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Clinical Practice Guidelines

Tibial shaft (diaphyseal) fracture - Fracture clinics

  • Fracture Guideline Index

    See also:  Tibial shaft (diaphyseal) fracture - Emergency Department

    1. How often should these fractures be followed up in fracture clinics?
    2. What should I review at each appointment?
    3. What are the potential complications associated with this injury?
    4. When should I refer for an orthopaedic consultant opinion?
    5. What are the indications for discharge?

    1. How often should these fractures be followed up in fracture clinics?

    Fracture type

    First appointment

    Subsequent review appointments

    Discharge advice to parents

    Toddler fracture

    2 weeks post-immobilisation with x-ray

    Removal of backslab at 2-4 weeks post injury

    Discharge to GP

    To be followed up by GP in 4-6 weeks post injury

    Some toddlers may take a number of weeks to start walking let alone walk freely again

    Undisplaced tibial shaft fracture

    1 week post-immobilisation with x-ray

    If stable at 1 week and the cast is appropriate, then at 4-6 weeks post-reduction for change to patella tendon-bearing cast

    If there is any concern for instability at the fracture site, then the patient should be seen weekly for the first 3 weeks

    It will take 3-4 months from injury before the patient will be back to sports activities

    Displaced tibial shaft fracture + / - fibular shaft fracture

    1 week for patients who had closed reduction and casting with x-ray

    Weekly for the first 3 weeks in patients with unstable fractures

    It will take 3-4 months from injury before the patient will be back to sports activities


    2. What should I review at each appointment?

    • Alignment parameters of the tibia
    • Assessment of fracture healing
    • Assessment of cast

    3. What are the potential complications associated with this injury?

    • Vascular injury - uncommon, however the sequelae can be serious. Complete vascular assessment needs to be done on all patients with tibia fractures.  Proximal tibial shaft fractures are at higher risk of causing a vascular injury
    • Angular deformity - tibial varus angular deformity can occur in isolated tibial fractures.  Therefore, close follow-up in the first 3 weeks is recommended. Casts can be wedged or repeat reduction may be needed. Patients under the age of 8 should remodel residual angular deformity up to 10 degrees. There is some remodelling for children aged 8-12 years.  Children over age 12 have little chance of remodelling residual deformity.  Most remodelling occurs in the first 2 years after deformity. Single plane deformity has a higher chance to remodel compared with biplanar deformity
    • Malrotation - malrotation of the tibia does not correct with remodelling after injury. Thus limited malrotation can be tolerated. A derotational osteotomy of the tibia may be needed in cases that heal with significant malrotation
    • Growth disturbance - growth disturbance can occur due to injury to the proximal tibial physis. This can lead to a recurvatum deformity.  This needs to be monitored in patients with proximal tibial shaft fractures who could have injuries that extend into the growth plate.
    • Leg length discrepancy - accelerated growth after a tibia fracture does not occur as reliably as in femoral shaft fractures. Overgrowth usually does not exceed 5 mm.  Leg length discrepancy can result from unrecognized injury to the proximal tibial physis
    • Delayed union and nonunion - most tibial shaft fractures should heal in 8-12 weeks post-injury with appropriate treatment. Risks for delay to union are open fractures and infection. Fractures that result in nonunion will need further treatment to promote union

    4. When should I refer for an orthopaedic consultant opinion?

    Indications for a consultant orthopaedic surgeon opinion are:

    • loss of position beyond acceptable parameters
    • concern for progressive loss of position that will not be acceptable
    • healed fracture with significant angular or rotational deformity

    5. What are the indications for discharge?

    Healed fracture clinically (i.e. pain-free on torsional stress and on palpation at the fracture site) and radiographically with no concerns of alignment (in all planes) or growth disturbance. 

    References (Outpatient setting)

    Mashru RP, Herman MJ, Pizzutillo PD. Tibial shaft fractures in children and adolescents. J Am Acad Ortho Surg 2005; 13(5): 345-52.

    Henrich SD, Mooney JF. Fractures of the shaft of the tibia and fibula. In Rockwood and Wilkins' Fractures in Children, 7th Ed. Beaty JH, Kasser JR (Eds). Lippincott Williams & Wilkins, Philadelphia 2010. p.930-66.