Tibial Shaft Fractures 

Updated: Oct 17, 2018
Author: Brian K Konowalchuk, MD; Chief Editor: Thomas M DeBerardino, MD 

Overview

Background

An understanding of the diagnosis and treatment of tibial shaft fractures is of importance to primary care physicians and orthopedic surgeons alike. Often, the primary care provider first comes into contact with tibial shaft fractures and must make the diagnosis and early treatment decisions.

High-speed lifestyles with motor vehicles, snowmobiles, and motorcycles, as well as the growing popularity of extreme sports, contribute to the increasing occurrence of tibial shaft fractures in today's society. In fact, the tibia is currently the most commonly fractured long bone in the body.

Although tibial shaft fractures are often the result of high-speed trauma, they can also be insidious in onset, such as stress fractures in active individuals. During the initial evaluation, the patient with a tibial shaft fracture should be evaluated carefully for open wounds at the fracture site, neurovascular sufficiency, and elevated compartment pressures. Abnormalities in any of these areas constitute a surgical emergency.

Several decades ago, plating was the treatment of choice for tibial shaft fractures. Since then however, intramedullary nailing and external fixation have replaced fracture plating because they are associated with decreased technical difficulty, lower infection rates, and less damage to local soft tissues (see Treatment).

For patient education resources, see the Breaks, Fractures, and Dislocations Center, as well as Broken Leg, Ankle Fracture, and Knee Dislocation.

Anatomy

The leg is divided into four distinct fascial compartments. The compartmental anatomy can become extremely important during a traumatic situation in which internal bleeding in the leg can lead to a compartment syndrome.

The anterior compartment contains the dorsiflexors of the foot, including the tibialis anterior, the extensor digitorum longus, the extensor hallucis, and the peroneus tertius. Also housed in the anterior compartment is the deep peroneal nerve. The major blood supply to the anterior compartment is from the anterior tibial artery and its associated vessels.

The lateral compartment contains the peroneus longus and the peroneus brevis, which primarily serve in eversion of the foot. The superficial peroneal nerve is contained in this compartment and innervates these two muscles.

The posterior aspect of the leg is divided into two compartments, superficial and deep. The deep compartment contains the plantarflexing muscles, including the tibialis posterior, the flexor hallucis longus, and the flexor digitorum longus. The peroneal and posterior tibial arteries also course through this compartment with their corresponding veins. The superficial posterior compartment is the largest of the four compartments but contains only muscle. These plantarflexing muscles include the soleus, the gastrocnemius, and the plantaris.

Etiology

In the etiology of tibial fractures, high-speed trauma is paramount. In areas where people drive cars at high speeds and engage in activities with high potential for leg trauma (eg, skiing or soccer), the number of tibial fractures seen in the emergency department is high. Although a direct blow to the tibia is the most common cause, countless other etiologies for tibial shaft fractures are encountered. Two of the most prevalent are falls or jumps from significant height and gunshot wounds to the lower leg.

Epidemiology

The tibia is currently the most commonly fractured long bone in the body. Alho et al reported an annual incidence of two tibial shaft fractures per 1000 individuals.[1]  A study from the Swedish Fracture Register cited an incidence of 15.7 per 100,000 population annually.[2] The average age of patients with tibial shaft fractures is approximately 37 years, and teenage males are reported to have the highest incidence.[3]

Prognosis

The outcome of tibial shaft fractures can be less than ideal under many circumstances. These fractures almost always heal with some angulation, rotation, or shortening, which alters load transmission across the extremity.

Patients with tibial shaft fractures have been evaluated with respect to joint pain, disability, osteoarthritis, and joint stiffness. Studies have shown that long-term outcomes for tibial shaft fractures generally are good, but a small increase in osteoarthritis of unclear etiology in the knee and ankle has been observed.[4, 5]  The cause of increased osteoarthritis appears to be multifactorial. Reamed intramedullary nails with interlocking screws provide an excellent means to control rotation and limb shortening (see Treatment, Intraoperative details, above).

Connelly et al carried out a prospective study to assess the clinical and functional outcome of tibial shaft fracture at 12-22 years, with the secondary aims of determining short- and long-term mortality and identifying any predictors of clinical or functional outcome or mortality.[6]  Most of the fractures (90.7%) united without further intervention. Pain and function scores were good, but 26% of patients reported ongoing knee pain, 10% reported ankle pain, and 17% reported both, and this joint pain correlated with poorer functional outcome.

 

Presentation

History

Patients with tibial shaft fractures report pain that may vary in degree but is usually severe. An inability to bear weight on the affected leg and a visible malformation of the leg are often present. Partial fractures may be less characteristic in presentation. The evaluating physician should always keep tibial fracture as part of the differential diagnosis after trauma, especially in a patient with an altered mental status who cannot provide a reliable history.

If the patient's symptoms stem from a stress fracture, the patient may report a recent change in lifestyle or an increase in physical activity. The pain is worse with weightbearing exercise and improves with rest. A classic presentation is an athlete who did not participate in conditioning work during summer vacation and presents to the physician's office 2 weeks after beginning vigorous training in a fall sport.[7]

Whatever the presentation, a complete history and a thorough physical examination are important. The history should include the patient's description of the events that brought him or her to the office. Important details to obtain from the patient include the following:

  • Exactly what the patient was doing at the time of the injury
  • The amount of time that has passed since the injury occurred
  • Nature and severity of pain
  • Any associated paresthesias or numbness
  • Any previous conditions that predispose to this injury or complicate surgery

Physical Examination

During the physical examination, the physician should not focus solely on the leg, because concomitant injury is common with tibial fractures. After the other aspects of the examination have been addressed, the physician should specifically attempt to assess the neurovascular status of the patient's injured leg. The results of these examinations are important because their outcomes determine the emergent level of the situation and dictate which surgical specialists must be consulted.

The overlying skin should also be examined, with particular care taken in assessing any open wounds or color changes that may indicate a more serious injury.

Classification

Classifications for fractures are useful for consistent communication between physicians. They have been used to predict probability of fracture union and, hence, as a guide for fracture treatment.[8, 9, 10, 11, 12, 13] The classic classification for open fractures is that developed by Gustilo et al, as follows[14] :

  • Type I - The wound is clean and is shorter than 1 cm
  • Type II - The wound is longer than 1 cm and does not have extensive soft tissue damage
  • Type IIIa - The wound is wound associated with extensive soft-tissue damage, usually larger than 10 cm, with periosteal coverage (periosteum, the outermost layer of bone, has a rich vascular supply and is important in bone growth and repair); this fracture type also includes less traumatic fractures with increased chances of complications (eg, gunshot wounds, farmyard injuries, and fractures requiring vascular repair)
  • Type IIIb - This type is defined as bone with periosteal stripping that must be covered; these fractures nearly always require flap coverage
  • Type IIIc - This type of injury requires vascular repair

The Orthopaedic Trauma Association (OTA) and the Arbeitsgemeinschaft für Osteosynthesefragen also adopted a system of classification applicable to tibial shaft fracture. This system, based on radiographic evaluation and building on the work of Müller et al,[15] was first published in 1996 and was subsequently revised in 2007[16] and 2018.[17]  In the current classification, tibial shaft fractures would first be labeled by the number of the bone involved (42 in the case of the  tibial diaphysis) and then be divided into the following three main types:

  • Type A - Simple fractures
  • Type B - Wedge fractures
  • Type C - Multifragmentary fractures

Each of these main type is divided into groups.

For type A (simple) fractures, the groups are determined by the angle of the fracture and consist of spiral fractures (A1), oblique (≥30º) fractures (A2), and transverse (< 30º) fractures (A3). The location of the fracture (proximal third, middle third, or distal third) is specified. 

Type B (wedge) fractures are divided into intact wedge fractures (B2) and fragmentary wedge fractures (B3). The location of the fracture (proximal third, middle third, or distal third) is specified.

Type C (multifragmentary) fractures are divided into intact segmental fractures (C2) and fragmentary segmental fractures (C3). Type C3 fractures are also subdivided on the basis of location (proximal diaphyseal–metaphyseal, pure diaphyseal, or distal diaphyseal–metaphyseal).

More detailed descriptions of these fractures may be achieved by using one or more "universal modifiers," which may be appended to the fracture code. Further information on the current AO/OTA classification is available on the AOTrauma Web site.

 

Workup

Laboratory Studies

When a previously healthy patient presents with a fractured tibia that is treated nonoperatively, laboratory studies are not necessarily required. If the patient is a surgical candidate, a complete blood count, chemistry panel, and a type and crossmatch should be performed, along with any other tests in the hospital protocol.

If the tibia was broken with minimal trauma, the physician should pay particular attention to the serum calcium and phosphorus levels; metabolic or endocrine causes may account for the decreased bone density related to the fracture.

Imaging Studies

Along with a complete history and physical examination, radiographs are invaluable in making a diagnosis and determining treatment. The standard protocol is to obtain anteroposterior (AP) and lateral radiographs of the injured leg (see the image below). The ipsilateral knee and ankle are also often radiographically imaged because concomitant injury to one or both of these joints is common.

Radiograph demonstrating a displaced tibial shaft Radiograph demonstrating a displaced tibial shaft fracture with associated fibula fracture.

If further imaging is necessary to define the fracture pattern or associated soft-tissue injury, computed tomography (CT) and magnetic resonance imaging (MRI) may also be performed.

A bone scan can provide evidence of a stress fracture if the physical examination and radiographic findings are unclear. An arteriogram is useful if vascular compromise is suspected.

 

Treatment

Approach Considerations

Most closed tibial fractures can be treated nonoperatively with good results, but infection risk and fracture stability must be considered. Littenberg et al reviewed 2372 case reports of closed tibial fractures and compared clinical outcomes of cast treatment, open reduction and internal fixation (ORIF), and intramedullary rod therapy.[18]  They showed cast treatment to be associated with fewer superficial infections than ORIF was; however, ORIF demonstrated a higher union rate at 20 weeks.

In some instances, the fracture cannot be treated properly with nonoperative methods. Operative fixation is required when fractures are unstable. Instability is defined as greater than 1.5 cm of shortening, more than 5° of varus or valgus angulation, 10° of anterior or posterior angulation, and/or more than 50% translation while the leg is in a cast. Factors that contribute to instability are the degree of comminution, the presence of ipsilateral fibular fractures, and the location of the fracture along the tibia.

The original presenting radiograph is useful because it is often the case with cast or brace treatment that the original amount of shortening is what the fracture ultimately heals with; therefore, shortening greater than 1 cm is a relative indication for operative stabilization.

Open fractures are surgical emergencies, and an orthopedic surgeon should be consulted immediately. In rare instances, a type I fracture can be treated nonoperatively, but in most cases, the patient should be scheduled for debridement and irrigation within 6 hours of the injury. Longer intervals have been shown to increase infection rates.[19]

Patients with Gustilo type II and III open fractures should always be taken to the operating room for irrigation, debridement, and possible surgical fixation (eg, intramedullary nailing, external fixation, plating). Situations in which an open fracture should not be corrected on an emergency basis are rare. In some cases, however, especially in the setting of polytrauma, definitive fracture treatment may be delayed. If surgery must be delayed, leg appearance and compartmental pressure must be monitored carefully.

Several contraindications for surgical treatment of tibial shaft fractures are recognized. All patients require a thorough preoperative evaluation and must be cleared for general anesthesia before any operation, including treatment of tibial shaft fractures. In cases of acute trauma, patients should be stabilized by the trauma team before fixation of a tibial shaft fracture.

Incision and drainage of infected fracture sites are often indicated; however, hardware should never be placed into an infected wound. In cases where infected hardware is removed, treat the infection with intravenous antibiotics and replace the hardware in a second surgical procedure after the infection has been treated thoroughly.

Nonoperative Therapy

Casting

Initially, all tibial shaft fractures should be stabilized with a long posterior splint with the knee in 10-15° of flexion and the ankle flexed at 90°. Admission to the hospital may also be necessary to control pain and to monitor closely for compartment syndrome.

Closed fractures with minimal displacement or stable reduction may be treated nonoperatively with a long leg cast, but cast application should be delayed for 3-5 days to allow early swelling to diminish. The cast should extend from the midthigh to the metatarsal heads, with the ankle at 90° of flexion and the knee extended. The cast increases tibial stability and can decrease pain and swelling.

Early ambulation with weight-bearing as tolerated should be encouraged. Tibial shaft fractures treated with casting must be monitored closely with frequent radiographs to ensure that the fracture has maintained adequate alignment. Adequate callus formation generally takes 6-8 weeks before cast therapy can be discontinued.

Despite proper casting techniques and adequate follow-up, not all nonoperatively treated tibial shaft fractures heal successfully. In addition, 6 weeks without knee motion often results in a stiff joint. In fact, Kyro et al found that 53% of patients reported a fair or poor result using long leg casts to treat tibial shaft fractures.[20] This and many other studies have shown that simply putting a tibial fracture in a long leg cast may lead to increased joint stiffness, some difficulty ambulating, and increased union times.[21, 22]

Another type of cast, the patellar tendon–bearing cast, was proposed by Sarmiento for use early in treatment of tibial shaft fractures in place of the long leg cast, and good results were reported.[23] In general, however, better results are reported with internal fixation of displaced tibial shaft fractures than with nonoperative treatment. Hooper et al found that the results of treatment of displaced tibial shaft fractures were not as satisfactory as those with intramedullary nailing.[24]

Bracing

Three years after describing the patellar tendon–bearing cast, Sarmiento proposed another treatment, the functional brace.[23] This device has replaced the long leg cast in many circumstances because it can be put on within 2-4 weeks of injury. It allows more movement of the knee and ankle while still protecting the tibial fracture. Movement of the knee and ankle may decrease the stiffness that patients encounter after the fracture is healed. However, the long leg cast is still used for the first few weeks until the fracture begins to stabilize.

As with the patellar cast, Sarmiento found very good results with the functional brace; however, others subsequently discovered problems, including a 40% nonunion rate in one trial.[19]

Although no definitive nonoperative treatment has been determined for tibial fractures, many authors have noted increased nonunion and healing time with casts and braces as compared with surgical fixation.[19, 20, 21] Therefore, casts and braces have limited use, especially with displaced fractures. The ideal candidate for nonoperative treatment is a young patient with a nondisplaced fracture.

Surgical Therapy

Operative fixation is required when fractures are unstable. Surgical options include plating, external fixation, intramedullary nailing, and, in some cases, amputation.

Preparation for surgery

The initial step in the operating room is to examine the injury with the patient under anesthesia. This gives the surgeon a better understanding of fracture stability without causing pain to the patient. In managing an open tibia fracture, the surgeon should then begin with extensive irrigation and debridement of devitalized tissue and bone. This step is very important to prepare the fracture for reduction and to combat infection.[25]

If a tibial shaft fracture is associated with a break in the skin, the wound should be treated as an open fracture (see the image below). The important factors for successful treatment of contaminated open tibial fractures include radical debridement of necrotic tissue, pulsed lavage of the area to remove bacteria, and prophylactic intravenous antibiotics.

Open tibial shaft fracture. Open tibial shaft fracture.

Open fractures are surgical emergencies. Most patients should be scheduled for debridement and irrigation within 6 hours of the injury (see Indications, above). For antibiotics, frequently an aminoglycoside combined with a cephalosporin is adequate. For low-grade open fractures, antibiotics such as first-generation cephalosporins are used. For higher-grade injuries in which dirty wounds and infection are more likely, penicillin and aminoglycosides are appropriate.

Repeat debridements (every 24 hours, as needed) often are used in injuries with extensive soft-tissue injury, in severely contaminated wounds, or in wounds with vascular compromise in which additional necrotic tissue may present itself. Soft tissue usually is covered (using sterile technique) within 1 week of injury.

A splint should be used for stabilization. The splint usually remains intact until the patient is prepared in the operating room.

Operative details

Plating is a viable surgical option for tibial shaft fractures and was once the treatment of choice. The procedure involves using a large surgical incision, reducing the fracture, placing a metal plate over the fracture, and fixing the plate onto the bone with multiple screws.

Because of the extensive soft-tissue manipulation required, plating can be difficult for the surgeon and damaging to the local vascular supply. In fact, some authors believe that it is not indicated for open fractures, because of an infection rate as high as 44%.[26]  Intramedullary nailing and external fixation have replaced fracture plating because they entail decreased technical difficulty, infection rates, and damage to local soft tissues.

One study designed a two-stage protocol for tibial segmental fractures and assessed the outcome of this treatment.[27]  After anatomic reduction followed by soft-tissue reconstruction, a low-profile locking plate was temporarily applied as an external fixator. In the second stage, internal fixation with a locking plate was applied by using a percutaneous plate osteosynthesis technique.

After a median follow-up of 32 months, the authors noted that all fractures achieved union; median time for the proximal fracture union was 23 weeks and 27 weeks for the distal fracture union.[27]  These results suggest that this two-stage procedure achieves excellent knee and ankle joint motion and good functional outcomes.

External fixation (see the image below), in which multiple pins are attached to the external rods to maintain length and alignment, is a widely used and very successful method of treating some types of tibial shaft fractures. It is particularly useful for proximal tibial fractures that may be difficult to align properly with intramedullary nailing. Another common indication for external fixation is a severely comminuted fracture pattern that is hard to align for reaming and nailing. External fixation is also useful for tibias in which the intramedullary canal is too narrow to ream.

External fixation of an open tibial shaft fracture External fixation of an open tibial shaft fracture. Note the fasciotomy incision along the lateral aspect of the left leg.

In one study, statically locked intramedullary nailing with traveling-traction external fixation was found to be successful in providing acceptable alignment for proximal and distal-third extra-articular tibial shaft fractures.[28]

Throughout the years, many different designs of external fixators have been used and studied, without a consensus favoring any specific type.[10, 26, 29, 30, 31]  Despite the various options available, external fixation has generally been associated with higher rates of nonunion and malunion than intramedullary nailing is.[29, 32, 33]  These complications may be avoided, however, with proper reduction in the operating room and with fracture fixation for at least 6 weeks.[30, 34]

Intramedullary nailing with locking screws (see the image below) has become the treatment of choice for most tibial shaft fractures.[35, 36, 37, 38, 39, 40]  The prevalence of nonunion and malunion is greatly decreased in comparison with the other methods of fixation. Patients are also able to return to low-impact activities much sooner than they can with the other treatments.

Standard anteroposterior radiograph of a tibial sh Standard anteroposterior radiograph of a tibial shaft fracture with intramedullary nail fixation. Note the commonly associated fibular fracture that is also apparent.

Although intramedullary nailing is generally accepted as the standard of care for treating many types of tibial shaft fractures, specific techniques are not without controversy. The point of contention most frequently involves whether the tibia should be reamed before the intramedullary nail is placed.

Animal studies have demonstrated an increase in blood flow to the periosteum and surrounding muscles with reaming, which would presumably lead to a better result.[41]  Keating et al performed a prospective, randomized trial that compared reaming with nonreaming in open tibial fractures, and no differences were noted in union time; rates of nonunion, malunion, or infection; or outcome.[42]

In a similar study performed on closed fractures, however, reamed tibial fractures had substantially better results than unreamed tibial fractures.[43]  A prospective, randomized trial also appears to show a benefit for reamed nailing over unreamed nailing in closed fractures.[44]  Regardless of preference for the reamed or unreamed technique, tibial nails remain the treatment of choice for open tibial fractures.

In a multicenter, blinded, randomized study of 1226 patients with tibial shaft fractures, reamed nailing (622 patients) and unreamed nailing (604 patients) were studied regarding rates of reoperations and complications. The investigators found a possible benefit for reamed intramedullary nailing in patients with closed fractures but found no difference between approaches in patients with open fractures.[44]

Another issue has to do with suprapatellar versus infrapatellar intramedullary nailing. A meta-analysis of 12 randomized controlled trials by Chen et al examined this question and concluded that suprapatellar intramedullary nailing had clear advantages over infrapatellar nailing for treatment of tibial shaft fractures in adults; however, the quality of the evidence was low, and additional trials of higher quality would be needed to confirm these findings.[45]  A meta-analysis by Gao et al reached similar conclusions about the superiority of suprapatellar nailing.[46]

In a randomized, prospective study of 121 patients with distal tibial shaft fractures who were treated by one of three surgical methods—minimally invasive plate osteosynthesis, locking intramedullary nail stabilization, or external fixation combined with limited open reduction and absorbable internal fixation—Li et al found no significant differences among the three groups with regard to hospital stay, time to radiographic union, and incidence of union status.[47]

Amputation is uncommon but is sometimes indicated for severe tibial fractures, especially those with extensive soft-tissue injury or those in patients with vascular compromise (eg, diabetic patients). Amputation for grades I and II fractures is rare, but the rate of amputation is increased for grade III fractures. In fact, fractures requiring revascularization (type IIIc fractures) have a corresponding amputation rate of greater than 20%.[48, 49]

The Mangled Extremity Severity Score is a tool that has been developed to help the surgeon decide whether or not amputation is indicated, but it is only part of the equation. Surgical expertise and patient communication are of vital importance when making amputation decisions.

Postoperative Care

After the surgical procedure, the patient should be monitored in the postanesthesia care unit until stable. Depending on the extent of the other injuries, the patient may be transferred to the surgical intensive care unit or to a regular ward bed. Initially, the patient's vital signs should be monitored repeatedly, with careful attention paid to any abnormalities. If a complication occurs, early discovery almost always improves the prognosis.

On postoperative day 1, the patient should be examined by the surgical team, and a complete blood count should be obtained. Once the patient has recovered from surgery and is considered safe to leave the hospital, he or she should be discharged home or to a suitable rehabilitation facility.

Complications

The complication that should concern every physician treating a tibial shaft fracture is compartment syndrome, which occurs when the pressure inside a particular fascial compartment of the leg is elevated to a point where it can cause restriction of blood flow and nerve damage.

The usual causes of compartment syndrome include hematoma and soft-tissue swelling. The signs of compartment syndrome traditionally are defined as increased pressure, pulselessness, paresthesia, pain, and pallor to the distal affected extremity (the five Ps); pulselessness and pallor are also associated with vascular injury. The most reliable signs are increasing pain with passive stretching of the muscles within the compartment and hypesthesia.

The physician need not observe all of the signs to diagnose compartment syndrome. A high index of suspicion should be maintained for this complication, and aggressive surgical treatment is mandatory. Always remember that decreased pulses may not manifest until late in the process. Many surgeons now advocate the use of pressure monitors to aid in treatment decisions. Compartment pressures higher than 25-30 mm Hg are concerning and indicate the need for a surgical consultation. Treatment of compartment syndrome involves fasciotomy.

A fasciotomy is performed by making two longitudinal incisions in the affected leg, one laterally and one medially. The lateral incision allows the surgeon to access and decompress the anterior and lateral compartments, while the medial incision offers access to the posterior compartments. During this procedure, all four compartments must be opened to survey damaged vessels and to ensure decompression.

Infection is a concern with any surgical procedure, especially with open fractures. The risk of infection also increases when surgical hardware (nails and fixator pins) is placed into the area. (See the image below.) For this reason, irrigation, debridement, and intravenous antibiotics are vitally important. Also, the value of conscientious nurses and house staff cannot be overemphasized for the recognition and treatment of early infection.

Infection after internal fixation of an open tibia Infection after internal fixation of an open tibial shaft fracture.

A common and frustrating complication of tibial fractures is nonunion, defined as a fracture that has been present for 9 months with no visible signs of healing for the past 3 months.[50] Some of the many causes of nonunion include infection, malnutrition, unstable fracture fixation, and incomplete fracture reduction.

Treatment of nonunion is guided by the underlying cause. If the wound is infected, irrigation, debridement, and antibiotics are indicated. After the infection is cleared and any malnutrition is treated, a different method of fixation may be used. It should be noted, however, that adding hardware such as intramedullary nails or external fixator pins is almost never indicated in an infected leg.

If nonunion is due to malalignment without infection or malnutrition, exchange nailing and bone grafting are the preferred treatments. Exchange nailing involves removing the previously used tibial nail, reaming the canal, and placing a new, larger nail in its place. This treatment has a very high success rate and has been advocated by many surgeons.[51]

Treatment of all forms of tibial shaft fracture has been fraught with complications. An analysis of prospective, randomized, controlled trials demonstrated that the combined prevalence of nonunion was lowest with operative treatment but the prevalence of infection was greatest with operative treatment.[52] The prevalence of infection with plate fixation was greater than that with intramedullary nailing.

To deal with the problem of nonunion, initial external fixation of open tibial shaft fractures has undergone subsequent conversion to intramedullary nailing. Studies have shown poor progression to union with this technique, as well as increased surgical complications.[53] Alternative treatment options should be considered before conversion of external fixation to intramedullary rodding.

Long-Term Monitoring

Depending on the surgeon's preference, the patient usually is seen in a clinic 2-3 days after discharge, and radiographs are taken to view the reduction. If the reduced fracture is still properly positioned, the patient returns on a regular, less frequent basis for radiographic and clinical examination of the leg. Once the patient has healed, braces and external fixators may be removed. Many tibial nails are not removed and may remain in the patient indefinitely.