Causes / typical injury mechanism: Tibial shaft fractures occur in multiple contexts, including high-energy, low-energy, and rotational mechanisms of injury. Common causes include sports, motor vehicle accidents, and falls. The superficial position of the tibia leads to increased risk of fracture due to direct contact, as well as potential for open fracture.

Classic history and presentation: Patients with distal tibial fractures commonly present after trauma, falls, or sporting accidents. The most commonly implicated sport is soccer due to direct blows to the tibia. Those with more proximal tibial shaft fractures most often present after high-energy trauma, such as motor vehicle accidents. Due to the potential association with compartment syndrome and neurovascular injury with these mechanisms and injury patterns, the latter may also present with neurosensory deficits, weakness, vascular compromise, and increasing swelling and pain.

Prevalence: Prevalence is poorly reported in the literature. Some evidence suggests that around 2% of fractures involve the tibial diaphysis. Incidence rates have been reported somewhere between 7-17 per 100 000 people per year.

• Age – The mean age for tibial fractures has been reported in the 40s, although sports-related injuries tend to occur in younger patients, while those with fall-related injuries tend to be older.
• Sex / gender – Older epidemiological studies showed an increased incidence of tibial fractures in men, but more recent data has shown that tibial fractures are equally common in men and women. Distal and diaphyseal fractures, however, are more common in men. Men tend to experience tibial fractures at a younger age than women (40s versus 50s).

Risk factors: Risk factors for tibial fractures are poorly reported, but there is some evidence to suggest that risk factors for low bone density may increase the risk of tibial shaft fractures. Patients with osteoporosis are at increased risk of tibial fracture from low-energy trauma, such as falls from standing.

Pathophysiology: The tibia is the primary load-bearing bone of the lower leg. Typically, higher-energy mechanisms result in more proximal fractures and more complex fracture patterns. Rotational or torsional force more often results in spiral fractures. Significant soft tissue or crush injury increases the risk of compartment syndrome and vascular injury.

Grade / classification system: There are several classification systems used for tibial shaft fractures, although no single system has gained predominance. Whichever classification system is used, it is important to note the location and degree of tibial fracture, associated fibular fracture, magnitude of surrounding soft tissue injury, and any articular extension.

The Gustilo classification system is often used for open fractures:

• Type I – open fracture, clean wound less than 1 cm
• Type II – open fracture, wound less than 10 cm without extensive soft tissue damage, flaps, or avulsions
• Type IIIA – open fracture from high-energy trauma, with adequate soft tissue coverage of bone despite laceration or flaps
• Type IIIB – open fracture with extensive soft tissue loss, periosteal stripping, and bone damage
• Type IIIC – open fracture associated with arterial injury requiring repair