10/28/2014 Tibial Shaft Fractures

http://emedicine.medscape.com/article/1249984-overview#showall 1/5

Tibial Shaft Fractures Author: Brian K Konowalchuk, MD; Chief Editor: Thomas M DeBerardino, MD more...

Updated: Oct 17, 2014

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

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

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

History of the ProcedureSeveral 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 withdecreased technical difficulty, lower infection rates, and less damage to local soft tissues (see Treatment,Intraoperative details, below).

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

Epidemiology

Frequency

The tibia is currently the most commonly fractured long bone in the body. Alho et al reported an annual incidence oftwo tibial shaft fractures per 1000 individuals.[1] The average age of patients with tibial shaft fractures isapproximately 37 years, and teenage males are reported to have the highest incidence.[2]

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

PresentationPatients with tibial shaft fractures report pain of varying degrees, but pain is usually severe. An inability to bearweight on the affected leg and a visible malformation of the leg are often present. Partial fractures may be lesscharacteristic in presentation. The evaluating physician should always keep tibial fracture as part of the differentialdiagnosis 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 anincrease in physical activity. The pain is worse with weightbearing exercise and improves with rest. A classicpresentation is an athlete who did not participate in conditioning work during summer vacation and presents to thephysician's office 2 weeks after beginning vigorous training in a fall sport.[3]

Whatever the presentation, a complete history and a thorough physical examination are important. The historyshould include the patient's description of the events that brought him or her to the office. Important details toobtain from the patient include exactly what the patient was doing at the time of the injury, the amount of time thathas passed since the injury occurred, a description of pain, any associated paresthesias or numbness, and a historyof previous conditions that predispose to this injury or complicate surgery.

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

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

Classification and nomenclature

Classifications for fractures are useful for consistent communication between physicians. They have been used topredict probability of fracture union and, hence, as a guide for fracture treatment.[4, 5, 6, 7, 8, 9] The classicclassification for open fractures was described by Gustilo et al, as follows[10] :

Type I - The wound is clean and is shorter than 1 cmType II - The wound is longer than 1 cm and does not have extensive soft tissue damageType IIIa - The wound is wound associated with extensive soft-tissue damage, usually larger than 10 cm,

10/28/2014 Tibial Shaft Fractures

http://emedicine.medscape.com/article/1249984-overview#showall 2/5

with periosteal coverage (periosteum, the outermost layer of bone, has a rich vascular supply and isimportant in bone growth and repair); this fracture type also includes less traumatic fractures with increasedchances 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 nearlyalways require flap coverageType IIIc - This type of injury requires vascular repair

The Orthopaedic Trauma Association has also adopted a system of classification for tibial shaft fracture. Theirsystem, based on radiographic evaluation, divides fractures into three main types as follows[11, 12] :

Type A - Unifocal fracturesType B - Wedge fracturesType C - Complex fractures

Each main type is divided into three groups, and each group is further divided into three subgroups.[11, 12]

For type A (unifocal) fractures, the groups are determined by the angle of the fracture and consist of spiral fractures(A1), oblique fractures (A2), and transverse fractures (A3).

Type B (wedge fractures) are divided into intact spiral wedge fractures (B1), intact bending wedge fractures (B2),and comminuted wedge fractures (B3). For both type A and type B fractures, the subgroups are determined by theextent of fibular injury and the location of the fracture with respect to the tibia.

Among type C (complex) fractures, spiral wedge fractures make up group C1, and the number of fragments presentdetermines the subgroup. For example, a C1 fracture with two fragments would be classified as C1.1, a fracturewith three fragments as C1.2, and a fracture with more than three fragments as C1.3. Segmental fractures areassigned to group C2. C2 fractures, like C1 fractures, are subclassified according the number of fracture fragmentspresent and the extent of comminution. For instance, highly comminuted fractures are labeled as C2.3.

IndicationsMost closed tibial fractures can be treated nonoperatively with good results, but infection risk and fracture stabilitymust be considered. Littenberg et al reviewed 2372 case reports of closed tibial fractures and compared clinicaloutcomes of cast treatment, open reduction and internal fixation, and intramedullary rod therapy.[13] They showedcast treatment to be associated with fewer superficial infections than open reduction and internal fixation. Openreduction and internal fixation (ORIF), however, demonstrated a higher union rate at 20 weeks.

In some instances, the fracture cannot be treated properly with nonoperative methods. Operative fixation is requiredwhen fractures are unstable. Instability is defined as greater than 1.5 cm of shortening, more than 5 of varus orvalgus angulation, 10 of anterior or posterior angulation, and/or less 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, andthe 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 theoriginal amount of shortening is what the fracture ultimately heals with; therefore, shortening greater than 1 cm is arelative indication for operative stabilization.

Open fractures are surgical emergencies, and an orthopedic surgeon should be consulted immediately. In rareinstances, a type I fracture can be treated nonoperatively, but in most cases, the patient should be scheduled fordebridement and irrigation within 6 hours of the injury. Longer intervals have been shown to increase infection rates.[14]

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 whichan open fracture should not be corrected on an emergency basis are rare. In some cases, however, especially in thesetting of polytrauma, definitive fracture treatment may be delayed. If surgery must be delayed, leg appearance andcompartmental pressure must be monitored carefully.

Relevant AnatomyThe leg is divided into four distinct fascial compartments. The compartmental anatomy can become extremelyimportant 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 digitorumlongus, the extensor hallucis, and the peroneus tertius. Also housed in the anterior compartment is the deepperoneal nerve. The major blood supply to the anterior compartment is from the anterior tibial artery and itsassociated vessels.

The lateral compartment contains the peroneus longus and the peroneus brevis, which primarily serve in eversion ofthe 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 compartmentcontains the plantarflexing muscles, including the tibialis posterior, the flexor hallucis longus, and the flexordigitorum longus. The peroneal and posterior tibial arteries also course through this compartment with theircorresponding veins. The superficial posterior compartment is the largest of the four compartments but contains onlymuscle. These plantarflexing muscles include the soleus, the gastrocnemius, and the plantaris.

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

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

Contributor Information and DisclosuresAuthorBrian K Konowalchuk, MD Staff Physician, Department of Orthopedic Surgery, University of MinnesotaCollege of Medicine

Brian K Konowalchuk, MD is a member of the following medical societies: Alpha Omega Alpha

10/28/2014 Tibial Shaft Fractures

http://emedicine.medscape.com/article/1249984-overview#showall 3/5

Disclosure: Nothing to disclose.

Specialty Editor BoardCharles T Mehlman, DO, MPH Professor of Pediatrics and Pediatric Orthopedic Surgery, Division of PediatricOrthopedic Surgery, Director, Musculoskeletal Outcomes Research, Cincinnati Children's Hospital Medical Center

Charles T Mehlman, DO, MPH is a member of the following medical societies: American Academy of Pediatrics,American Fracture Association, American Medical Association, American Orthopaedic Foot and Ankle Society,American Osteopathic Association, Arthroscopy Association of North America, North American Spine Society,Ohio State Medical Association, Pediatric Orthopaedic Society of North America, and Scoliosis Research Society

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

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 OrthopaedicSurgeons, American Association for the Advancement of Science, American College of Rheumatology, AmericanCollege of Sports Medicine, American College of Surgeons, American Diabetes Association, AmericanOrthopaedic Association, American Orthopaedic Foot and Ankle Society, Association for the Advancement ofAutomotive Medicine, Eastern Orthopaedic Association, Orthopaedic Research Society, Orthopaedic TraumaAssociation, and Southern Orthopaedic Association

Disclosure: Nothing to disclose.

Dinesh Patel, MD, FACS Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief ofArthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of OrthopaedicSurgeons

Disclosure: Nothing to disclose.

Chief EditorThomas M DeBerardino, MD Associate Professor, Department of Orthopedic Surgery, Consulting Surgeon,Sports Medicine, Arthroscopy and Reconstruction of the Knee, Hip and Shoulder, Team Physician, OrthopedicConsultant to UConn Department of Athletics, University of Connecticut Health Center

Thomas M DeBerardino, MD is a member of the following medical societies: American Academy of OrthopaedicSurgeons, American Orthopaedic Association, and American Orthopaedic Society for Sports Medicine

Disclosure: Arthrex, Inc. Grant/research funds Other; Arthrex, Inc. Consulting fee Speaking and teaching;Musculoskeletal Transplant Foundation Honoraria Board membership; Histogenics Grant/research funds None;Advanced Biomedical Technologies Stock Options Medical Director, North America; Linvatec Consulting feeSpeaking and teaching; Aesculp Board membership

Additional ContributorsMarc Swiontkowski, MD Chair, Professor, Department of Orthopedic Surgery, University of Minnesota atMinneapolis

Marc Swiontkowski, MD is a member of the following medical societies: American Academy of OrthopaedicSurgeons, American College of Surgeons, American Orthopaedic Association, and Canadian OrthopaedicAssociation

Disclosure: Nothing to disclose.

Brian Tollefson, MD Flight Surgeon, United States Air Force

Disclosure: Nothing to disclose.

Nicholas J Wills, MD Fellow, Twin Cities Spine Center

Disclosure: Nothing to disclose.

References

1. Alho A, Benterud JG, Hogevold HE, et al. Comparison of functional bracing and locked intramedullarynailing in the treatment of displaced tibial shaft fractures. Clin Orthop. Apr 1992;(277):243-50. [Medline].

2. Court-Brown CM, McBirnie J. The epidemiology of tibial fractures. J Bone Joint Surg Br. May1995;77(3):417-21. [Medline].

3. Heyworth BE, Green DW. Lower extremity stress fractures in pediatric and adolescent athletes. Curr OpinPediatr. Feb 2008;20(1):58-61. [Medline].

4. 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].

5. Court-Brown CM, McQueen MM, Quaba AA, Christie J. Locked intramedullary nailing of open tibialfractures. J Bone Joint Surg Br. Nov 1991;73(6):959-64. [Medline].

6. Court-Brown CM, Wheelwright EF, Christie J, McQueen MM. External fixation for type III open tibialfractures. J Bone Joint Surg Br. Sep 1990;72(5):801-4. [Medline].

7. Schandelmaier P, Krettek C, Rudolf J, et al. Superior results of tibial rodding versus external fixation ingrade 3B fractures. Clin Orthop. Sep 1997;(342):164-72. [Medline].

8. Tornetta P 3rd, Bergman M, Watnik N, et al. Treatment of grade-IIIb open tibial fractures. A prospectiverandomised comparison of external fixation and non-reamed locked nailing. J Bone Joint Surg Br. Jan1994;76(1):13-9. [Medline].

9. Whittle AP, Russell TA, Taylor JC, Lavelle DG. Treatment of open fractures of the tibial shaft with the useof interlocking nailing without reaming. J Bone Joint Surg Am. Sep 1992;74(8):1162-71. [Medline].

10/28/2014 Tibial Shaft Fractures

http://emedicine.medscape.com/article/1249984-overview#showall 4/5

10. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty- five openfractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. Jun1976;58(4):453-8. [Medline].

11. Mller ME, Nazarian S, Koch P. The Comprehensive Classification of Fractures of Long Bones. Berlin,Germany; Springer-Verlag; 1990.

12. Orthopaedic Trauma Association. Fracture and Dislocation Classification Compendium - 2007 OrthopaedicTrauma Association/Classification, Database & Outcomes Committee. Orthopaedic Trauma Association.Available at http://www.ota.org/compendium/compendium.html. Accessed May 15, 2009.

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

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

15. Kyro A, Tunturi T, Soukka A. Conservative treatment of tibial fractures. Results in a series of 163 patients.Ann Chir Gynaecol. 1991;80(3):294-300. [Medline].

16. Karaharju EO, Alho A, Nieminen J. The results of operative and non-operative management of tibialfractures. Injury. Aug 1975;7(1):47-52. [Medline].

17. van der Linden W, Larsson K. Plate fixation versus conservative treatment of tibial shaft fractures. Arandomized trial. J Bone Joint Surg Am. Sep 1979;61(6A):873-8. [Medline].

18. Sarmiento A. A functional below-the-knee cast for tibial fractures. J Bone Joint Surg Am. Jul1967;49(5):855-75. [Medline].

19. Hooper GJ, Keddell RG, Penny ID. Conservative management or closed nailing for tibial shaft fractures. Arandomised prospective trial. J Bone Joint Surg Br. Jan 1991;73(1):83-5. [Medline].

20. Edwards CC. Staged reconstruction of complex open tibial fractures using Hoffmann external fixation.Clinical decisions and dilemmas. Clin Orthop. Sep 1983;(178):130-61. [Medline].

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

22. Ma CH, Tu YK, Yeh JH, Yang SC, Wu CH. Using external and internal locking plates in a two-stageprotocol for treatment of segmental tibial fractures. J Trauma. Sep 2011;71(3):614-9. [Medline].

23. Wysocki RW, Kapotas JS, Virkus WW. Intramedullary nailing of proximal and distal one-third tibial shaftfractures with intraoperative two-pin external fixation. J Trauma. Apr 2009;66(4):1135-9. [Medline].

24. Benum P, Svenningsen S. Tibial fractures treated with Hoffmann's external fixation: a comparative analysisof Hoffmann bilateral frames and the Vidal-Adrey double frame modification. Acta Orthop Scand. Jun1982;53(3):471-6. [Medline].

25. Court-Brown CM, Hughes SP. Hughes external fixator in treatment of tibial fractures. J R Soc Med. Oct1985;78(10):830-7. [Medline].

26. Eidelman M, Katzman A. Treatment of complex tibial fractures in children with the Taylor spatial frame.Orthopedics. Oct 2008;31(10):[Medline].

27. Gershuni DH, Pinsker R. Bone grafting for nonunion of fractures of the tibia: a critical review. J Trauma.Jan 1982;22(1):43-9. [Medline].

28. Clifford RP, Lyons TJ, Webb JK. Complications of external fixation of open fractures of the tibia. Injury.May 1987;18(3):174-6. [Medline].

29. Lawyer RB Jr, Lubbers LM. Use of the Hoffmann apparatus in the treatment of unstable tibial fractures. JBone Joint Surg Am. Dec 1980;62(8):1264-73. [Medline].

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

31. Busse JW, Morton E, Lacchetti C, Guyatt GH, Bhandari M. Current management of tibial shaft fractures: asurvey of 450 Canadian orthopedic trauma surgeons. Acta Orthop. Oct 2008;79(5):689-94. [Medline].

32. Dasgupta S, Banerji D, Mitra UK, Ghosh PK, Ghosh S, Ghosh B. Studies on Ender's intramedullary nailingfor closed tibial shaft fractures. J Indian Med Assoc. Jun 2011;109(6):375-7. [Medline].

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

34. Labronici PJ, Santos Pires RE, Franco JS, Alvachian Fernandes HJ, Dos Reis FB. Recommendations foravoiding knee pain after intramedullary nailing of tibial shaft fractures. Patient Saf Surg. Dec 12011;5(1):31. [Medline]. [Full Text].

35. Hupel TM, Aksenov SA, Schemitsch EH. Effect of limited and standard reaming on cortical bone bloodflow and early strength of union following segmental fracture. J Orthop Trauma. Aug 1998;12(6):400-6.[Medline].

36. Keating JF, O'Brien PJ, Blachut PA, et al. Locking intramedullary nailing with and without reaming foropen fractures of the tibial shaft. A prospective, randomized study. J Bone Joint Surg Am. Mar1997;79(3):334-41. [Medline].

37. Court-Brown CM, Will E, Christie J, McQueen MM. Reamed or unreamed nailing for closed tibial fractures.A prospective study in Tscherne C1 fractures. J Bone Joint Surg Br. Jul 1996;78(4):580-3. [Medline].

38. [Best Evidence] Bhandari M, Guyatt G, Tornetta P 3rd, Schemitsch EH, Swiontkowski M, Sanders D, etal. Randomized trial of reamed and unreamed intramedullary nailing of tibial shaft fractures. J Bone JointSurg Am. Dec 2008;90(12):2567-78. [Medline].

39. Li Y, Jiang X, Guo Q, Zhu L, Ye T, Chen A. Treatment of distal tibial shaft fractures by three differentsurgical methods: a randomized, prospective study. Int Orthop. Jun 2014;38(6):1261-7. [Medline]. [FullText].

40. Brinker MR, Bailey DE Jr. Fracture healing in tibia fractures with an associated vascular injury. J Trauma.Jan 1997;42(1):11-9. [Medline].

10/28/2014 Tibial Shaft Fractures

http://emedicine.medscape.com/article/1249984-overview#showall 5/5

Medscape Reference 2011 WebMD, LLC

41. Lange RH, Bach AW, Hansen ST Jr, Johansen KH. Open tibial fractures with associated vascular injuries:prognosis for limb salvage. J Trauma. Mar 1985;25(3):203-8. [Medline].

42. Taylor JC. Delayed union and non-union of fractures. In: Crenshaw AH, ed. Campbell's OperativeOrthopaedics. 8th ed. St Louis, Mo: CV Mosby; 1992:. 1287.

43. Templeman D, Thomas M, Varecka T, Kyle R. Exchange reamed intramedullary nailing for delayed unionand nonunion of the tibia. Clin Orthop. Jun 1995;169-75. [Medline].

44. Coles CP, Gross M. Closed tibial shaft fractures: management and treatment complications. A review ofthe prospective literature. Can J Surg. Aug 2000;43(4):256-62. [Medline].

45. McGraw JM, Lim EV. Treatment of open tibial-shaft fractures. External fixation and secondaryintramedullary nailing. J Bone Joint Surg Am. Jul 1988;70(6):900-11. [Medline].

46. Milner SA, Davis TR, Muir KR, et al. Long-term outcome after tibial shaft fracture: is malunion important?.J Bone Joint Surg Am. Jun 2002;84-A(6):971-80. [Medline].

47. Vallier HA, Cureton BA, Patterson BM. Factors Influencing Functional Outcomes After Distal Tibia ShaftFractures. J Orthop Trauma. Dec 22 2011;[Medline].

48. Connelly CL, Bucknall V, Jenkins PJ, Court-Brown CM, McQueen MM, Biant LC. Outcome at 12 to 22years of 1502 tibial shaft fractures. Bone Joint J. Oct 2014;96-B(10):1370-7. [Medline].

49. Clifford RP, Beauchamp CG, Kellam JF, et al. Plate fixation of open fractures of the tibia. J Bone JointSurg Br. Aug 1988;70(4):644-8. [Medline].

50. den Outer AJ, Meeuwis JD, Hermans J, Zwaveling A. Conservative versus operative treatment of displacednoncomminuted tibial shaft fractures. A retrospective comparative study. Clin Orthop. Mar 1990;(252):231-7. [Medline].

51. Digby JM, Holloway GM, Webb JK. A study of function after tibial cast bracing. Injury. Mar 1983;14(5):432-9. [Medline].

52. Duda GN, Mandruzzato F, Heller M, et al. Mechanical boundary conditions of fracture healing: borderlineindications in the treatment of unreamed tibial nailing. J Biomech. May 2001;34(5):639-50. [Medline].

53. Hussain R, Umer M, Umar M. Treatment of tibial diaphyseal fractures with closed flexible intramedullaryender nails: 39 fractures followed for a period of two to seven years. J Pak Med Assoc. May2001;51(5):190-3. [Medline].

54. Jensen JS, Hansen FW, Johansen J. Tibial shaft fractures. A comparison of conservative treatment andinternal fixation with conventional plates or AO compression plates. Acta Orthop Scand. 1977;48(2):204-12. [Medline].

55. Karladani AH, Granhed H, Fogdestam I, Styf J. Salvaged limbs after tibial shaft fractures with extensivesoft-tissue injury: a biopsychosocial function analysis. J Trauma. Jan 2001;50(1):60-4. [Medline].

56. Skoog A, Soderqvist A, Tornkvist H, Ponzer S. One-year outcome after tibial shaft fractures: results of aprospective fracture registry. J Orthop Trauma. Mar-Apr 2001;15(3):210-5. [Medline].

57. Toivanen JA, Honkonen SE, Koivisto AM, Jarvinen MJ. Treatment of low-energy tibial shaft fractures:plaster cast compared with intramedullary nailing. Int Orthop. 2001;25(2):110-3. [Medline].