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Tibia Fractures, Open

Minoo Patel, MBBS, MS, FRACS, Senior Lecturer, Monash University; Director, Centre for Limb Reconstruction and Deformities, Epworth Centre, Melbourne, Australia; Orthopaedic Adult/Pediatric Surgeon, Epworth Hospital, Melbourne, Australia; Consulting Adult/Pediatric Orthopedic Surgeon, Department of Orthopedic Surgery, Monash Medical Center, Australia
John Herzenberg, MD, FRCSC, Head of Pediatric Orthopedics, Director of International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore

Updated: Nov 2, 2009

Introduction

Because the tibia is a subcutaneous bone, tibial fractures are frequently open fractures.

Problem

When an individual presents with an open tibial fracture, the physician strives to save the life of the patient and the limb, to unite the fracture, and to prevent infection. Maintaining a functional limb is the goal; when that is not possible, the physician must consider amputation.

Open tibial fracture.

Open tibial fracture.



Recent studies

Gougoulias et al reviewed 14 studies for data on management of open tibial fractures in children. They found that patients older than 10 years and those with grade II, or severe, open fractures had complications and outcomes similar to those that occur in adult patients. They found no clear effect of any particular fracture fixation method on time to union. They suggested based on the evidence that adolescents may best be managed as adults.1

In another study of open tibial fractures in the pediatric population, Baldwin et al performed a review of the literature to help determine the risk of infection and time to union with various fractures and current treatment. They found no significant changes having occurred in management of type I and III fractures in the past 3 decades, but in more recent years, type II fractures have been more likely to be treated by closed procedures. Type III fractures were associated with a 3.5-fold and 2.3-fold greater risk of infection than type I and II fractures, respectively, but there was no significant difference in infection risk between types I and II. As might be expected, the mean time to union increased with increasing severity of injury, from type I to II to III.2

Giannoudis et al performed a questionnaire study with 130 patients treated for different types of tibial injury (33 patients with compartment syndrome (no underlying fracture), 30 with closed diaphyseal tibial fractures, 45 with grade IIIB/IIIC open fractures, and 22 requiring below-the-knee amputation) to measure long-term functional outcome and health-related quality of life. Patients who had reconstructed IIIB fractures reported problems with pain and carrying out normal activities at a higher rate than amputees and problems with mobility as frequently as amputees. In the patients with open fractures and amputees, anxiety and depression were more common, as were problems with self-care. Injury type, in general, was significantly predictive of all measured outcomes except self-care.3
 
In addition, Giannoudis et al performed a systematic review of the literature concerning the efficacy and safety of plating for open fractures of the tibial diaphysis, which is currently considered controversial. They found that overall union rate ranged from 62-95%; time to union ranged from 13-42 weeks; reoperation rate ranged from 8-69%; and a pooled estimate of deep infection rate was calculated at 11%. The authors suggested that plate fixation for open tibial fractures may be considered under specific conditions but that well-designed clinical trials still need to be conducted.4

Frequency

Behrens et al reported an incidence of 2 open tibia fractures per 1000 injuries per year in a defined population group in an industrialized western society; this is 0.2% of all injuries.5,6 The incidence and severity may be even higher in the developing world.

Etiology

Motor vehicle accidents, skiing accidents, and high-energy falls are the common causes. The mechanism of injury determines the fracture configuration (eg, skiing injuries typically cause spiral fractures). Most fractures are comminuted. Pedestrians who are hit in the upper and middle one third of the tibia sustain bumper injuries. Distal tibial and plafond fractures are commonly a result of a fall from a significant height.

Presentation

All persons who have undergone high-energy trauma should be examined in accordance with the principles defined by the Road Trauma Committee of the Royal Australasian College of Surgeons/Emergency Management of Severe Trauma.7,8 The primary survey includes the ABCs (ie, airway, breathing, circulation). A Glasgow Coma Scale score indicates the severity of any head injury component. The secondary survey should include the chest, abdomen, and pelvis for associated injuries, as well as the upper limbs and the contralateral lower limb. The ipsilateral limb also may have other fractures, such as a femur fracture, leading to a floating knee, or joint injuries such as knee dislocations.

The dictum is to save the patient first and the limb next.

Limb examination should consist of a detailed examination of the vascularity of the limb, including limb color, warmth and perfusion, palpable pulses, capillary return (normal <3 seconds), and transcutaneous oxygenation and pulse wave forms using pulse oximetry. A detailed neurologic examination should document the sensory and motor function.

The skin over the fracture should be examined carefully. Any break in the skin at the level of the fracture should be considered indicative of a possible open fracture. Remember that wounds away from the fracture can communicate with the fracture. Periarticular open fractures almost always contaminate the associated joints.

Signs of crush injury should be sought if indicated by the mechanism of injury (eg, pedestrian hit by a car). These injuries may exhibit few external signs.

Compartment syndrome

Persons who sustain high-energy tibial fractures have a high frequency of compartment syndrome. Importantly, note that even open fractures can be associated with a compartment syndrome. Assuming that the open wound has decompressed the compartment is wrong. Blood clots can impede effective decompression. The muscle or fascial layers can close the trap door with similar effects. Blick et al from the Adam Cowley Shock Trauma Centre reported a 9% rate of compartment syndrome in persons with open tibial fractures.9

The earliest signs of compartment syndrome are stretch pain and loss of the sensations (eg, fine touch, proprioception) carried by the fast conducting, and therefore more hypoxia-susceptible, fibers. Because these patients require surgical debridement and stabilization, performing a fasciotomy and compartment release is imperative. With delayed presentations or a diagnosis of compartment syndrome, performing an early fasciotomy may be preferable to merely monitoring it with a wick catheter.10,11,12 The traumatized soft tissues and bone are susceptible to hypoxia, and delaying a compartment release decreases oxygen delivery and impedes healing.

In fractures treated with intramedullary nailing, McQueen et al found no difference in the pressures recorded between the different Tscherne soft-tissue grades, between open and closed fractures, between low- and high-energy injuries, or between fractures treated early and those not treated until more than 24 hours after injury.13

Classification

Open fractures are typed using the Gustilo-Anderson classification, which was first proposed in 1976 and subsequently modified in 1984.14,15,16

Table 1. Gustilo-Anderson Classification of Open Fractures

TypeWound DescriptionOther Criteria
I<1 cm (so-called puncture wounds) 
II1-10 cm 
IIIA>10 cm, coverage availableSegmental fractures, farm injuries,
or any injury occurring in a highly contaminated environment
High-velocity gunshot injuries
IIIB10 cm, requiring soft tissue coverage procedurePeriosteal stripping
IIIC With vascular injury requiring repair

Table 2. Tscherne Classification of Soft Tissue Injuries

GradeSoft Tissue Injury
(Superficial)		Soft Tissue Injury
(Deep)		Compartments
0Absent or negligibleAbsent or negligibleSoft and/or normal
1Superficial abrasionContusion from withinSoft and/or normal
2Deep contaminated abrasionSignificant contusionImpending compartment syndrome
3Crushed skin, subcutaneous avulsionsCrushed devitalized muscleCompartment syndrome

Note that both of these classifications have poor interobserver agreement.17 However, they serve as good general guides for management and for comparison in studies.

Patients who are polytraumatized and immunocompromised develop infections more frequently, and their fractures take longer to unite. Sterett et al found that patients with splenectomies had a significantly higher prevalence of chronic osteomyelitis (25% vs 4.6%), their fractures took almost twice as long to unite, and they required additional tibial surgeries to achieve union (75% vs 16%) following open tibial fractures.18

Indications

The various limb salvage scoring systems, such as the MESS (Mangled Extremity Severity Score), are good indicators for salvage but poor indicators for amputation; thus, a limb with a good MESS usually should be salvaged, but a limb with a poor MESS does not necessarily require amputation.

Regarding nailing versus external fixation, Bhandari et al reported from a meta-analysis that compared with external fixation, the use of unreamed nails decreased the risk of reoperation, superficial infection, and malunion in persons with open tibial fractures.19,20 They also found a reduced risk of reoperation with using reamed nails compared with unreamed nails. This appears to support some authors who have suggested initial nailing with a small-diameter nail and subsequent exchange nailing with a larger-diameter reamed nail. Plate fixation was found to be uniformly the worst of all methods of internal fixation. Although it may be tempting to use plate fixation for a fracture that is exposed (ie, because of the open nature of injury), the risk of nonunion, malunion, and deep infection is too high to justify the action.20

Relevant Anatomy

See Surgical therapy.

Contraindications

Absolute contraindications to limb salvage are a completely mangled limb, the presence of warm ischemia for longer than 6 hours, and poor facilities for salvage.

Absolute contraindications to nailing an open fracture are untreated compartment syndrome and types IIIB and IIIC open fractures.

Workup

Laboratory Studies

  • Routine preoperative blood tests are ordered.

Imaging Studies

  • Routine limb, chest, and cervical spine radiographs are ordered.

Treatment

Medical Therapy

Intravenous antibiotics are administered promptly. First-generation cephalosporins (Gram-positive coverage) such as cephalothin (1-2 g q6-8h) suffice for Gustilo-Anderson type I fractures. An aminoglycoside (Gram-negative coverage) such as gentamycin (120 mg q12h; 240 mg/d) is added for types II and III injuries. Additionally, metronidazole (500 mg q12h) or penicillin (1.2 g q6h) can be added for coverage against anaerobes. Tetanus prophylaxis should be instituted. Antibiotics generally are continued for 72 hours following wound closure.

After initial assessment, the wound is irrigated in the emergency department.21 A sterile dressing is applied, and the limb is splinted. Debridement should be performed in the operating room as soon as feasible.21 Debridement within 6 hours is necessary to keep the rate of infection low.22 A key factor in infection prevention is early, rigid stabilization of the fracture.

The aim of antibiotic therapy and debridement is to sterilize the wound to a negligible bacterial load and render the wound similar to a typical surgical wound. The first debridement is the best chance for infection prevention.

A tourniquet should not be used. This helps in identifying the devitalized tissue. The skin is sharply cut back to bleeding edges. Radical debridement is performed using sharp dissection until bleeding tissue is visualized. "Red is good, and gray is bad" is the general dictum. Devitalized muscle can also be identified by its lack of response to electrical stimulus.

All extrinsic debris is meticulously removed. Copious irrigation is used. "The solution to pollution is dilution" is another dictum. Irrigation works predominantly by mechanical means. A pulsatile lavage system works by creating local eddy currents and dislodging the debris from the soft tissues. High-pressure pulsatile lavage should be avoided because it can cause soft-tissue damage. Bhandari et al also found that high-pressure pulsatile lavage resulted in bacterial seeding into the intramedullary canal and significant damage to the architecture of the bone.23 However, both high- and low-pressure lavage were associated with similar degrees of periosteal separation from the cortical bone surface.23 Both high- and low-pressure lavage were effective in removing adherent bacteria from bone after a delay of 3 hours before irrigation, but only high-pressure lavage removed adherent bacteria from bone at a delay of 6 hours before irrigation.24

The bone ends should be debrided thoroughly. Aggressive bone debridement has been demonstrated to lower infection rates in high-grade open fractures.15,25

Soft-tissue coverage can be achieved primarily in all cases except those with extensive contamination and risk of anaerobic infection.26 A delayed primary closure or coverage is provided for wounds with extensive contamination and risk of anaerobic infection. If the wound cannot be closed primarily, skin grafting or flap coverage can be provided, although muscle flaps provide better coverage and results.27 Gustilo-Anderson types I and II injuries can also be allowed to granulate and close spontaneously by secondary intention.

Surgical Therapy

Following primary debridement, the surgical set-up should be changed and the limb redraped without losing sterility.

Fracture repair

Intramedullary nailing is the best option for Gustilo-Anderson types I, II, and III fractures.28,29 Type IIIB fractures can also be treated with unreamed nails. Solid core nails are associated with the lowest rate of infection.30 External fixation is used for Gustilo-Anderson types IIIA and IIIB fractures. Thakur and Patankar have demonstrated excellent results using a protocol of early bone grafting and fixator dynamisation with monolateral fixators.31

Alternatively, an exchange nailing can be performed after removal of the fixator. This procedure is associated with a high risk of infection. Infection risk can be minimized by avoiding and treating pin-site infection and by exchanging to a nail after less than 15 days of external fixation.32,33 Alternately, the fixator can be removed and the limb immobilized in a cast until the pin sites have healed; the tibia can then be nailed.

Bhandari et al, in a meta-analysis, found that compared with external fixation, the use of unreamed nails decreased the risk of reoperation, superficial infection, and malunion in open tibial fractures.19,20 They also found a reduced risk of reoperation with reamed nails compared with unreamed nails. This appears to support some authors who have suggested initial nailing with a small-diameter nail and subsequent exchange nailing with a larger-diameter reamed nail. Plate fixation was found to be uniformly the worst of all methods of internal fixation. Although plating a fracture that is exposed may be tempting (ie, because of the open nature of the injury), the risk of nonunion, malunion, and deep infection is too high to justify it.20

Cast treatment is avoided for many reasons. It does not provide rigid fracture stabilization, the wound is not open for inspection and regular dressing changes, and a circumferential cast increases the risk of circulatory compromise.

Delayed union or nonunion may be avoided with early prophylactic posterolateral bone grafting.31,34

Monolateral external fixators generally are preferred for the tibia, although multiplanar and circular fixators provide greater stability. For periarticular plateau and plafond fractures, circular or hybrid frames yield the best results, with the lowest morbidity, especially related to infection and soft-tissue complications.

Newer devices such as the Taylor Spatial Frame can be applied quickly in an emergent situation. Using the so-called rings-first method, each ring is applied individually orthogonal to each fragment and the struts are connected. The fracture is then reduced gradually in a nonemergent fashion by bringing all the struts to equal length and all the rings parallel. The reduction can then be fine-tuned using the residual correction program. This is especially useful when rapid stabilization is required prior to a vascular repair, although the device may impede surgical access.

Amputation

Not every severely injured limb can be salvaged. Several scoring methods have been developed to predict the chances of limb salvage. The MESS is the best known. Many authors have found these scoring systems to be unreliable.28 The presence of warm ischemia for longer than 6 hours, infrapopliteal vascular injury, and posterior tibial and/or common peroneal nerve neurotmesis are the strongest indications for amputation.28 With a good MESS, a limb should be considered salvageable; however, a poor MESS should not automatically prompt amputation. Clinical judgment and availability of limb reconstruction facilities should be the ultimate factors in decision making.35

Preoperative Details

See Medical therapy.

Follow-up

Open tibial fractures have higher rates of nonunion, infection, and chronic pain syndrome (CPS). Close follow-up is required until union. CPS should be anticipated and treated early, rather than after the pain patterns are entrenched. Osteomyelitis can be acute, subacute, or chronic and may surface many months or years after injury. Pin-site infections are common with external fixation and should be dealt with aggressively with oral or parenteral antibiotics and debridement or even pin exchange. Pin-site chronic osteomyelitis is also relatively common.

Complications

Open tibial fractures have higher rates of nonunion, infection, and CPS.36

Osteomyelitis may occur and can be acute, subacute, or chronic. It may surface many months or years after injury.

Pin-site infections are common with external fixator treatment. Chronic osteomyelitis in the pin sites is relatively common.

Outcome and Prognosis

The Gustilo-Anderson classification system is a good prognostic indicator. The higher grades of injury (eg, type III fractures) are commonly associated with infection and nonunion.

Multimedia

Open tibial fracture.

Media file 1: Open tibial fracture.

References

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  2. Baldwin KD, Babatunde OM, Russell Huffman G, Hosalkar HS. Open fractures of the tibia in the pediatric population: a systematic review. J Child Orthop. Jun 2009;3(3):199-208. [Medline].

  3. Giannoudis PV, Harwood PJ, Kontakis G, Allami M, Macdonald D, Kay SP, et al. Long-term quality of life in trauma patients following the full spectrum of tibial injury (fasciotomy, closed fracture, grade IIIB/IIIC open fracture and amputation). Injury. Feb 2009;40(2):213-9. [Medline].

  4. Giannoudis PV, Papakostidis C, Kouvidis G, Kanakaris NK. The role of plating in the operative treatment of severe open tibial fractures: a systematic review. Int Orthop. Feb 2009;33(1):19-26. [Medline].

  5. Behrens F. Current concepts of external fixation of fractures. Berlin:. Springer-Verlag;1982.

  6. Behrens F, Searls K. External fixation of the tibia. Basic concepts and prospective evaluation. J Bone Joint Surg Br. Mar 1986;68(2):246-54. [Medline].

  7. Geller E. Emergency treatment of the trauma patient. In: Dee R, Hurst LC, Gruber MA, Kottmeier SA, eds. Principles of Orthopedic Practice. NY:. McGraw-Hill;1997:379-388.

  8. Shuler TE. Adult trauma. In: Miller MD, ed. Review of Orthopedics. Philadelphia:. WB Saunders Co;1996:350-393.

  9. Blick SS, Brumback RJ, Poka A, et al. Compartment syndrome in open tibial fractures. J Bone Joint Surg Am. Dec 1986;68(9):1348-53. [Medline].

  10. McQueen MM, Christie J, Court-Brown CM. Acute compartment syndrome in tibial diaphyseal fractures. J Bone Joint Surg Br. Jan 1996;78(1):95-8. [Medline].

  11. McQueen MM, Court-Brown CM. Compartment monitoring in tibial fractures. The pressure threshold for decompression. J Bone Joint Surg Br. Jan 1996;78(1):99-104. [Medline].

  12. McQueen MM, Gaston P, Court-Brown CM. Acute compartment syndrome. Who is at risk?. J Bone Joint Surg Br. Mar 2000;82(2):200-3. [Medline].

  13. McQueen MM, Christie J, Court-Brown CM. Compartment pressures after intramedullary nailing of the tibia. J Bone Joint Surg Br. May 1990;72(3):395-7. [Medline].

  14. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty- five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. Jun 1976;58(4):453-8. [Medline].

  15. 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. Aug 1984;24(8):742-6. [Medline].

  16. Gustilo RB, Gruninger RP, Davis T. Classification of type III (severe) open fractures relative to treatment and results. Orthopedics. Dec 1987;10(12):1781-8. [Medline].

  17. Brumback RJ, Jones AL. Interobserver agreement in the classification of open fractures of the tibia. The results of a survey of two hundred and forty-five orthopaedic surgeons. J Bone Joint Surg Am. Aug 1994;76(8):1162-6. [Medline].

  18. Sterett WI, Ertl JP, Chapman MW, Moehring HD. Open tibia fractures in the splenectomized trauma patient: results of treatment with locking, intramedullary fixation. J Trauma. Apr 1995;38(4):639-41. [Medline].

  19. Bhandari M, Guyatt GH, Tong D, et al. Reamed versus nonreamed intramedullary nailing of lower extremity long bone fractures: a systematic overview and meta-analysis. J Orthop Trauma. Jan 2000;14(1):2-9. [Medline].

  20. Bhandari M, Guyatt GH, Swiontkowski MF, et al. Treatment of open fractures of the shaft of the tibia. J Bone Joint Surg Br. Jan 2001;83(1):62-8. [Medline].

  21. Tripuraneni K, Ganga S, Quinn R, Gehlert R. The effect of time delay to surgical debridement of open tibia shaft fractures on infection rate. Orthopedics. Dec 2008;31(12):[Medline].

  22. Kindsfater K, Jonassen EA. Osteomyelitis in grade II and III open tibia fractures with late debridement. J Orthop Trauma. Apr 1995;9(2):121-7. [Medline].

  23. Bhandari M, Adili A, Lachowski RJ. High pressure pulsatile lavage of contaminated human tibiae: an in vitro study. J Orthop Trauma. Sep-Oct 1998;12(7):479-84. [Medline].

  24. Bhandari M, Schemitsch EH, Adili A, et al. High and low pressure pulsatile lavage of contaminated tibial fractures: an in vitro study of bacterial adherence and bone damage. J Orthop Trauma. Nov 1999;13(8):526-33. [Medline].

  25. Gustilo RB, Merkow RL, Templeman D. The management of open fractures. J Bone Joint Surg Am. Feb 1990;72(2):299-304. [Medline].

  26. Choudry U, Moran S, Karacor Z. Soft-tissue coverage and outcome of Gustilo grade IIIB midshaft tibia fractures: a 15-year experience. Plast Reconstr Surg. Aug 2008;122(2):479-85. [Medline].

  27. Richards RR, McKee MD, Paitich CB, et al. A comparison of the effects of skin coverage and muscle flap coverage on the early strength of union at the site of osteotomy after devascularization of a segment of canine tibia. J Bone Joint Surg Am. Oct 1991;73(9):1323-30. [Medline].

  28. Tornetta P. Tibial fractures. In: Dee R, Hurst LC, Gruber MA, Kottmeier SA, eds. Principles of Orthopedic Practice. NY:. McGraw-Hill;1997:519-530.

  29. Lefaivre KA, Guy P, Chan H, Blachut PA. Long-term follow-up of tibial shaft fractures treated with intramedullary nailing. J Orthop Trauma. Sep 2008;22(8):525-9. [Medline].

  30. Riemer BL, DiChristina DG, Cooper A, et al. Nonreamed nailing of tibial diaphyseal fractures in blunt polytrauma patients. J Orthop Trauma. Feb 1995;9(1):66-75. [Medline].

  31. Thakur AJ, Patankar J. Open tibial fractures. Treatment by uniplanar external fixation and early bone grafting. J Bone Joint Surg Br. May 1991;73(3):448-51. [Medline].

  32. Antich-Adrover P, Marti-Garin D, Murias-Alvarez J, Puente-Alonso C. External fixation and secondary intramedullary nailing of open tibial fractures. A randomised, prospective trial. J Bone Joint Surg Br. May 1997;79(3):433-7. [Medline].

  33. Blachut PA, Meek RN, O''Brien PJ. External fixation and delayed intramedullary nailing of open fractures of the tibial shaft. A sequential protocol. J Bone Joint Surg Am. Jun 1990;72(5):729-35. [Medline].

  34. Blick SS, Brumback RJ, Lakatos R, et al. Early prophylactic bone grafting of high-energy tibial fractures. Clin Orthop. Mar 1989;(240):21-41. [Medline].

  35. Saddawi-Konefka D, Kim HM, Chung KC. A systematic review of outcomes and complications of reconstruction and amputation for type IIIB and IIIC fractures of the tibia. Plast Reconstr Surg. Dec 2008;122(6):1796-805. [Medline].

  36. Cannada LK, Anglen JO, Archdeacon MT, Herscovici D Jr, Ostrum RF. Avoiding complications in the care of fractures of the tibia. J Bone Joint Surg Am. Aug 2008;90(8):1760-8. [Medline].

Keywords

tibia fracture, open tibia fractures, open tibial fractures, open tibial fracture, tibial fracture, broken leg, fractured leg, fractured tibia, MESS, Mangled Extremity Severity Score, Gustilo-Anderson fracture, Gustilo fracture, reamed nailing

Contributor Information and Disclosures

Author

Minoo Patel, MBBS, MS, FRACS, Senior Lecturer, Monash University; Director, Centre for Limb Reconstruction and Deformities, Epworth Centre, Melbourne, Australia; Orthopaedic Adult/Pediatric Surgeon, Epworth Hospital, Melbourne, Australia; Consulting Adult/Pediatric Orthopedic Surgeon, Department of Orthopedic Surgery, Monash Medical Center, Australia
Minoo Patel, MBBS, MS, FRACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, AO Foundation, Australian Association of Surgeons, Australian Medical Association, Australian Orthopaedic Association, Bombay Orthopedic Society, Indian Orthopedic Association, Orthopaedic Research Society, Orthopaedics Overseas, and Royal Australasian College of Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

John Herzenberg, MD, FRCSC, Head of Pediatric Orthopedics, Director of International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore
John Herzenberg, MD, FRCSC is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine, American Academy of Orthopaedic Surgeons, Limb Lengthening and Reconstruction Society ASAMI-North America, and Pediatric Orthopaedic Society of North America
Disclosure: Smith and Nephew, EBI, Orthofix Educational Grant None

Medical Editor

Dennis P Grogan, MD, Clinical Professor, Department of Orthopedic Surgery, University of South Florida College of Medicine; Chief of Staff, Department of Orthopedic Surgery, Shriners Hospital for Children of Tampa
Dennis P Grogan, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Eastern Orthopaedic Association, Irish American Orthopaedic Society, Pediatric Orthopaedic Society of North America, and Scoliosis Research Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Shepard R Hurwitz, MD, Executive Director, American Board of Orthopaedic Surgery
Shepard R Hurwitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for the Advancement of Science, American College of Rheumatology, American College of Sports Medicine, American College of Surgeons, American Diabetes Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Association for the Advancement of Automotive Medicine, Eastern Orthopaedic Association, Orthopaedic Research Society, Orthopaedic Trauma Association, and Southern Orthopaedic Association
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Carlos J Lavernia, MD, FAAOS, Adjunct Clinical Professor, Department of Orthopedic Surgery, University of Miami School of Medicine; Medical Director, Orthopedic Institute at Mercy Hospital
Carlos J Lavernia, MD, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Hip and Knee Surgeons, Arthritis Foundation, Biomedical Engineering Society, Florida Orthopaedic Society, and Orthopaedic Research Society
Disclosure: Zimmer Stock Implant Designer

Further Reading

Related eMedicine topics
Diaphyseal Tibial Fractures

Tibial Plateau Fractures

Tibial Shaft Fractures

Tibial Nonunions

Tibial Plateau Fractures

Fracture, Tibia and Fibula

The Polytraumatized Patient

Clinical trials

 Percutaneous Autologous Bone-Marrow Grafting for Open Tibial Shaft Fracture (IMOCA)

TRial to Evaluate UltraSound in the Treatment of Tibial Fractures

Adjunctive Therapy to Treat Tibial Shaft Fractures

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