Background information:

The most common long bone fractures are tibial shaft fractures, which have a bimodal distribution according to age and sex. Older women and young male patients are more likely to sustain a fracture(1). A fracture of the tibial shaft accounts for approximately 2% of all adult fractures(2). Few epidemiological studies have been made concerning the incidence and mechanism of this injury(3). In a study done in Sweden it was revealed that The overall incidence of tibia fractures was 51.7 per 100,000 and year. The incidence of proximal, diaphysis and distal tibia fractures was 26.9, 15.7 and 9.1 respectively per 100,000 and year(4). In China it was revealed fracture of patella, tibia or fibula, and ankle were the most frequent fracture types, with an ASYR of 116 per 100 000(5). There is a limited number of studies on the overall prevalence of tibia fractures in sub-Saharan Africa and Tanzania(2). Traditionally, the most typical cause of a tibial shaft fracture, especially in men, has been a major trauma, such as a traffic collision or a high-energy fall(2, 6). Tibial shaft fractures are classified according to the AO Classification of long bones (7) and are divided into simple, wedge and complex fractures (Type 42. A/B/C). Type A fractures are subdivided into spiral, oblique and transverse fractures, type B into spiral wedge, oblique wedge and transversal wedge fractures. Finally Type C fractures are subdivided into spiral, segmental and irregular fractures. Closed soft tissue injuries can be classified by the classification of Tscherne/Oestern(8) and open fractures by the classification of Gustilo/Anderson(9). Most patients experience excruciating pain and can explain how the injury occurred. They frequently exhibit instability, malposition, edema, and hematoma during the clinical examination. X-rays in two planes are sufficient as the primary diagnostic tool and should include the knee and ankle(10).


Stable, non-displaced fractures of the tibial shaft can be treated conservatively by cast application(11). Due to a long period of immobilization conservative treatment includes a high risk of deep venous thrombosis, compartment syndrome, soft tissue injury and chronic regional pain syndrome. Treatment of tibial fractures by casting is associated with the lowest incidence of infection but the highest incidence of delayed union, nonunion and malunion(11). According to the AWMF Guidelines conservative treatment is only recommended in non-displaced tibial shaft fractures in patients with good compliance(12). Operative treatment with standardized protocols is very common. Absolute indications for immediate surgical treatment are for example open fractures, compartment syndrome, concomitant nerve and/or vessel injury or multiple injured patients. Several different implants are available to the orthopedic surgeon. external fixators, plating, and intramedullary nails (IMNs) are the methods used to treat tibial fractures. Shortening and malunion are reduced and faster union is achieved using intramedullary nailing. Nailed patients have less time off work with a more predictable and rapid return to full function(13). In skeletally mature patients with displaced tibial shaft fracture, the most common treatment is intramedullary nail fixation. Seroma, necrosis and infection with the late onset of osteomyelitis are the most common complications in closed fractures(14). Compartment syndrome complicates tibia fractures with an incidence ranging from 1,4% to 48% in various(15, 16). in open fractures, infection is a severe complication requiring radical surgical intervention to avoid chronic osteitis. Once medullary cavity is infected intramedullary nails should be removed and replaced by external fixation(10).