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Closed Tibial-Shaft Fractures: Which Ones Benefit From Surgical Treatment?

Department of Orthopedic Surgery, Baylor College of Medi-cine, Houston.

Closed tibial-shaft fractures can usually be managed effectively with cast or brace immobilization if acceptable alignment is maintained and cyclic loading (weight-bearing) is initiated early. However, certain tibial fractures are at greater risk for nonunion or malunion and merit consideration for early operative stabilization. Among the tibial fracture characteristics that warrant fixation are instability, metaphyseal-diaphyseal location, significant limb edema, and the need for repeated realignment procedures. Deleterious patient-specific factors, such as obesity, poor compliance, and health conditions favoring immediate function, should also be considered. Absolute criteria for stabilization include coronal angulation exceeding 5 degrees, sagittal angulation greater than 10 degrees, rotation greater than 5 degrees, shortening exceeding 1 cm, displacement greater than 50%, and severe comminution (loss of 50% or more of cortical circumferential continuity). Relative indications for fixation include an inability to bear weight, distal or oblique fractures, prominent edema, and patient-specific considerations necessitating early function. When tibial stabilization is preferable, the authors believe that closed locked intramedullary nailing is the treatment of choice.