Tibia Shaft Fracture (Adult)

1. Clinical Overview

Summary

Tibial shaft fractures represent the most common long bone fracture in adults, with an incidence of 16-26 per 100,000 person-years. [1,2] The tibia's unique anatomy—with approximately one-third of its circumference being subcutaneous along the anteromedial border—renders it particularly vulnerable to both direct trauma and soft tissue complications. This subcutaneous location makes tibial shaft fractures the most frequent site for open fractures, accounting for up to 25% of all tibial diaphyseal injuries. [3]

Management is fundamentally dictated by the soft tissue envelope and the energy of injury. High-energy mechanisms carry substantial risks of compartment syndrome (5-10% incidence), vascular injury, and severe soft tissue damage that can compromise bone healing. [4,5] The gold standard for definitive management in most cases is reamed intramedullary nailing, supported by Level I evidence from the landmark SPRINT trial, which demonstrated superior outcomes compared to unreamed techniques in closed fractures. [6]

For open fractures, strict adherence to BOAST 4 Guidelines is mandatory: intravenous antibiotics within 1 hour, surgical debridement within 24 hours, and soft tissue coverage within 72 hours. [7] This standardized approach has significantly reduced infection rates and improved functional outcomes in this challenging injury pattern.

Key Facts

• Epidemiology: Bimodal age distribution—young males (high-energy trauma) and elderly females (low-energy falls) [1]
• Anatomy: Tibia receives blood supply from nutrient artery (proximal entry) and periosteal vessels; distal third has poorest vascularization [8]
• Compartment Syndrome: Four tight fascial compartments; anterior compartment most commonly affected (40-60% of cases) [9]
• Open Fracture Rate: 25% of tibial shaft fractures are open, with infection risk rising from 2% (closed) to 10-50% (open Type IIIB) [3,10]
• Healing Complications: Nonunion rate 5-10% overall; increases to 15-50% in high-grade open fractures [11]

Clinical Pearls

"Pain Out of Proportion": The cardinal sign of evolving compartment syndrome. If a patient with a splinted tibial fracture experiences escalating pain despite adequate analgesia, or develops pain on passive dorsiflexion of the toes, compartment pressures must be measured or compartment release performed immediately. Do not wait for late signs (pulselessness, paralysis, pallor)—these indicate irreversible damage. [9]

"Antibiotics Beat the Clock": In open fractures, time to antibiotic administration directly correlates with infection risk. For every hour of delay, infection rates increase. The standard protocol is Co-Amoxiclav 1.2g + Gentamicin 1.5mg/kg IV within 1 hour of emergency department arrival. For farm injuries or gross contamination, add anaerobic coverage. [7,12]

"Ream for Success": The SPRINT trial definitively answered the reaming debate—reamed intramedullary nails reduce reoperation rates by 37% compared to unreamed nails in closed fractures. Reaming provides autogenous bone graft from the medullary canal and allows insertion of larger-diameter nails with superior biomechanical stability. [6]

"The Backslab Safety Check": Never trust a circumferential cast or tight dressing applied by another clinician. If the patient complains of increasing pain, split the cast down to skin immediately. Casts can function as external tourniquets, precipitating compartment syndrome. [13]

"Fibula Fixation Paradox": In most tibial shaft fractures, the fibula should NOT be fixed. An intact or "strutting" fibula can prevent appropriate compression at the tibial fracture site, increasing nonunion risk. However, in proximal or distal fractures where alignment is difficult, fibula fixation may aid length and rotation control. [14]

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2. Epidemiology

Incidence and Demographics

Tibial shaft fractures demonstrate a bimodal age and gender distribution reflecting distinct injury mechanisms:

Overall incidence: 16-26 per 100,000 person-years in industrialized nations, with significant geographic variation based on traffic safety standards and activity patterns. [1,2]

Injury Mechanisms and Fracture Patterns

The fracture pattern provides critical information about energy transfer and soft tissue damage:

Exam Detail: Viva Pearl: The Tscherne-Oestern classification specifically grades soft tissue injury in closed fractures, complementing Gustilo-Anderson for open injuries. Grade 3 closed injuries (extensive contusion, muscle crushing, possible compartment syndrome) may have worse outcomes than low-grade open fractures due to internal soft tissue damage. [15]

Risk Factors for Complications

Nonunion Risk Factors (multivariate analysis from 1,000+ patient cohorts): [11,16]

1. Active smoking: Hazard ratio 2.3-4.1 (dose-dependent; nicotine causes vasoconstriction and inhibits osteoblast differentiation)
2. Open fracture: HR 2.8-3.5 (biological compromise, infection risk)
3. Segmental fracture: HR 3.2 (disrupts blood supply, multiple fracture sites)
4. Fracture gap > 5mm after fixation: HR 2.6 (excessive interfragmentary strain)
5. Infection: HR 5.2 (biofilm formation, chronic inflammation)
6. NSAIDs in first 3 months: HR 1.8-2.3 (controversial; inhibit COX-2 mediated fracture healing)

Compartment Syndrome Risk Factors: [9,17]

• High-energy mechanism (RTA, crush injury)
• Young age (less than 35 years—more muscular compartments)
• Tibial shaft fracture combined with proximal tibial or distal tibia fracture
• Bleeding diathesis or anticoagulation
• Prolonged limb compression (obtunded patient, cast/dressing constriction)

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3. Anatomy and Pathophysiology

Osseous Anatomy

The tibia is the weight-bearing bone of the lower leg, with three anatomical regions of the diaphysis:

• Proximal third: Triangular cross-section, thick cortices, well-vascularized
• Middle third: Transition zone, "watershed" vascular region
• Distal third: More circular cross-section, thinner cortices, poorest periosteal blood supply—highest nonunion and malunion rates [8]

The anteromedial border is subcutaneous throughout its length, receiving no muscular coverage. This explains both the high open fracture rate and the propensity for skin necrosis over prominent hardware.

Vascular Anatomy

Exam Detail: Critical for Viva: Understanding tibial blood supply explains why reaming and periosteal stripping affect healing:

Three Vascular Systems: [8,18]

1. Nutrient Artery (branch of posterior tibial artery):

   • Enters posterior cortex at proximal-middle third junction
   • Descends within medullary canal
   • Supplies inner 2/3 of cortex
   • Destroyed by reaming—why periosteal preservation is critical in reamed nailing

2. Periosteal Arteries (from anterior tibial, posterior tibial, and peroneal arteries):

   • Form extraosseous network on bone surface
   • Supply outer 1/3 of cortex
   • Disrupted in open fractures with periosteal stripping
   • Dominant supply after reaming

3. Metaphyseal Vessels (proximal and distal):

   • Supply epiphyseal regions
   • Contribute to fracture healing in metaphyseal injuries

Clinical Implication: In high-grade open fractures (Type IIIB) with extensive periosteal stripping, the bone is rendered relatively avascular after reamed nailing. This explains the high nonunion rate (20-50%) and need for early soft tissue coverage to allow revascularization. [10]

Compartment Anatomy

The leg contains four osteofascial compartments bounded by tibia, fibula, interosseous membrane, and investing fascia: [9,19]

Compartment Syndrome Pathophysiology:

Tissue pressure within a closed fascial space exceeds capillary perfusion pressure → microvascular collapse → tissue ischemia → cellular necrosis → inflammatory cascade → further edema → cycle perpetuates [9]

Stryker Pressure Monitor Criteria (most widely used):

• Absolute pressure > 30-40mmHg: High risk zone
• Delta pressure less than 30mmHg: FASCIOTOMY INDICATED
  • Delta P = Diastolic BP – Compartment Pressure
  • "Rationale: Capillary perfusion pressure approximates diastolic BP; when compartment pressure approaches this, tissue perfusion ceases [20]"

Clinical Pearl: Hypotension Doubles the Risk: A trauma patient with systolic BP 90mmHg (diastolic ~60mmHg) reaches critical Delta P at compartment pressure of only 30mmHg—a level that might be "safe" in a normotensive patient. Always consider hemodynamic status when interpreting compartment pressures. [20]

Biomechanics of the Fibula

The fibula bears approximately 10-15% of axial load in the intact leg. In tibial shaft fractures:

• Intact fibula ("strutting fibula"): Prevents compression at tibial fracture site → nonunion risk increased [14]
• Fibula fracture at same level: Allows physiologic compression → promotes union
• Fibula fracture at different level: Suggests rotational injury mechanism; may complicate length/rotation control

Controversial Fibular Osteotomy: Some surgeons advocate prophylactic fibular osteotomy in tibial nonunions to allow compression, but evidence is weak. [21]

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4. Classification Systems

Gustilo-Anderson Classification (Open Fractures)

The most widely used system for open fractures, predicting infection risk, amputation rates, and guiding antibiotic therapy: [22]

Exam Detail: Viva Trap Question: "What's the difference between Type IIIA and IIIB?"

Answer: The critical distinction is adequacy of soft tissue coverage. Type IIIA has extensive soft tissue damage, but bone can be covered by local muscle or fascia (e.g., gastrocnemius slide, soleus flap). Type IIIB has such severe soft tissue loss that a free tissue transfer (free flap) or rotational flap from distant site is required. This distinction may not be apparent until surgical debridement—initial grading is provisional. [22]

Historical Note: Gustilo-Anderson was developed in the 1970s-1980s for open tibial shaft fractures specifically. It's now applied to all open long bone fractures, though validity in other anatomic regions is less established. [22]

Tscherne-Oestern Classification (Closed Fractures)

Often overlooked but clinically important for predicting complications in closed injuries: [15]

Clinical Application: Tscherne Grade 3 injuries require damage control (external fixation, delayed nailing) similar to high-grade open fractures, despite intact skin. [15]

AO/OTA Classification

Alphanumeric system used in research and operative planning:

• 42-A: Simple fracture (spiral, oblique, transverse)
• 42-B: Wedge/butterfly fragment
• 42-C: Complex/comminuted

Further subdivisions (1, 2, 3) indicate increasing severity within each category.

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5. Clinical Presentation

History

Key Questions:

1. Mechanism: High vs low energy? (Predicts open fracture risk, compartment syndrome, polytrauma)
2. Time of injury: Critical for compartment syndrome risk window (peak 12-48 hours)
3. Open wound?: Direct trauma to anterior shin should raise suspicion for open fracture
4. Neurovascular symptoms: Numbness, tingling, foot drop
5. Smoking status: Modifiable risk factor for nonunion
6. Medications: NSAIDs, anticoagulation, steroids

Symptoms

• Severe pain: Location over tibial shaft; may radiate to knee or ankle
• Inability to weight-bear: Universal finding
• Deformity: Visible angulation or shortening (especially in displaced fractures)
• Swelling: Progressive over first 24-48 hours
• "Pain out of proportion": Red flag for compartment syndrome—pain that seems excessive for injury, worsening despite splinting/analgesia

Physical Examination

Inspection

• Skin integrity: Critical examination—inspect full 360° circumference of leg

  • Lift the leg and check posterior calf
  • Look for tiny puncture wounds (Type I open)—easily missed on cursory exam
  • Note fracture blisters (indicate high soft tissue energy)
  • Assess for "skin tenting" (bone pressing on skin from inside—requires urgent reduction)

• Deformity: Note angulation, rotation, shortening

• Swelling: Circumferential vs localized

Palpation

• Tenderness: Localize maximum tenderness to tibial shaft vs plateau/pilon
• Crepitus: Confirms fracture
• Compartment tension: Palpate all four compartments
  • Anterior (anterolateral leg)
  • Lateral (lateral to fibula)
  • Superficial posterior (calf)
  • Deep posterior (deep to calf—difficult to assess by palpation)
  • "Woody hard" feeling indicates elevated pressure [9]

Neurovascular Examination

MANDATORY in every tibial fracture (5-10% have vascular injury in high-energy trauma): [23]

Clinical Pearl: Passive Stretch Test for Compartment Syndrome:

• Anterior compartment: Passively plantarflex ankle and toes → severe pain indicates anterior compartment syndrome (stretches tibialis anterior, EDL, EHL)
• Deep posterior compartment: Passively dorsiflex toes → severe pain indicates deep posterior compartment syndrome (stretches FDL, FHL)

Pitfall: Late signs of compartment syndrome (pulselessness, paralysis, pallor, poikilothermia) indicate irreversible damage. Diagnosis must be made on early signs (pain, pressure, pain with passive stretch). [9]

Associated Injuries

• Ipsilateral femur fracture: "Floating knee"—high-energy injury, poor prognosis [24]
• High fibula fracture: Maisonneuve injury (syndesmosis disruption)—examine ankle
• Knee/ankle ligamentous injury: Easy to miss with deformity; reassess after reduction/fixation
• Foot fractures: Especially calcaneus, talus in axial load injuries

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6. Investigations

Imaging

Plain Radiographs

MANDATORY: Full-length tibia and fibula AP and lateral views, including knee and ankle joints ("joint above and below")

Assessment Checklist:

1. Fracture location: Proximal, middle, or distal third (affects fixation strategy)
2. Fracture pattern: Spiral, oblique, transverse, comminuted, segmental
3. Displacement: Translation (medial/lateral, anterior/posterior), angulation, rotation, shortening
4. Fibula involvement: Fractured at same level, different level, or intact
5. Intra-articular extension: Into knee (tibial plateau) or ankle (pilon)
6. Bone quality: Osteoporosis, Paget's disease, metastatic lesions (pathological fracture?)

Special Views:

• High fibula fracture: Obtain ankle XR and full-leg views to rule out Maisonneuve injury (syndesmosis disruption)

CT Scan

Indications:

• Suspected intra-articular extension (plateau or pilon component)
• Severe comminution requiring preoperative planning (rotation assessment, wedge fragment size)
• Concomitant plateau or pilon fracture
• Assessment of bone loss in open fractures

Exam Detail: CT is NOT routinely needed for simple diaphyseal fractures amenable to intramedullary nailing. Plain XR with intraoperative fluoroscopy is sufficient. [25]

CT Angiography (CTA)

URGENT Indications: [23]

• Absent distal pulses with ABI less than 0.9
• "Hard signs" of vascular injury: expanding hematoma, pulsatile bleeding, bruit/thrill
• Knee dislocation or floating knee (15-40% vascular injury rate)
• Open fracture with pulselessness

Soft indications (controversial):

• High-energy mechanism with asymmetric pulses
• Shotgun injury
• Compartment syndrome refractory to fasciotomy (may indicate arterial injury)

Laboratory Investigations

In open fractures or polytrauma:

• FBC: Baseline hemoglobin (hemorrhage assessment), WCC (infection baseline)
• Coagulation profile: Especially if anticoagulated or bleeding diathesis suspected
• Group and Save/Cross-match: 2-4 units for open fractures requiring debridement
• Lactate: Marker of shock/hypoperfusion in polytrauma

In suspected compartment syndrome:

• Creatine kinase (CK): Marker of muscle necrosis (usually > 5,000 U/L indicates significant rhabdomyolysis)
• Myoglobin: Urine myoglobin indicates rhabdomyolysis risk for acute kidney injury
• Renal function: Baseline and serial monitoring if fasciotomy performed late

Compartment Pressure Measurement

Indications: [9,20]

• Clinical suspicion of compartment syndrome BUT examination equivocal (e.g., obtunded patient, regional anesthesia, uncooperative patient)
• Borderline clinical findings where decision for fasciotomy is uncertain

Devices:

• Stryker Intra-Compartmental Pressure Monitor (most common)
• Arterial line transducer setup (ICU setting)

Technique:

1. Calibrate device at level of compartment (not heart level)
2. Insert needle 5cm from fracture site
3. Measure all four compartments (anterior, lateral, superficial posterior, deep posterior)
4. Record patient's blood pressure simultaneously

Interpretation:

• Delta P (ΔP) = Diastolic BP – Compartment Pressure
  • ΔP less than 30 mmHg: Fasciotomy indicated [20]
  • ΔP 30-40 mmHg: Gray zone—close clinical monitoring
  • ΔP > 40 mmHg: Low risk, continue observation

Clinical Pearl: Clinical Diagnosis Trumps Numbers: Compartment pressure measurement is an adjunct, not a replacement for clinical judgment. If a patient has classic findings (severe pain, pain on passive stretch, tense compartment), do not delay fasciotomy to obtain pressure measurements. "Treat the patient, not the number." [9]

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7. Management

Initial Emergency Department Management

Primary Survey (High-Energy Trauma)

ATLS Protocol: [26]

• Airway, Breathing, Circulation (tibial fractures can be bleeding significantly into soft tissues—2-4 units blood loss)
• Disability (GCS—head injury?)
• Exposure (identify all injuries)

Secondary Survey: Focused Limb Assessment

BOAST 4 Guidelines for Open Fractures: [7]

Within 1 Hour of Arrival:

1. Antibiotics:

   • Co-Amoxiclav 1.2g IV (or Cefazolin 2g if penicillin allergy)
   • Gentamicin 1.5mg/kg IV (for Type II and Type III)
   • Add Metronidazole 500mg IV for farm injuries or gross fecal contamination
   • Continue Q8H until definitive soft tissue coverage

2. Tetanus Prophylaxis:

   • Tetanus toxoid booster if > 5 years since last dose OR unknown status
   • Tetanus immunoglobulin if never immunized

3. Photograph Wound:

   • Take ONE high-quality photograph
   • Prevents repeated dressing removal
   • Documents injury severity for medicolegal purposes

4. Wound Coverage:

   • Irrigate with sterile saline (gentle—avoid high-pressure in ED)
   • Cover with saline-soaked gauze and occlusive dressing
   • Do NOT re-examine until operating theatre

5. Remove Gross Contamination:

   • Remove visible dirt, grass, debris
   • Do NOT perform extensive debridement in ED (requires anesthesia and proper lighting)

Closed Fractures: Immobilization and Analgesia

1. Analgesia:

   • Opioids (morphine 0.1mg/kg IV) for acute pain
   • Paracetamol 1g IV/PO
   • Avoid NSAIDs in acute phase (less than 2 weeks) due to nonunion concern [27]

2. Reduction (if deformed):

   • Procedural sedation or femoral nerve block
   • Inline traction and manipulation to restore length and alignment
   • URGENT if skin tenting (impending open fracture/skin necrosis)

3. Splinting:

   • Above-knee backslab (not circumferential cast—compartment syndrome risk)
   • Ensure adequate padding
   • Knee in 5-10° flexion, ankle in neutral
   • Split backslab if swelling increases

4. Elevation and Ice:

   • Elevate leg above heart level (reduces swelling)
   • Ice packs (20 min on, 20 min off) for first 48-72 hours

Indications for Urgent (less than 6 hour) Surgery

1. Open fracture (all grades—higher grade, more urgent)
2. Vascular injury (limb-threatening ischemia)
3. Compartment syndrome (confirmed or high clinical suspicion)
4. "Tenting" skin (bone pressing against skin from inside—imminent skin necrosis)

Indications for Semi-Urgent (6-24 hour) Surgery

• Closed fracture with acceptable alignment (can await daytime trauma list)
• Tscherne Grade 2-3 closed fracture (high soft tissue injury)

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Definitive Management: Surgical

Decision Algorithm

┌─────────────────────────────────────────────┐
│         TIBIAL SHAFT FRACTURE               │
└────────────────┬────────────────────────────┘
                 │
    ┌────────────┴────────────┐
    │ OPEN? VASCULAR?         │
    │ COMPARTMENT SYNDROME?   │
    └────────────┬────────────┘
                 │
        ┌────────┴─────────┐
       YES                 NO
        │                   │
        ▼                   ▼
┌───────────────┐   ┌──────────────────┐
│   EMERGENCY   │   │ SOFT TISSUES OK? │
│  DEBRIDEMENT  │   │ (Tscherne 0-1)   │
│  + FIXATION   │   └────────┬─────────┘
└───────────────┘            │
        │              ┌─────┴──────┐
        │             YES           NO
        │              │             │
        │              ▼             ▼
        │      ┌──────────────┐  ┌──────────────┐
        │      │   IM NAIL    │  │DAMAGE CONTROL│
        └──────│(Gold Standard)│  │  (Ex-Fix)    │
               └──────────────┘  └──────┬───────┘
                                         │
                                  ┌──────▼────────┐
                                  │ WAIT 7-14 DAYS│
                                  │(Swelling ↓ )  │
                                  └──────┬────────┘
                                         │
                                         ▼
                                  ┌──────────────┐
                                  │CONVERT TO IM │
                                  │    NAIL      │
                                  └──────────────┘

Exam Detail: "Damage Control Orthopaedics" Concept: [28]

In polytrauma patients (ISS > 18, shock, coagulopathy, severe chest injury), definitive fixation with reamed intramedullary nailing can exacerbate systemic inflammation ("second hit" phenomenon), leading to ARDS and MOF. Initial management with external fixation ("span, scan, plan") stabilizes fracture, allows patient resuscitation, and permits definitive nailing once physiologically optimized (typically 5-14 days). [28]

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1. Intramedullary Nailing (IMN) – Gold Standard

Indications (90% of tibial shaft fractures): [6,29]

• Closed fractures
• Open fractures Type I, II, IIIA (after debridement)
• Diaphyseal fractures (excludes very proximal or very distal fractures within 5cm of joint)

Contraindications:

• Active infection at fracture site
• Severe osteoporosis (canal too wide for nail fixation)
• Very proximal or distal fractures (insufficient bone for interlocking)
• Extremely narrow medullary canal (less than 6mm)

Technique Overview

Patient Positioning:

• Supine on radiolucent table
• Affected leg in traction or on radiolucent triangle

Surgical Approaches:

Steps:

1. Entry point: Ideal entry is apex of intercondylar notch (confirmed on AP and lateral fluoroscopy)

   • Too anterior → procurvatum deformity
   • Too posterior → apex anterior angulation

2. Guidewire insertion: Pass ball-tip guidewire across fracture under fluoroscopy

   • Achieve provisional reduction with manual traction
   • Confirm wire in distal canal on AP and lateral views

3. Reaming:

   • Reaming Protocol (per SPRINT trial): [6]
     • Start with 8mm reamer
     • Sequentially increase in 0.5mm increments
     • Ream 1.5mm larger than planned nail diameter
     • Save reamings (autogenous bone graft—can be used for nonunion site or comminution)
   • Unreamed technique (rarely used): Insert nail without reaming—only for very specific indications (pathologic fracture, severe osteoporosis)

4. Nail insertion:

   • Select nail diameter (typically 9-11mm for reamed, 8-9mm for unreamed)
   • Nail length: Measure from entry to 1-2cm above ankle joint
   • Insert over guidewire

5. Proximal interlocking:

   • Insert 2 screws (AP and mediolateral) using jig
   • Prevents rotation and shortening

6. Distal interlocking:

   • Typically 2 screws (AP or oblique) using freehand or electromagnetic technique
   • Static locking (screws in all holes): For unstable fracture patterns, prevents shortening
   • Dynamic locking (leave one distal screw hole empty): Controversial—allows "dynamization" for compression

7. Confirm reduction:

   • AP, lateral, and oblique fluoroscopy
   • Accept less than 5° varus/valgus, less than 10° procurvatum/recurvatum, less than 10° rotation, less than 1cm shortening

Evidence: SPRINT Trial (Study to Prospectively Evaluate Reamed Intramedullary Nails in Tibial Fractures)

Design: Multicenter RCT, 1,226 patients, reamed vs unreamed IM nailing [6]

Results:

Conclusions:

• Closed fractures: Reamed nailing reduces reoperation for autodynamization/fixation failure by 37%
• Open fractures: No difference in reoperation or infection
• Current Practice: Reamed nailing is standard for closed fractures; debate continues for high-grade open fractures

Evidence Debate: Unreamed Nailing in Open Fractures?

Theoretical concern: Reaming destroys endosteal blood supply, potentially increasing infection risk in open fractures where periosteal blood supply is already compromised. However, SPRINT showed no infection difference. [6]

Current Consensus: Reamed nailing is acceptable for Type I, II, and IIIA open fractures. Some surgeons use unreamed for Type IIIB/C, but evidence is weak. [10]

Postoperative Protocol

• Weight-bearing: Immediate weight-bearing as tolerated (WBAT)

  • IM nail is load-sharing device (shares load with bone, unlike load-bearing like plate)
  • Early mobilization stimulates fracture healing (Wolff's law)
  • "Exception: Severely comminuted or segmental fractures may require 6-week protected weight-bearing"

• Thromboprophylaxis: LMWH for 14-35 days (high VTE risk in trauma)

• Physiotherapy: Knee and ankle range of motion exercises from day 1

• Smoking cessation: CRITICAL—counsel at every visit [16]

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2. External Fixation

Indications:

1. Damage control orthopaedics: Polytrauma, hemodynamic instability [28]
2. Severe soft tissue injury: Tscherne Grade 3, Open Type IIIB (temporization until soft tissues ready for definitive fixation)
3. Active infection: Infected nonunion, chronic osteomyelitis
4. Bone loss: Segmental defects requiring bone transport (Ilizarov/Taylor Spatial Frame)
5. Pediatric fractures: Flexible nails preferred in children; ex-fix if unstable

Monolateral External Fixator (Temporary)

Technique:

• 2-3 pins proximal and distal to fracture
• Pins in "safe corridor" (anterolateral—avoids neurovascular structures)
• Maintain alignment and length
• Plan for definitive fixation within 2-3 weeks (before pin tracts become infected)

Conversion to IM Nail:

• Timing: 5-14 days (once swelling decreased, soft tissues recovered)
• Risk: Pin tract infection increases risk of deep infection after nailing (some studies show 2-4% deep infection rate after conversion) [31]

Circular External Fixation (Definitive)

Ilizarov/Taylor Spatial Frame (TSF): [32]

• Indications: Infected nonunion, bone defect, severe deformity correction
• Bone Transport Technique:
  • Corticotomy (preserves periosteum)
  • Gradual distraction (1mm/day in 4 increments of 0.25mm)
  • New bone forms in distraction gap ("distraction osteogenesis")
  • Can regenerate 10-15cm of bone over 6-12 months
• Cons: Pin site care intensive, prolonged treatment (1 month per cm of bone transport), patient compliance critical

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3. Plate Fixation (MIPO - Minimally Invasive Plate Osteosynthesis)

Indications (uncommon for diaphyseal fractures):

• Fractures extending into metaphysis (proximal or distal tibia) where IM nail insufficient
• Very distal fractures unsuitable for nailing
• Deformity correction (osteotomy)
• Pediatric physeal considerations

Technique:

• Percutaneous plate insertion (MIPO approach)
• Locking screws for fixed-angle stability
• Preserves periosteal blood supply

Cons:

• Prominent hardware (subcutaneous border)
• Delayed weight-bearing (6-12 weeks)
• Higher infection risk than IM nail

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4. Conservative Management (Functional Bracing)

Indications (RARE in modern practice):

• Low-energy, minimally displaced (less than 50% translation, less than 5° angulation) stable fractures
• Compliant patient
• Medical comorbidities precluding surgery

Technique (Sarmiento Method): [33]

1. Above-knee cast for 4-6 weeks (until early callus)
2. Patellar Tendon-Bearing (PTB) cast for 4-8 weeks (functional bracing—allows knee/ankle motion)
3. Progressive weight-bearing

Outcomes:

• Union rates: 80-95% (acceptable)
• Malunion rates: 20-40% (varus, procurvatum, shortening) [33]
• Stiffness: Knee and ankle stiffness common
• Current Practice: Largely supplanted by IM nailing (superior outcomes, faster recovery, early mobilization)

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Management of Open Fractures: "BOAST 4 Protocol"

Within 1 Hour: Antibiotics (covered above)

Within 6-24 Hours: Surgical Debridement [7,12]

Urgency Stratification:

Debridement Principles ("The 6 Ps"):

1. Pulsatile lavage: 6-9L normal saline (controversial—high pressure may drive bacteria deeper; low pressure adequate per recent evidence) [34]
2. Preserve viable tissue: Excise only clearly nonviable tissue
   • Muscle viability: "4 Cs"—Color (pink), Consistency (firm), Contractility (responds to stimulation), Circulation (bleeding)
   • Bone: Remove only loose, detached fragments; preserve periosteal attachments
3. Perform thorough wound extension: Extend skin incision to visualize full injury zone
4. Photograph: Document debridement extent
5. Plan for re-look: If contamination severe or viability uncertain, plan second-look debridement in 24-48h
6. Plastic surgery involvement: Early involvement (ideally same sitting as initial debridement) for Type IIIB

Fixation at Initial Debridement:

• Type I, II: IM nailing acceptable at initial debridement (after debridement, before wound closure)
• Type IIIA: IM nailing or temporary ex-fix (surgeon preference)
• Type IIIB/C: Temporary external fixation → definitive fixation after soft tissue coverage

Soft Tissue Coverage ("72-Hour Rule")

Evidence: Early flap coverage (less than 72h) reduces deep infection from 30-50% to 10-20% in Type IIIB open fractures. [35]

Coverage Options:

Negative Pressure Wound Therapy (NPWT):

• Temporary measure (not definitive coverage)
• Reduces edema, promotes granulation
• Do NOT use for > 7 days without plan for definitive coverage (increases infection risk)

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8. Complications

Early Complications (less than 6 weeks)

Compartment Syndrome

Incidence: 5-10% of tibial shaft fractures (higher in high-energy injuries) [4,9]

Pathophysiology: Covered in Section 3

Clinical Presentation:

• Pain: Severe, "out of proportion," poorly responsive to opioids
• Pain on passive stretch: MOST SENSITIVE early finding [9]
  • "Anterior compartment: Pain on passive plantarflexion of toes"
  • "Deep posterior: Pain on passive dorsiflexion of toes"
• Pressure: Compartment feels tense, "woody"
• Paresthesias: Numbness in nerve distribution (deep peroneal → first web space)
• Paralysis: Late finding (indicates muscle necrosis)
• Pulselessness: VERY late finding (ischemia is microvascular, not macrovascular)
• Pallor: Late finding

Diagnosis:

• Clinical diagnosis (do not delay for pressure measurement if classic findings present)
• Compartment pressure measurement if equivocal (Delta P less than 30mmHg → fasciotomy)

Treatment: 4-Compartment Fasciotomy

Technique: [19]

1. Lateral incision (anterolateral leg):

   • Releases anterior and lateral compartments
   • Incision centered over fibula, extends from fibular head to 5cm above lateral malleolus
   • Incise fascia over anterior and lateral compartments separately

2. Medial incision (posteromedial leg):

   • Releases superficial posterior and deep posterior compartments
   • Incision 2cm posterior to posteromedial tibial border (avoids saphenous vein/nerve)
   • Incise superficial posterior fascia
   • Detach soleus from tibia to access deep posterior compartment

Pitfall: Single-incision fasciotomy (fibulectomy) is INADEQUATE—misses deep posterior compartment.

Postoperative Care:

• Leave wounds open (cover with moist dressings or NPWT)
• Delayed primary closure at 5-7 days (if swelling resolved) vs split-thickness skin graft
• Aggressive physiotherapy to prevent contracture

Prognosis:

• If treated within 6-8 hours: Excellent recovery (> 90% normal function)
• If treated at 12-24 hours: Variable (20-50% chronic pain, weakness)
• If treated > 24 hours: Poor (ischemic contracture, chronic pain, functional impairment common) [9]

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Vascular Injury

Incidence: 5% (high-energy trauma); up to 15-40% in floating knee [23,24]

Presentation:

• Absent pulses
• ABI less than 0.9
• Expanding hematoma
• Pulsatile bleeding from wound

Management:

1. CTA (if patient hemodynamically stable)
2. Immediate vascular surgery consult
3. Revascularization within 6 hours (ischemia > 6h → amputation risk > 50%)
4. Sequence: "Fix the fracture first" vs "Fix the vessel first"?
   • Current evidence: Temporary shunt to restore flow → stabilize fracture (ex-fix) → definitive vascular repair [23]
   • Exception: If fracture unstable, rapid external fixation may prevent re-injury to vascular repair

"Type IIIC Open Fracture" (vascular injury + fracture):

• Historically 50-90% amputation rate
• Modern series: 10-30% amputation if warm ischemia time less than 6h and revascularization successful [36]

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Infection (Acute)

Incidence:

• Closed fractures: 1-2%
• Open Type I/II: 2-5%
• Open Type IIIA: 5-10%
• Open Type IIIB: 10-50% [10,12]

Risk Factors:

• High-grade open fracture
• Delay to debridement > 24h
• Inadequate debridement
• Smoking, diabetes, malnutrition
• Failure of soft tissue coverage

Presentation:

• Fever, wound erythema, purulent drainage
• Elevated inflammatory markers (CRP, ESR, WCC)

Management:

1. Wound culture (deep tissue samples, not swab)
2. Blood cultures if systemic sepsis
3. Surgical debridement: Remove all necrotic tissue, obtain cultures, irrigate
4. Antibiotics: Empiric (vancomycin + anti-Gram negative) → organism-specific (usually Staph aureus, Pseudomonas, Enterobacteriaceae)
5. Retention of hardware: If fracture stable and less than 3 weeks from injury, attempt hardware retention with debridement + suppressive antibiotics
6. Remove hardware: If fracture unstable, loose hardware, or infection not controlled

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Late Complications (> 6 weeks)

Malunion

Incidence: 5-10% with IM nailing; 20-40% with casting [29,33]

Types:

• Varus: Most common (intact fibula "struts" medially)
• Procurvatum (apex anterior angulation): Entry point too anterior
• Rotation: Difficult to detect clinically; compare to contralateral limb (foot progression angle)
• Shortening: Acceptable less than 1-1.5cm (usually asymptomatic)

Acceptable Alignment (heal without functional deficit):

• less than 5° varus/valgus
• less than 10° procurvatum/recurvatum
• less than 10° rotation
• less than 1cm shortening [29]

Indications for Correction:

• Symptomatic (pain, limp, functional limitation)

• 10° varus/valgus (alters knee biomechanics → arthritis risk)

• 15° procurvatum/recurvatum

• 15° rotation (cosmetic, altered gait)

Correction Techniques:

• Acute osteotomy + plating
• Gradual deformity correction with Ilizarov frame

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Nonunion

Definition: Failure to progress toward union for 3+ consecutive months, or not healed at 6-9 months [11]

Incidence:

• IM nailing: 5-10%
• Open fractures: 15-50% (grade-dependent) [11]

Classification:

• Hypertrophic ("Elephant foot"): Abundant callus, fracture gap present

  • Biological activity present
  • Usually mechanical instability
  • "Treatment: Mechanical stabilization (dynamization, exchange nailing, compression)"

• Atrophic ("No callus"): Minimal callus, fracture gap

  • Biological inactivity (avascular, infected, poor bone quality)
  • "Treatment: Biological augmentation (bone graft, BMP-7) + mechanical stabilization"

Treatment Algorithm:

1. Rule out infection: ESR, CRP, WCC; consider aspiration for culture

2. Assess mechanical stability: Is nail too small? Interlocking screws broken?

3. Treatment Options:

   Dynamization (remove interlocking screws):

   • Allows axial compression at fracture site
   • Success rate: 50-70% (works best in hypertrophic nonunion with less than 1cm gap) [37]

   Exchange Nailing (remove nail, ream larger, insert larger nail):

   • Reaming provides bone graft, larger nail provides stability
   • Success rate: 80-95% [37]

   Bone Grafting:

   • Autograft (iliac crest) or allograft
   • Add if exchange nailing alone insufficient (large gap, atrophic)

   BMP-7 (OP-1): Off-label use; expensive; some evidence for atrophic nonunion [38]

   Ilizarov Bone Transport: For infected nonunion or segmental defect

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Infection (Chronic Osteomyelitis)

Incidence: 2-5% after IM nailing (higher in open fractures) [10]

Presentation:

• Persistent wound drainage (sinus tract)
• Pain, swelling, erythema
• Nonunion with elevated inflammatory markers (CRP, ESR chronically elevated)

Diagnosis:

• MRI: Bone marrow edema, abscess, soft tissue involvement
• Nuclear medicine: WBC scan, FDG-PET (if MRI contraindicated due to hardware)
• Culture: Deep tissue or bone biopsy (gold standard)

Management (Cierny-Mader Principles): [39]

1. Debridement: Remove all necrotic bone, infected soft tissue, biofilm-coated hardware
2. Dead space management:
   • Antibiotic cement spacer (Masquelet technique)
   • Muscle flap (vascularized tissue)
3. Soft tissue coverage: Free or local flap if defect
4. Bone stability: External fixation or antibiotic-coated nail
5. Prolonged antibiotics: 6 weeks IV, then 3-6 months oral (organism-specific)
6. Bone reconstruction (if segmental defect):
   • Ilizarov bone transport
   • Induced membrane technique (Masquelet)
   • Vascularized fibula graft

Suppression vs Cure:

• Cure: Eradicate infection (requires all above steps)
• Suppression: Chronic suppressive antibiotics (if patient not fit for extensive surgery)

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Anterior Knee Pain

Incidence: 30-50% after infrapatellar IM nailing [30]

Etiology:

• Patellar tendon damage (splitting during approach)
• Nail prominence (impingement on patella)
• Heterotopic ossification in tendon
• Patellofemoral arthritis (nail entry damages articular cartilage)

Presentation:

• Pain with kneeling, squatting, stairs
• Chronic (persistent > 1 year post-surgery)

Management:

1. Physiotherapy: Quadriceps strengthening, patellar mobilization
2. Nail removal: After fracture union (12-18 months); relieves symptoms in 50-70%
3. Suprapatellar approach: Reduces anterior knee pain to 10-15% (use prospectively if concerned) [30]

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Leg Length Discrepancy

Incidence: 5-10% (usually less than 1cm, asymptomatic)

Causes:

• Comminution with bone loss
• Fibula "strutting" preventing compression
• Distraction at fracture site during nailing

Management:

• less than 1.5 cm: Usually asymptomatic; shoe lift if needed

• 2 cm: Consider limb lengthening (Ilizarov) or contralateral epiphysiodesis (children)

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9. Prognosis and Outcomes

Union Rates

Functional Outcomes

Return to Work: [40]

• Sedentary job: 3-6 months
• Manual labor: 6-12 months
• High-grade open fractures: May never return to heavy manual labor (30-40%)

Return to Sports: [40]

• Low-impact (cycling, swimming): 3-6 months
• High-impact (running, contact sports): 9-12 months
• Elite sports: Variable; some never return to pre-injury level

SF-36 and SMFA Scores (health-related quality of life):

• Closed fractures: Return to baseline by 12 months in 70-80%
• Open Type IIIB: Only 40-50% return to baseline; many have chronic pain, functional limitation [41]

Predictors of Poor Outcome

Multivariate Analysis: [41]

1. High-grade open fracture (Type IIIB/C)
2. Compartment syndrome (especially if delayed treatment > 12h)
3. Infection
4. Smoking (ongoing)
5. Polytrauma (ISS > 16)
6. Worker's compensation/litigation (controversial, but consistent finding)

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10. Prevention Strategies

Primary Prevention

• Road safety: Seatbelts, helmets, lower speed limits
• Fall prevention in elderly: Home assessments, balance training, vitamin D, bone health
• Occupational safety: Protective equipment, safe work practices

Secondary Prevention (Prevent Complications)

Compartment Syndrome:

• Avoid circumferential casts in acute phase
• Educate patients on warning signs
• Low threshold for fasciotomy in high-risk injuries

Infection in Open Fractures:

• less than 1 hour antibiotics (most important modifiable factor) [12]
• Adequate debridement (excise all nonviable tissue)
• Early soft tissue coverage (less than 72h for Type IIIB) [35]

Nonunion:

• Smoking cessation: Counsel at every visit; consider nicotine replacement, varenicline [16]
• Avoid NSAIDs in first 6-12 weeks (controversial, but prudent) [27]
• Optimize nutrition: Protein, calcium, vitamin D
• Diabetes control: HbA1c less than 7%

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11. Guidelines and Key Evidence

BOAST 4: Open Fractures (British Orthopaedic Association) [7]

Key Recommendations:

1. Antibiotics less than 1h (Co-amoxiclav + Gentamicin for Type II/III)
2. Photograph wound once, apply occlusive dressing
3. Debridement less than 24h (sooner for contaminated/high-energy)
4. Involve plastics early; soft tissue coverage less than 72h for Type IIIB
5. Repeat debridement if contamination concerns or uncertain viability

SPRINT Trial (2008) [6]

Impact: Established reamed IM nailing as gold standard for closed tibial fractures; settled decades-long debate

AO Principles of Fracture Management

4 Principles:

1. Fracture reduction to restore anatomy
2. Fracture fixation for absolute/relative stability
3. Preserve blood supply (minimize soft tissue stripping)
4. Early mobilization

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12. Examination Focus (Viva Vault)

Exam Detail: ### Viva Question 1: "Describe the Gustilo-Anderson Classification"

Model Answer:

"The Gustilo-Anderson classification grades open fractures based on wound size, soft tissue damage, and bone exposure. It predicts infection and amputation risk and guides antibiotic therapy.

• Type I: Wound less than 1cm, clean, minimal muscle damage. Infection risk less than 2%. Treatment: Cefazolin.
• Type II: Wound 1-10cm, moderate soft tissue damage. Infection risk 2-5%. Treatment: Cefazolin.
• Type IIIA: Wound > 10cm, extensive soft tissue injury, but adequate coverage achievable with local tissue. Infection risk 5-10%. Treatment: Cefazolin + Gentamicin.
• Type IIIB: Wound > 10cm, extensive soft tissue loss requiring free flap or rotational flap for coverage. Infection risk 10-50%. Treatment: Cefazolin + Gentamicin.
• Type IIIC: Any size wound with arterial injury requiring repair. Infection risk 25-50%, amputation risk up to 90% historically (now 10-30% with modern vascular surgery). Treatment: Cefazolin + Gentamicin.

The critical distinction between IIIA and IIIB is the need for flap reconstruction—IIIB requires plastic surgery involvement for soft tissue coverage, ideally within 72 hours to minimize infection."

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Viva Question 2: "How do you diagnose compartment syndrome clinically?"

Model Answer:

"Compartment syndrome is a clinical diagnosis. I rely on pain out of proportion and pain on passive stretch as the earliest and most sensitive findings.

Clinical Features (in order of appearance):

1. Pain out of proportion: Severe pain not adequately controlled by opioids, seems excessive for the injury
2. Pain on passive stretch:
   • Anterior compartment: Severe pain when I passively plantarflex the toes (stretches tibialis anterior, EDL, EHL)
   • Deep posterior: Severe pain when I passively dorsiflex the toes (stretches FDL, FHL)
3. Pressure: Palpable tension in the compartment—feels 'woody hard'
4. Paresthesias: Numbness in nerve distribution (e.g., deep peroneal → first web space)
5. Paralysis: Late sign—indicates muscle necrosis
6. Pulselessness/Pallor: Very late signs—indicate irreversible ischemia

If I suspect compartment syndrome clinically, I proceed directly to fasciotomy. If the examination is equivocal—for example, in an obtunded patient or someone with a regional block—I measure compartment pressures. The critical value is Delta P (diastolic BP minus compartment pressure). If Delta P is less than 30mmHg, I perform a four-compartment fasciotomy emergently."

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Viva Question 3: "What did the SPRINT trial show?"

Model Answer:

"The SPRINT trial was a multicenter randomized controlled trial published in 2008 that compared reamed versus unreamed intramedullary nailing in 1,226 patients with tibial shaft fractures.

Key Findings:

• In closed fractures, reamed nailing reduced the reoperation rate for implant failure (autodynamization or exchange nailing) by 37%—from 13.0% with unreamed nails to 8.2% with reamed nails (P=0.03).
• In open fractures, there was no significant difference in reoperation rates or infection rates between reamed and unreamed techniques.
• Reamed nailing did not increase infection rates, even in open fractures.

Clinical Implication: Reamed intramedullary nailing is now the gold standard for closed tibial shaft fractures. The reaming process provides autogenous bone graft from the medullary canal and allows insertion of larger-diameter nails, which are biomechanically stronger. For open fractures, most surgeons still use reamed nailing for Type I, II, and IIIA, though some debate remains for Type IIIB."

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Viva Question 4: "Describe the blood supply to the tibia"

Model Answer:

"The tibia receives blood from three sources:

1. Nutrient artery: A branch of the posterior tibial artery, entering the posterior cortex at the proximal-middle third junction. It descends within the medullary canal and supplies the inner two-thirds of the cortex. This is destroyed during reamed intramedullary nailing.

2. Periosteal arteries: Derived from the anterior tibial, posterior tibial, and peroneal arteries. They form an extraosseous network and supply the outer one-third of the cortex. These are disrupted in open fractures with periosteal stripping.

3. Metaphyseal vessels: Supply the proximal and distal ends of the tibia.

Clinical Significance: After reamed nailing, the bone relies on periosteal blood supply. If the periosteum is stripped—as in high-grade open fractures—the bone is rendered relatively avascular, explaining the high nonunion rate (20-50% in Type IIIB open fractures). This underscores the importance of early soft tissue coverage to allow revascularization."

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Viva Question 5: "A patient has persistent pain 6 months after tibial nailing—what are your differential diagnoses?"

Model Answer:

"I would systematically consider:

Fracture-related:

1. Nonunion: Most common cause. I'd examine for tenderness, mobility at fracture site, and review serial X-rays for lack of callus progression.
2. Malunion: Varus, procurvatum, or rotational deformity causing altered biomechanics.
3. Hardware irritation: Prominent proximal or distal screws, proud nail.

Infection:

4. Chronic osteomyelitis: Persistent drainage, elevated inflammatory markers (ESR, CRP).

Soft Tissue:

5. Anterior knee pain: Very common (30-50% after infrapatellar nailing)—kneeling pain, patellar tendon pathology.
6. Muscle weakness/imbalance: Deconditioning after prolonged immobility.

Nerve:

7. Nerve injury: Persistent deep peroneal or superficial peroneal nerve symptoms.
8. Complex regional pain syndrome (CRPS): Allodynia, swelling, skin changes.

Other:

9. Referred pain: Hip or knee pathology.

My approach: Detailed history (character, location, exacerbating factors), examination (neurovascular, fracture site, hardware), and investigations (X-rays for union/alignment, inflammatory markers, consider MRI if infection suspected)."

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13. Patient Explanation

What is a tibial shaft fracture?

You've broken your shin bone, which is the larger of the two bones in your lower leg. This bone is called the tibia, and it carries most of your weight when you stand and walk. The "shaft" is the long, straight part of the bone between your knee and ankle.

How did this happen?

Tibial fractures usually happen from:

• High-energy injuries: Car accidents, motorcycle crashes, sports injuries, or falls from a height
• Direct blows: Someone or something hitting your shin directly
• Twisting injuries: Your foot gets caught while your body rotates
• Older adults: Sometimes a simple fall can cause this fracture if the bones are weaker (osteoporosis)

Why is this bone so vulnerable?

The front of your shin is right under the skin—there's very little muscle or fat protecting it. That's why it's easy to break and why it's the most common long bone fracture.

What treatment will I need?

Most patients need surgery with a metal rod (called an intramedullary nail) inserted inside the bone:

• We make a small incision near your knee
• We insert a titanium rod down the hollow center of your shin bone
• We lock it in place with screws at the top and bottom
• This acts like an "internal splint"

Why a rod instead of a cast?

• Faster healing: The rod allows you to put weight on your leg right away, which actually helps the bone heal faster
• Better alignment: Keeps the bone straight while it heals
• Fewer complications: Lower risk of stiffness, malunion (healing crooked), or nonunion (not healing)

Can I walk on it?

Yes, usually right away—as much as pain allows. This seems counterintuitive, but:

• The metal rod is very strong and shares the load with your bone
• Walking stimulates bone healing (your body responds to the stress by laying down new bone)
• You'll use crutches initially, then gradually increase weight as pain improves

What are the risks?

Compartment syndrome (5-10% risk):

• Swelling inside the tight compartments of your leg can cut off blood flow to muscles and nerves
• Warning sign: Severe pain that doesn't improve with pain medication, especially pain when moving your toes
• What we do: Emergency surgery to release the pressure (fasciotomy)
• Important: Tell your nurse immediately if your pain gets worse or you have numbness/tingling

Infection (1-2% in closed fractures, higher if the bone broke through the skin):

• We give you antibiotics and use sterile technique to minimize this risk
• If your bone broke through the skin ("open fracture"), we'll take you to surgery urgently to clean the wound

Non-healing (nonunion) (5-10% risk):

• Sometimes the bone doesn't heal
• Biggest risk factor: Smoking—nicotine constricts blood vessels and prevents bone cells from working
• If you smoke, you MUST stop—it can double or triple your nonunion risk

Anterior knee pain (30-50%):

• Pain with kneeling or squatting after the rod is inserted
• Usually improves over time; we can remove the rod after the bone heals (12-18 months) if it bothers you

How long until I'm back to normal?

What can I do to help my bone heal?

1. Stop smoking: This is the single most important thing you can do
2. Eat well: Protein (meat, fish, eggs), calcium (dairy), and vitamin D (we may give you supplements)
3. Follow physiotherapy: Keeping your knee and ankle moving prevents stiffness
4. Weight-bear as directed: Don't be afraid to put weight on your leg—it helps
5. Attend follow-ups: We'll monitor healing with X-rays at 2, 6, and 12 weeks

When should I worry?

Call your doctor or go to the emergency department if:

• Severe pain that's getting worse, not better, despite pain medication
• Numbness, tingling, or weakness in your foot
• Your toes turn blue, white, or very cold
• You can't move your toes
• Fever, chills, or drainage from your surgical wound
• Foul smell from your cast or dressing

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