajasekharan's preliminary results suggested that this system of classification of type 3B
fractures is easy to apply and reliable in determining the prognosis after limb salvage and the
outcome measures in severe, open injuries of the tibia.

Closed soft-tissue injuries associated with fractures

Tscherne and Oestern classified closed soft-tissue injuries associated with fractures as
follows [19] :
Grade 0 - Soft-tissue damage is absent or negligible; the fracture is a result of indirect
forces with a simple fracture pattern
Grade 1 - Superficial abrasion or contusion is caused by fragment pressure from within;
the fracture configuration is more severe than that of grade 0
Grade 2 - Deep, contaminated abrasion is associated with localized skin or muscle
contusion from direct trauma; impending compartment syndrome is part of this grade of
injury, which is usually the result of direct violence
Grade 3 - This injury is characterized by extensively crushed, contused skin and severe
muscle damage; other criteria are subcutaneous avulsions, decompensated compartment
syndrome, and rupture of a major blood vessel; usually, patients have a severe, complex
fracture pattern

Acceptability of reduction

Criteria for acceptability of reduction are as follows:

Less than 5 varus/valgus angulation
Less than 10 anterior/posterior angulation
Less than 10 rotational deformity
 Less than 1 cm of shortening
Greater than 50% cortical contact
More angulation along the AP axis and external rotation are both acceptable. Also, external
rotation deformities are more easily tolerated than internal rotation deformities.
These traditional guidelines are not based on hard data. Merchant and Dietz assessed the
amount of angulation that was compatible with good long-term function and the avoidance of
osteoarthrosis by evaluating a group of patients an average of 29 years after a fracture of the
tibia. [20] Clinical and radiographic outcomes were unaffected by the amount of anterior,
posterior, varus, or valgus angulation. Their data suggested that angular deformities of less than
10-15 are well tolerated over the long term with respect to the development of late
osteoarthrosis.
However, some data indicate that as the level of deformity approaches the distal third of the
tibia, even a minor degree of malalignment can affect the ankle joint. The malalignment alters
the biomechanics of the ankle joint by decreasing the total area of contact pressure, which
results in regions of increased pressure where the residual contact occurs. This increased
pressure may cause increased shear stresses on the articular cartilage in the areas of high stress,
and the shear stresses may result in premature osteoarthrosis of the joint.
Malrotation is a less understood phenomenon in tibial injuries treated with intramedullary
nailing. A paper in the Indian Journal of Orthopedics addressed this problem by analyzing the
malrotation in 60 patients treated with reamed intramedullary nailing for diaphyseal fractures.
A surprising 30% of patients had malrotation greater than 10. [21]
Approach Considerations
The two general modes of management for an acute tibial fracture are as follows:
Nonoperative - External casting with a long leg cast, followed by a patellar tendon-
bearing cast or a cast brace; functional bracing
Operative - Procedures involve plating, intramedullary nailing, and external fixation
Definitive indications for surgery include the following:
Associated intra-articular and shaft fractures
Open fractures
Major bone loss
Neurovascular injury
Limb reimplantation
Compartment syndrome
Floating knee
Relative indications for surgery include the following:
Associated intra-articular and shaft fractures
Unstable fractures
Inability to maintain reduction
Relative shortening of segmental fractures
Tibial fracture with an intact fibula
Transition-zone fracture
Polytrauma
Delayed indications for surgery include the following:
Failure to maintain the reduction
Unacceptable reduction
Complications
Reports in the literature have described the effects of growth factorimpregnated
sponges and the use of recombinant bone morphogenic protein in both closed and open
fractures of the tibia. Results with both methods are encouraging, and they are expected
to be useful in the future.
One restricting factor may be cost; however, newer designs and innovations in external
fixators and newer techniques of internal fixation in combination with imaging and
computer-assisted surgeries may make the fixation methods that are used in current
practice more effective in the management of compound and closed tibial fractures.
Medical Therapy

External casting

The use of plaster of paris casts has long been the most popular method of treatment for
fractures of the shaft of the tibia. This method was used irrespective of the degree of soft-tissue
damage or comminution or stability of the fracture. The early days of conservative management
of tibial shaft fractures involved a preliminary period of traction followed by the use of a
weightbearing cast. Ernst Dehne first studied the effects of weightbearing casts versus traction
followed by casting. He advocated immediate weightbearing in the cast and achieved good
results despite shortening of the affected limb. Hindfoot stiffness is not mentioned in his study.
About the time of Dehne's studies, distraction caused by traction was recognized as a probable
deleterious influence on union. Sarmiento and Latta noted that the initial shortening rarely
increases with weight bearing. [23]
Indications and considerations
Cast immobilization is the mainstay of treatment for low-energy fractures of the tibial
shaft with a soft-tissue injury of Tscherne grade 0 or 1, provided that postreduction deformity
is within acceptable limits. Charnley emphasized the role of the intact soft-tissue hinge and the
interosseous membrane for the cast treatment to succeed. High-energy injuries with extensive
soft-tissue disruption and comminution are best treated optimally with intramedullary rods.
When one opts for cast management, one must be reasonably sure that the above-the-knee cast
is removed in 12-16 weeks and converted to a patellar tendon-bearing cast or brace. Longer
periods in a cast cause severe ankle and subtalar stiffness. A long leg cast is usually applied as
soon as possible after the injury. The fracture reduction is best achieved with the gravity-
assisted method, with the patient's leg hanging by the side of a table. Bony prominences are
padded, and a below-the knee cast is first applied and then extended above the knee. In the
event of swelling at this time, the cast is slit to the skin and elevated for 48 hours, and the
patient is monitored for compartment syndrome. The cast must to be changed after the swelling
subsides. A very common mistake is to apply the cast with the leg extended and an assistant
holding the toes. This would create a hyperextension deformity at the fracture site. Gravity-
assisted reduction with the leg dependent is the best method to reduce the tibia. The degree of
flexion allowed at the knee would depend on the desirability of allowing weight bearing in the
cast. The lead author of this topic gives 10-20 of knee flexion in the cast if weightbearing is
not to be encouraged. The patient is allowed to stand and bear weight, as tolerated and
comfortable, reaching full weightbearing by 2-3 weeks. Serial radiography at 15 days, 1 month,
and 2 months permits close follow-up of the position of the fracture. By 4-8 weeks or when the
earliest sign of union is seen, a patellar tendon-bearing cast or functional brace is applied.
This protocol essentially depends on the nature of injury. An excessively comminuted fracture
or an isolated tibial fracture with an intact fibula needs a longer period in a long leg cast.
Factors influencing outcomes
Factors influencing outcome and healing times include the initial displacement, the
degree of comminution, and the status of the fibula.Littenberg et al performed a matched pair
analysis to study the three most common methods of treatment of these fractures. [24] The
authors analyzed the literature between 1966 and 1993 and found that the data from the
literature were insufficient to establish decision-making protocols with respect to the treatment
of closed fracture in tibias. However, it was determined that closed treatment was associated
with shorter union times and better functional results compared with those of open reduction
and internal fixation. It is important to note that in the presence of a documented infection and
an external wound, delayed internal fixation should be avoided. The tenets of the Ilizarov
method should be followed, and an internal bone transport should be performed. Thus,
changing the fixator frame to a hybrid or ring fixator and then internal bone transport would be
the best management option in these cases.
Complications
Joint stiffness, mainly of the ankle and subtalar joints, is clearly the major problem
associated with casting of tibial fractures. This long-term disability is often associated with
fractures that are rigidly immobilized for the full period of treatment in an extended cast.
Joint stiffness is often attributed to plaster disease. However, Tile argued that the argument for
plaster disease needs careful scrutiny. [1] According to Tile, plaster disease is a syndrome
characterized by swelling under the cast, followed by permanent stiffness of the immobilized
joints, and this condition is a residual of one of the following unrecognized events:
Compartment syndrome
Reflex sympathetic dystrophy
Thromboembolic disease
Severe soft-tissue injury
McMaster looked at hindfoot disability after the use of a long leg cast. [25] All the fractured tibia
were unilateral fractures. The author noted that patients who had good hindfoot function were
younger and had been immobilized for a relatively short time in a cast. Merchant and Dietz
retrospectively analyzed long-term outcomes of tibial and fibular fractures at an average of 29
years after surgery. [26] Clinical and radiographic outcomes were unaffected by the amount of
anterior, posterior, varus, or valgus angulation. These data suggested that angular deformities
of less than 10-15 are well tolerated over the long term with respect to the development of
osteoarthrosis. Court-Brown analyzed a large body of literature and noted the extreme paucity
of detailed analyses of patient function. [4]

Functional bracing

Sarmiento analyzed, popularized, and refined functional bracing. He published a report

of 135 cases of tibial fractures that were treated using a patellar tendon-bearing type of
functional brace. [27] The average time to union was 15.5 months, with an average shortening
of just 6.4 mm. In a later paper, Sarmiento and Latta discussed the indications for the use of
bracing, which included most closed fractures and many open fractures with a low degree of
soft-tissue damage. [23]Unstable tibial fractures were excluded. Rigid attention to detail ensures
success with functional bracing in well-selected cases. The patellar tendon-bearing cast was
designed on the basis of the patellar tendon-bearing prosthesis used by below-the-knee
amputees. (See the image below.) Sarmiento stated that the maintenance of limb length is the
result of the hydraulic environment created by the compressed water-rich soft tissue
surrounding the fractured limb.

Patellar tendon-bearing brace fabricated from Orfit Industries.

The degree of shortening is determined by the local soft-tissue damage. The motion that
takes place between fragments during function and weight bearing is elastic and conducive to
union. The use of functional bracing is likely to be successful if the fracture is intrinsically
stable (eg, reduced transverse fractures) or axially unstable (eg, oblique, spiral, comminuted),
with acceptable initial shortening of less than 12 mm and angular deformities within acceptable
limits. [23] A circular, well-fitting cast or cast brace should be made of a material that can be
adjusted to the girth of the limb, which is likely to change with changes in soft-tissue edema
and resolution of soft-tissue injury. If this is not done, unacceptable angulation may occur.
Angulatory deformity of less than 8 in the mediolateral plane is not of importance and is easily
tolerated. The ideal time for application of the brace is week 2-4 after the injury, when the
patient's comfort levels are good enough to permit brace application. The interim period has
the limb spent in a cast. Any fracture that is likely to require the patient be anesthetized in order
to undergo a reduction is probably unstable and is best managed operatively. The lead author
of this article does not use cast bracing as a primary mode of management of tibial shaft
fractures. Rather, a cast brace is applied after the tibia has had an initial period in a long leg
cast and some documentation of a primary union has been obtained. Sarmientos treatment
methods however are well documented and can be used when the indications are suitable.
Indications
Indications for functional bracing include the following:
Low-energy transverse fractures that are intrinsically stable because of lack of
displacement or that have been rendered stable after closed reduction
Closed, axially unstable fractures that are oblique, spiral, or comminuted
Low-energy closed segmental fractures with initial shortening of less than 12 mm
Grade 1 open fractures that fit these criteria for length and angulation
Surgical Therapy
Operative methods of treating tibial fractures involve the following two main approaches:
External fixation
Intramedullary nailing and plating

External fixation

External fixation, though popularized as the primary treatment of fractures, is currently

most popular in the management of complex limb fractures such as diaphyseal fractures that
extend into the metaphysis or joint, nonunions, delayed unions, and fractures with infections.
External fixators are used as the primary management of high-grade open fractures and as the
primary management in damage-control surgery in polytrauma. [28] (See the images below.)

A Gustilo grade 3A midshaft, open tibial fracture in a 25-year-old man. An external fixator was
applied.
 Anteriorly applied T frame for a grade 3 open injury.

The recommended initial frame constructs include the uniplanar unilateral, uniplanar
bilateral, unilateral biplanar, and unilateral uniplanar types. One of the recommended frame
constructs is a unilateral and uniplanar frame applied anteriorly or anteromedially on the tibia.
Variations of this frame can be devised for fractures that extend into the knee, ankle, or the
metaphysis. Application of an external fixator in open injuries should also take into account
the requirements of providing a soft-tissue cover. An anteromedial frame might interfere with
a cross-legged flap and may need to be revised to an anterior frame. It is best to anticipate this
at the primary application itself.
Advantages of external fixators include the following:
Ease of application
Good stability
Excellent access to the limb for wound care and secondary soft-tissue procedures
Early ambulation
The major problem with external fixators is the high rate of hardware-related complications.
Most of these are related to the pins, including pin-track infection, pin loosening, and pin
breakage. The prevalence of pin-track infections can be decreased with meticulous attention to
detail when the fixator pins are inserted and with good pin-track care. The risk increases with
the time the affected limb is spent in the fixator; therefore, a plan to minimize this time is
required.
Some of the alternative options are conversion to a cast, dynamization, early posterolateral
bone grafting, and conversion to intramedullary nails.
Dynamization is a procedure wherein the external fixator is modified to allow axial loading
and micromotion without permitting torque and loss of reduction. Approximately 0.5 mm of
micromotion is ideal; more motion may actually be detrimental. Early removal of the frame
and cast application has had mixed responses, with a high prevalence of delayed union and
nonunion.
If one opts to keep the frame on the limb once the soft tissue has healed and until fracture union
occurs, it may be advisable to carry out posterolateral bone grafting at an early stage. The
advantage of this approach is that it permits placement of a large volume of graft material in a
well-vascularized virgin area away from compromised anterolateral and anteromedial tissues.
Before bone grafting, an interim period during which antibiotic beads are implanted in the
wound may be necessary in grade 3 open injuries.
Delayed nailing (see the image below) is associated with a higher risk of infection than that of
primary nailing, especially if the patient has a history of pin-track sepsis or if the index fracture
is a high-grade open injury with contamination and sepsis. Secondary intramedullary nailing
following external fixation is somewhat controversial, especially with respect to the duration
of external fixation that is allowable before the risk of infection following later nailing becomes
too great. [29] Siebenrock et al reported that early intramedullary nailing was preferable to
plating.[29] Sequential nailing can be performed as early as 2-3 weeks after trauma without the
necessity of a safety interval between removal of an external fixator and the insertion of a nail.
According to Court-Brown et al, several principles and indications for nailing after external
fixation are applicable. [30, 31] The procedure should be performed as early as possible, before
pin sepsis develops, preferably within 4 weeks. Soft-tissue healing should be complete. No pin-
track sepsis should be present. No open tracks should be present; wait for all pin tracks to heal
completely, in a cast or cast brace, if necessary. No ring sequestrum should be visible.
Antibiotic coverage should be administered. The preferred procedure is static locked nailing.
Finally, reaming should be slow, gentle, and not excessive in order to decrease trauma to the
bone and soft tissues.
Indications and contraindications
Indications for external fixation include the following:
Gustilo grade 3 open fractures
Tscherne type 2 or 3 closed fractures (to permit fixation without waiting for soft-tissue
healing)
Temporary use of external fixation intraoperatively for reduction
Limb lengthening, internal bone transport, and secondary limb reconstruction procedures
following primary soft-tissue healing
According to Court-Brown, relative contraindications include the following [30, 31] :
 Osteoporosis
Poorly controlled diabetes
Predictable poor patient compliance
Hemiplegia, tetraplegia, or paraplegia
HIV or hepatitis B virus (HBV) positivity
Severe vascular disease

Intramedullary nailing

Intramedullary nailing is the gold standard in the treatment of diaphyseal long-bone fractures.
The options include the following:
A single unlocked nail (eg, Lottes nail, V nail or Kntscher-Herzog nail, Kntscher nail,
Rush rod) [32]
A single, large-diameter, interlocking tubular nail, with or without reaming
Multiple flexible intramedullary pins (although this is less popular)
An expandable nail
The most important indication for the use of an intramedullary nail in tibial fractures is an
unstable diaphyseal tibial fracture. Factors involved in classifying a tibial fracture as unstable
include the severity of the soft-tissue injury, the scope of articular extension, the presence of a
complete initial displacement, and comminution that exceeds 50% of the circumference of the
bone. The presence of transverse fractures, fractures of the fibula, and fractures of both the
fibula and tibia are indicative of a high-energy mechanism and should be a contraindication to
nonoperative management. (See the images below.)

Unstable tibial fracture treated with an interlocking nail.

 Unstable tibia with comminution treated with interlocked nails.

Goals of management
The goal of management is solid union within a reasonable time period. Results should be
comparable to those of closed management.
Treatment failures should be minimized, and secondary procedures such as bone grafting and
nail exchanging should be avoided in order to decrease the prevalence of implant-related
complications such as nail and cross-bolt breakage and pin-track infections. Intramedullary
nails are the ideal implants for closed diaphyseal, short oblique, simple transverse, or short
oblique fractures with or without comminution. Extended indications include proximal and
distal metaphyseal extension of a diaphyseal fracture and more proximal and distal fractures.
With grade 1 or 2 open injuries and closed Tscherne type 0-2 injuries, Court-Brown et al found
that the results of closed nailing were essentially good, but a detailed analysis of the treatment
times indicates that union times increase as the degree of soft-tissue injury increases. [31]
Most orthopedic surgeons agree that Gustilo grade 1 and 2 open fractures can be safely treated
with emergency closed intramedullary locked nails without much increase in nonunion or
infection rates. The preferred method is use of a static locked nail. Infections or nonunions can
be successfully managed by exchange nailing. Puno et al also found that the results of
intramedullary nailing are superior to those of casts. [33]
Court-Brown et al have written extensively on high-grade open tibial fractures treated with
reamed and unreamed intramedullary nails, aggressive soft-tissue management and early
coverage, and exchange nailing and bone grafting early when indicated. [30, 31] They reported
high union rates and manageable complications.
Petrisor et al evaluated the possible causes of intramedullary infection in closed and open
fractures treated with reamed intramedullary reaming. [17] The authors noted the causes of
infection, possible effects on union time, and the requirement for additional reconstructive
procedures. Of the closed fracture group, 43.8% developed infection; the causes were related
to inappropriate fasciotomy closure and poor attention to exchange nailings. In open fractures
the rate of infection was 62.5%, attributed to complications of plastic surgery.
Petrisor et al noted that most infections are preventable if one pays adequate attention to
details. [17] Particular attention must be paid to correct reaming, exchange nailing, and
fasciotomy closure in closed fractures. In open fractures, marginal flap necrosis should be
actively treated and not left to granulate. Brumback and Virkus reported that the terms "small-
diameter nailing" and "large-diameter nailing," which are often used for unreamed (small
diameter) and reamed nails (large diameter), do not specify whether reaming is part of the
nailing process. Therefore, such terms are best avoided. [34] The term reamed nail is used for
the technique wherein the proximal and distal fragments are reamed with the specific intention
of enlarging the endosteal diameter to permit insertion of the largest possible nail diameter.
The instrumentation inside the medullary canal has the potential to disrupt the blood supply to
the endosteum, especially where the nail fit is the tightest. This type of vascular disruption is
less with unreamed nailing because the fit is relatively looser, with more space between the
endosteal cortex and the nail. Additional damage to the endosteum can be caused by the rise in
temperature that is associated with reaming, causing thermal damage in addition to the
mechanical effects. Nailing is also associated with an elevation in intramedullary pressure,
which disseminates fat and marrow emboli into the systemic circulation, with the potential to
cause acute respiratory distress. This risk is higher with reamed nails. Careful intraoperative
assessment and meticulous technique, including the use of slow and gentle reaming in a to-
and-fro motion with sharp reamers, can significantly limit the risk of this complication, as does
good hydration during and after surgery.
Reaming
Reaming has the following advantages:
It ensures passage of the intramedullary nail into the center of the medullary canal without
obstruction or incarceration
It permits insertion of the largest possible nail, providing better resistance to fatigue
failure
It increases endosteal contact with better stability
 The reaming material deposited at the fracture site is thought to have an osteogenic effect,
much like a bone graft
The use of reaming in Gustilo 3 fractures is still controversial. Devascularization of the cortex,
inherent to reaming, leads to a higher complication rate with respect to infection, nonunion,
and delayed unions. The combination of endosteal damage and bone necrosis resulting from
injury can cause extensive damage. This, in association with the insertion of a tight
intramedullary nail and a potentially contaminated soft-tissue environment, gives rise to the
higher risk of infection.
Advantages of unreamed solid nails include the following:
Less damage to the intramedullary circulation
Lower infection rates in open and high-grade, closed soft-tissue injuries
Feasibility of use in high-grade open fractures
Decreased risk of compartment syndrome in at-risk limbs
Tile described the use of unreamed solid nails as "conventional wisdom in the management of
open injuries and in fractures associated with extensive soft-tissue injury." [1]
Several disadvantages of using unreamed solid nails are noted. This approach involves small-
diameter nails; hence, by necessity, they are solid and stiff. The locking screws must also be
smaller than standard nails. When a small-diameter nail is used in a wide canal, a blocking
screw may be used in the canal to ensure central placement of the nail. Such screws are known
as Poller screws. The most common complication is failure or breakage of the nails and cross-
bolts. The construct is less stable than that with reamed nails. In addition, the risk of failure is
higher with fractures that are more proximal or distal or that extend into the metaphysis. Finally,
delayed unions and nonunions are more prevalent with the use of unreamed nails than with
other methods. Prospective studies comparing reamed nails with unreamed nails have
confirmed the efficacy of reamed and locked nailing in low-energy and low-grade tibial
fractures. The benefits and disadvantages of reaming are in question only with Gustilo grade 3
fractures. In these cases, the use of a statically locked unreamed nail is recommended. Reuss
and Cole analyzed the effect of delayed treatment on open tibial fractures. [35] In a series of 77
patients with 81 tibial fractures, the authors found that time to fixation was not a predictor of
nonunion or infection. Conversion nailing from external fixation to intramedullary nailing had
a significantly higher rate of infection. Severity of injury had a definite influence on outcomes,
and multiple debridements and infection were related. Longer time to treatment up to 48 hours
did not adversely affect outcomesprovided that adequate trauma department open fracture
care and early initiation of antibiotics were coupled with standardized and thorough
debridement in the operative theater. Although closed reduction is the usual procedure, it may
at times be necessary to perform an open reduction of the fracture through a minimal incision
rather than accept an inappropriate reduction. Tang et al studied the relative risks of infection
if open reduction had to be carried out during intramedullary nailing. [36] The authors showed
that limited open techniques can greatly facilitate the reduction of closed tibial shaft fractures
but raise concern for infection through exposure of the fracture site" and that although the rate
of infection for open reduction was higher relative to closed reductions, the difference was not
statistically significant. One-stage reconstruction in grade 3B injuries of the tibial shaft was
reported by Tropet et al. [37] The study involved five patients and described a combination
of two procedures in the emergency department: internal stabilization of the bone by
intramedullary locked nailing whenever possible and coverage of the fracture site with a
pedicle (upper third of the leg) or free muscle flap (lower third of the leg). When there was
extensive bone loss, Tropet et al also performed autogenous cancellous grafting. They reported
no nonunions and excellent functional results, concluding that Aggressive emergency
management of severe open tibial fractures provides good results... improves end results
markedly, not only by reducing tissue loss from infection, but also reducing healing and
rehabilitation times. [37]
Expandable nails
These are newer nails that have been available for some time. Used in the unreamed fashion,
expandable nails are formed of a hollow rod that can be inflated once inside the canal, with
normal saline and the use of a special pump. Expandable nails were created to retain the
advantages of large-diameter nails and to improve the torsional stability, while avoiding the
biologic disadvantages of reaming and inserting tight-fitting, large-diameter intramedullary
nails. The nail is folded longitudinally in a specially designed press. This tubular structure is
sealed distally with a cone-shaped cap and proximally with a one-way valve. The cross-section
of the nail is circular with four reinforcement bars; after expansion, abutment of the
longitudinal bars to the inner surface of the canal along its entire length provides fixation of
the nail to the bone, ensuring no risk of migration, rotatory stability, fragment alignment, and
the length of the fragments, excluding the need for interlocking screws. [38] The clinical and
economic factors of using both expandable and interlocking nails was explored by Ben Galim
et al. [39] They noted that using expandable nails decreased surgical and hospital costs by 39%.
In addition, expandable nails showed important clinical advantages for the fixation of tibial
fractures, and complications related to lengthy operations, reoperations, and rehospitalizations
were substantially reduced. [39]
Preparation for surgery

Preoperative planning is essential to achieve the goals of treatment as defined earlier. This
planning starts with assessing the characteristics of the fracture, determining the degree of soft-
tissue injury, and evaluating the extent of the fracture and the presence of any comorbid factors
and life- or limb-threatening injuries. Once preoperative planning is completed, the implant is
selected. If the patient does not have a soft-tissue injury or has only a low-grade soft-tissue
injury, locked intramedullary nailing is the operation of choice. Internal fixators such as the
locked compression plate (see the first image below) may be a better choice than conventional
plates. However, the authors of this topic have no experience with this technique and thus
cannot make any recommendation regarding its use. Conventional plating poses a risk of soft-
tissue breakdown (see the second image below) and should be avoided. We prefer biologic
plating and minimally invasive plate osteosynthesis.

Locked compression plate and the combination hole.

 Tibial plating with wound breakdown.

Once the implant and system are selected, the appropriate size is determined. The length of the
nails needed can be determined using many methods, including scanograms, spotograms,
intraoperative radiography, the two=guide-wire technique with reamed nails, and preoperative
templates, or assessing the nail against the limb on fluoroscopy images in cases of unreamed
nails. An analysis of these methods showed that the preoperative technique of joint lineto
joint line measurement is the most error-free and reproducible method for planning nail length.
Other modes of fixation
The use of plates has been associated with a high rate of complications in the tibia, leading to
a paradigm shift toward the use of intramedullary nails. In the past few years, there has been a
significant effort to reduce the incidence of plate-related complications such as stress shielding
and refracture by using biologic principles and indirect reduction techniques. The principles
used have led to the development of the point-contact fixator plate (PC-FIX), the limited-
contact dynamic compression plate (LC-DCP), the less-invasive stabilization system (LISS),
and the locking compression plate (which combines the best features of the DCP with that of
the locking plate). Indirect reduction techniques and minimal but optimal use of implant
material is the most recent concept to achieve undisturbed fracture repair in diaphyseal and
metaphyseal fractures. [40] The aim of fracture fixation is no longer rigid anatomic fixation.
Rapid integration of unreduced but vital fragments into the fracture callus, which increases the
mechanical strength of the fracture and reduces the risk of overload and fatigue failure of the
implant, seems to be of the greatest importance. Thus, biologic techniques maintain alignment
by bridging the fracture without compression, rather than relying on absolute rigid fixation
through compression. These are frequently referred to as internal splintage fracture fixation
methods.[40] Some of the plates used include the LISS and the PC-FIX, the noncontact plate
(NCP), the Zespol plate, and the locking compression plate. These plates are not just simple
plates but complex systems with holes designed to fit the region in question. The locking
compression plate in particular has been designed to incorporate the features of the locking
plate as well as the DCP in the same hole, thus providing versatility for the operating surgeon.
It is also important that the plate itself stays off the bone, making no contact with the periosteum,
thus functioning essentially as an internal fixator. [41] This means that the plate is fixed in the
bone at a stable angle without direct contact between the plate and cortical bone. Technically
the angular stability is achieved by means of an entirely new screw and plate design. The screws
have a smaller pitch and, consequently, a higher core diameter and are firmly fixed in the plate.
This fixation in the plate is achieved with a conical thread on the screw head and a
corresponding conical threaded hole in the plate. When locked in this way the screw is axially
and laterally secured without pressing the plate onto the bone in the process. In contrast to
previous conventional systems, the stability of the bone fixation is not achieved by pulling the
fragments toward the plate. [41] The use of minimally invasive percutaneous plate
osteosynthesis has been found to be effective in metaphyseal and diaphyseal tibial fractures. [42]

Procedural details

The limb position for nailing may vary with the surgeon. The most common position is
the leg hanging with the knee flexed to 90 , with a bolster placed under the knee. However,
the best method is placement on a fracture table, with the knee flexed 90 with a calcaneal pin
for traction. This method permits good control of length and rotations and unobstructed motion
of the image intensifier. The incision for nailing is identified on the basis of the entry point.
The authors of this topic prefer a paramedian incision approximately 2-3 cm in length; the entry
portal may be taken through the patellar tendon or next to the patellar tendon after retracting it
to one side. Reamed nails are preferred, except in type 3 Gustilo injuries, wherein an unreamed
nail is preferred. The progress of the reamer in the canal must be carefully observed. It should
be slowly progressed with a to-and-fro motion without any exertion of pressure. This method
not only prevents incarceration of the reamer in a tight canal, but it also decreases other
potential for deleterious effects. Maintenance of hydration and good intraoperative monitoring
are mandatory for preventing fat embolism and acute respiratory distress. Distal locking is
performed freehand by using the standard techniques of visualizing the locking hole as a perfect
hole on the lateral image and then using an aiming device to introduce the bolt. The number of
cross-bolts depends on the fracture configuration. In an uncomplicated comminuted fracture,
the authors of this topic routinely lock both cross-bolts proximally and distally. Before locking,
ensure that no fracture gap has been left and that the alignment has been restored well; these
steps help prevent early failure. We routinely use a tourniquet for nailing and plating
procedures, as well as drains in posterolateral bone grafts and plating procedures. However, in
nailing operations, suction drains are avoided.
Postoperative Care
Antibiotics are given immediately before and after surgery for 24-48 hours. The use of
antibiotics is therapeutic, not prophylactic; therefore, antibiotics should not be misused, even
when treating open injuries. A bulky postoperative dressing is applied, and the limb is elevated
on a pillow or pillows for 48 hours. Compartment pressures must be monitored if the limb is
deemed to be at risk for compartment syndrome. Once the patient is comfortable, he or she is
allowed to be mobile on a walker or crutches. Weightbearing is permitted in nailing procedures,
depending on the fracture configuration. In a simple low-energy fracture, immediate
weightbearing is permissible. Otherwise, instituting nonweightbearing or partial weightbearing
schedules is preferred. Patients undergoing plating and external fixation should not be allowed
to bear weight until signs of healing are evident radiologically. In extensively comminuted
fractures, the authors of this topic use a well-molded functional brace to provide added
protection and to stimulate early healing.
Complications
The use of reaming in Gustilo type 3 fractures is still controversial. The
devascularization of the cortex inherent to reaming leads to a higher complication rate with
respect to infection, nonunion, and delayed union. Furthermore, the combination of endosteal
damage and bone necrosis due to the injury can cause extensive damage. This, in combination
with the insertion of a tight intramedullary nail and a potentially contaminated soft-tissue
environment, gives rise to the increased risk of infection. Compartment syndrome is a transient
increase in intracompartmental pressures. The extravasation of reaming material and blood into
the tight tibial compartments can increase the risk of compartment syndrome. Anterior knee
pain can be a complication. Possible causes are multiple injuries, ipsilateral fractures in other
bones, the presence of a proximal locking screw, quadriceps weakness, an unrecognized knee
injury, and the incision itself, among others. Neurologic damage can occur as a result of traction,
local pressure from the limb being in casts or splints, soft-tissue injury, and injury to the fibula
or proximal tibiofibular joint. Other complications include thermal injury to the cortical bone,
posterior cortical perforation, screw discomfort, delayed union or nonunion, amputation, and
implant failure. Another risk is pulmonary embolism (PE) and acute respiratory distress
syndrome (ARDS) with the dissemination of fat emboli into the system. Fat embolism
syndrome has been defined as a complex alteration of homeostasis that occurs as a
complication of fractures of the pelvis and long bones, manifesting clinically as acute
respiratory insufficiency, cerebral dysfunction, and petechial rash occurring 24-48 hours after
injury. [16] Fat embolism syndrome has been estimated to occur in 0.5-11% of all long-bone
fractures and approaches an incidence of 5-10% in multiple fractures associated with pelvic
injuries. Gurds criteria for diagnosis of fat embolism syndrome are divided into major and
minor features; the diagnosis requires at least 1 major feature and at least 4 minor
features. [16] Major features are respiratory insufficiency or hypoxemia, central nervous system
depression, and petechial rash. Minor features are pyrexia, tachycardia, retinal changes,
jaundice, presence of fat in the urine or oliguria, sudden anemia or thrombocytopenia, high
erythrocyte sedimentation rate (ESR), and fat macroglobulinemia. Fat embolism syndrome can
be further subcategorized into primarily neurologic, pulmonary, or systemic.
Long-Term Monitoring
Once mobile, the patient is discharged from inpatient care. Radiographs should be
obtained at periodic intervals. The authors of this topic prefer intervals of 3 weeks, 6 weeks, 3
months, and every 6 weeks thereafter until radiologic evidence of union occurs. Regaining full
knee and ankle function should be stressed while the union is being achieved. As signs of union
are noted, crutches may be discarded in favor of a cane. If union is delayed or is not progressing,
early bone grafting or exchange nailing to stimulate union is better than other approaches.