Diaphyseal Tibial Fractures Workup

  • Author: Murali Poduval, MBBS, MS, DNB; Chief Editor: Thomas M DeBerardino, MD  more...
Updated: Apr 11, 2016

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. Isolated tibial fracture without fibular fracture.
Clinical and radiographic findings of a compound g 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.[15]


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.



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 g Clinical and radiographic findings of a compound grade 2 injury.
Compound grade 3C injury with an extensive soft-ti Compound grade 3C injury with an extensive soft-tissue injury.
Management of a grade 3 injury in an external fixa Management of a grade 3 injury in an external fixator followed by delayed nailing using a Küntscher-Herzog nail.

Subclassification of grade B injury with special reference to limb salvage

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 10º-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]

Contributor Information and Disclosures

Murali Poduval, MBBS, MS, DNB Associate Professor, Department of Orthopedic Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), India

Murali Poduval, MBBS, MS, DNB is a member of the following medical societies: Indian Orthopedic Association, Association of Medical Consultants of Mumbai, Bombay Orthopedic Society, Indian Society of Hip and Knee Surgeons

Disclosure: Nothing to disclose.


Satishchandra Kale, MD, MS, MBBS, MCh, MBA, FRCS(Edin) FRCS(Tr & Orth), FRCS(Edin), MCh(Orth), Diploma in Sports and Exercise Medicine(UK), MS(Orthopaedics)

Satishchandra Kale, MD, MS, MBBS, MCh, MBA, FRCS(Edin) is a member of the following medical societies: British Orthopaedic Association, Royal College of Surgeons of Edinburgh, Bombay Orthopedic Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Thomas M DeBerardino, MD Orthopedic Surgeon, The San Antonio Orthopaedic Group; Research Director, BRIO of the San Antonio Orthopaedic Group; Consulting Surgeon, Sports Medicine, Arthroscopy and Reconstruction of the Knee, Hip and Shoulder, Team Physician; Adjunct Associate Professor, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine

Thomas M DeBerardino, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, Herodicus Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Arthrex, Inc.; Ivy Sports Medicine; MTF; Aesculap; The Foundry, Cotera; ABMT<br/>Received research grant from: Histogenics; Cotera; Arthrex.

Additional Contributors

Phillip J Marone, MD, MSPH Clinical Professor, Department of Orthopedic Surgery and Department of Rehabilitation Medicine, Jefferson Medical College of Thomas Jefferson University

Phillip J Marone, MD, MSPH is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Medical Association, American Orthopaedic Society for Sports Medicine, Philadelphia County Medical Society

Disclosure: Nothing to disclose.

  1. Tile M. Fractures of the tibia. Schatzker J, Tile M, eds. The Rationale of Operative Fracture Care. 2nd ed. New York, NY: Springer-Verlag; 2000.

  2. Canale ST, ed. Campbell's Operative Orthopaedics,. 10th ed. St Louis, Mo: Mosby-Year Book; 2003.

  3. Koval KJ, Zuckerman JD, eds. Handbook of Fractures. 2nd ed. Baltimore, Md: Lippincott, Williams & Wilkins; 2002.

  4. Court-Brown CM. Epidemiology of fractures of the tibia and fibula. Court-Brown CM, Pennig D, eds. Tibia and Fibula. Oxford, United Kingdom: Butterworth Heinemann; 1997.

  5. French B, Tornetta P 3rd. High-energy tibial shaft fractures. Orthop Clin North Am. 2002 Jan. 33(1):211-30, ix. [Medline].

  6. Norris BL, Kellam JF. Soft-tissue injuries associated with high-energy extremity trauma: principles of management. J Am Acad Orthop Surg. 1997 Jan. 5(1):37-46. [Medline].

  7. Court-Brown CM, Rimmer S, Prakash U, McQueen MM. The epidemiology of open long bone fractures. Injury. 1998 Sep. 29(7):529-34. [Medline].

  8. Rajasekharan S. Ganga Hospital open injury severity score - a score to prognosticate limb salvage and outcome measures in Type IIIb open tibial fractures. Presented at: Indian Orthopaedic Association Silver Jubilee Commemoration Lecture; Coimbatore, TamilNadu, India; December 19, 2003. Indian J Orthop. 2005 Jan. 39(1):4-13.

  9. Duan X, Al-Qwbani M, Zeng Y, Zhang W, Xiang Z. Intramedullary nailing for tibial shaft fractures in adults. Cochrane Database Syst Rev. 2012 Jan 18. 1:CD008241. [Medline].

  10. Gaebler C, McQueen MM, Vecsei V, Court-Brown CM. Reamed versus minimally reamed nailing: a prospectively randomised study of 100 patients with closed fractures of the tibia. Injury. 2011 Sep. 42 Suppl 4:S17-21. [Medline].

  11. Bonnevialle P, Bellumore Y, Foucras L, Hezard L, Mansat M. [Tibial fracture with intact fibula treated by reamed nailing]. Rev Chir Orthop Reparatrice Appar Mot. 2000 Feb. 86(1):29-37. [Medline].

  12. Chua W, Murphy DP, Siow W, Kagda FH, Thambiah J. Epidemiological analysis of outcomes in 323 open tibial diaphyseal fractures: a nine-year experience. Singapore Med J. 2012 Jun. 53(6):385-9. [Medline].

  13. Gopal S, Majumder S, Batchelor AG, Knight SL, De Boer P, Smith RM. Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia. J Bone Joint Surg Br. 2000 Sep. 82(7):959-66. [Medline].

  14. Penn-Barwell JG, Bennett PM, Fries CA, Kendrew JM, Midwinter MJ, Rickard RF. Severe open tibial fractures in combat trauma: management and preliminary outcomes. Bone Joint J. 2013 Jan. 95-B(1):101-5. [Medline].

  15. Capozza RF, Feldman S, Mortarino P, Reina PS, Schiessl H, Rittweger J, et al. Structural analysis of the human tibia by tomographic (pQCT) serial scans. J Anat. 2010 Jan 28. [Medline].

  16. Meyer N, Pennington WT, Dewitt D, Schmeling GJ. Isolated cerebral fat emboli syndrome in multiply injured patients: a review of three cases and the literature. J Trauma. 2007 Dec. 63(6):1395-402. [Medline].

  17. Petrisor B, Anderson S, Court-Brown CM. Infection after reamed intramedullary nailing of the tibia: a case series review. J Orthop Trauma. 2005 Aug. 19(7):437-41. [Medline].

  18. Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma. 1984 Aug. 24(8):742-6. [Medline].

  19. Tscherne H, Oestern HJ. [A new classification of soft-tissue damage in open and closed fractures (author's transl)] [German]. Unfallheilkunde. 1982 Mar. 85(3):111-5. [Medline].

  20. Merchant TC, Dietz FR. Long-term follow-up after fractures of the tibial and fibular shafts. J Bone Joint Surg Am. 1989 Apr. 71(4):599-606. [Medline]. [Full Text].

  21. Jafarinejad AE, Bakhshi H, Haghnegahdar M, Ghomeishi N. Malrotation following reamed intramedullary nailing of closed tibial fractures. Indian J Orthop. 2012 May. 46(3):312-6. [Medline].

  22. Koo TK, Papuga MO. A computer aided method for closed reduction of diaphyseal tibial fracture using projection images: A feasibility study. Comput Aided Surg. 2009. 14(1-3):45-57. [Medline].

  23. Sarmiento A, Latta LL. Functional fracture bracing. J Am Acad Orthop Surg. 1999 Jan. 7(1):66-75. [Medline].

  24. Littenberg B, Weinstein LP, McCarren M, et al. Closed fractures of the tibial shaft. A meta-analysis of three methods of treatment. J Bone Joint Surg Am. 1998 Feb. 80(2):174-83. [Medline].

  25. McMaster M. Disability of the hindfoot after fracture of the tibial shaft. J Bone Joint Surg Br. 1976 Feb. 58(1):90-3. [Medline]. [Full Text].

  26. Merchant TC, Dietz FR. Long-term follow-up after fractures of the tibial and fibular shafts. J Bone Joint Surg Am. 1989 Apr. 71(4):599-606. [Medline]. [Full Text].

  27. Sarmiento A. A functional below-the-knee brace for tibial fractures. A report on its use in one hundred thirty-five cases. J Bone Joint Surg Am. 1970 Mar. 52(2):295-311. [Medline]. [Full Text].

  28. Dall'oca C, Christodoulidis A, Bortolazzi R, Bartolozzi P, Lavini F. Treatment of 103 displaced tibial diaphyseal fractures with a radiolucent unilateral external fixator. Arch Orthop Trauma Surg. 2010 Apr 2. [Medline].

  29. Siebenrock KA, Schillig B, Jakob RP. Treatment of complex tibial shaft fractures. Arguments for early secondary intramedullary nailing. Clin Orthop Relat Res. 1993 May. 290:269-74. [Medline].

  30. Court-Brown CM, Keating JF, Christie J, McQueen MM. Exchange intramedullary nailing. Its use in aseptic tibial nonunion. J Bone Joint Surg Br. 1995 May. 77(3):407-11. [Medline]. [Full Text].

  31. Court-Brown CM, Christie J, McQueen MM. Closed intramedullary tibial nailing. Its use in closed and type I open fractures. J Bone Joint Surg Br. 1990 Jul. 72(4):605-11. [Medline]. [Full Text].

  32. Gadegone WM, Salphale YS. Dynamic osteosynthesis by modified Kuntscher nail for the treatment of tibial diaphyseal fractures. Indian J Orthop. 2009 Apr. 43(2):182-8. [Medline]. [Full Text].

  33. Puno RM, Teynor JT, Nagano J, Gustilo RB. Critical analysis of results of treatment of 201 tibial shaft fractures. Clin Orthop Relat Res. 1986 Nov. 212:113-21. [Medline].

  34. Brumback RJ, Virkus WW. Intramedullary nailing of the femur: reamed versus nonreamed. J Am Acad Orthop Surg. 2000 Mar-Apr. 8(2):83-90. [Medline].

  35. Reuss BL, Cole JD. Effect of delayed treatment on open tibial shaft fractures. Am J Orthop. 2007 Apr. 36(4):215-20. [Medline].

  36. Tang P, Gates C, Hawes J, Vogt M, Prayson MJ. Does open reduction increase the chance of infection during intramedullary nailing of closed tibial shaft fractures?. J Orthop Trauma. 2006 May. 20(5):317-22. [Medline].

  37. Tropet Y, Garbuio P, Obert L, Jeunet L, Elias B. One-stage emergency treatment of open grade IIIB tibial shaft fractures with bone loss. Ann Plast Surg. 2001 Feb. 46(2):113-9. [Medline].

  38. Lepore S, Capuano N, Lepore L, Romano G. Preliminary clinical and radiographic results with the Fixion intramedullary nail: an inflatable self-locking system for long bone fractures. J Orthop Trauma. 2000 Dec. 1(3):135-140.

  39. Ben-Galim P, Rosenblatt Y, Parnes N, Dekel S, Steinberg EL. Intramedullary fixation of tibial shaft fractures using an expandable nail. Clin Orthop Relat Res. 2007 Feb. 455:234-40. [Medline].

  40. Bilinski PJ, Morandi MM. A precursor of the locking plate system: noncontact plate osteosynthesis by zespol, construction, technique, and tactic. Tech in Orthop. 2007 Dec. 22(4):227-37.

  41. Raschke M, Stange R, Vordemvenne T, Frerichmann U, Fuchs T. Locked plating: biomechanics and biology and locked plating-clinical indications. Tech in Orthop. Dec 2007. 22(4):238-46.

  42. Aksekili MA, Celik I, Arslan AK, Kalkan T, Ugurlu M. The results of minimally invasive percutaneous plate osteosynthesis (MIPPO) in distal and diaphyseal tibial fractures. Acta Orthop Traumatol Turc. 2012. 46(3):161-7. [Medline].

Unstable tibial fracture treated with an interlocking nail.
Mechanism of compounding.
Atrophic nonunion with deformity after conservative management of a grade 3 open fracture.
Unstable tibia with comminution treated with interlocked nails.
Isolated tibial fracture without fibular fracture.
Clinical and radiographic findings of a compound grade 2 injury.
Compound grade 3C injury with an extensive soft-tissue injury.
Management of a grade 3 injury in an external fixator followed by delayed nailing using a Küntscher-Herzog nail.
Malunion in an unacceptable position as a result of suboptimal management of an unstable fracture.
Patellar tendon-bearing brace fabricated from Orfit Industries.
Anteriorly applied T frame for a grade 3 open injury.
Tibial plating with wound breakdown.
Locked compression plate and the combination hole.
A Gustilo grade 3A midshaft, open tibial fracture in a 25-year-old man. An external fixator was applied.
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