Fractures of the Tibia

Ovid: Manual of Orthopaedics

Editors: Swiontkowski, Marc F.; Stovitz, Steven D.
Title: Manual of Orthopaedics, 6th Edition
> Table of Contents > 25 – Fractures of the Tibia

Fractures of the Tibia
I. Fractures of The Tibial Plateau (1, 2, 3, 4)
  • For practical purposes, fractures of the tibial plateau are classified as follows:
    • Undisplaced (a vertical fracture of the plateau)
    • Split (a split fracture with displacement, with or without slight comminution)
    • Depressed (centrally depressed fracture)
    • Split and depressed with an intact tibial rim
    • Any of 1 through 4 with metaphyseal or even diaphyseal extension. The elements of these descriptions are contained within Schatzker’s system (Fig. 25-1).
  • Examination
    is different from that for other knee injuries. It is wise to carry out
    a definitive examination only after roentgenographs have been obtained.
    Differential diagnosis includes a major ligamentous injury or knee
    dislocation (5,6,7).
    The examination should include inspection for wounds, evaluation of the
    distal circulation (pulses and capillary refill), and neurologic (motor
    or sensory) function. Motion and stability should not routinely be
    assessed in these injuries; however, this type of injury can be
    associated with ligamentous or meniscal damage (1).
  • Radiographs.
    Oblique films in addition to the routine anteroposterior and lateral
    radiographs are often helpful in identifying fracture lines and
    articular displacement. Computed tomography demonstrates minor
    fractures and accurately depicts the degree of depression of the tibial
    plateau; axial cuts with sagittal reconstruction are the routine.
  • Magnetic resonance imaging (MRI) can be helpful when there is clinical concern for associated ligamentous injury.
    • Undisplaced fractures.
      In some settings, especially when multiple injuries are involved,
      fixation with two percutaneous cannulated cancellous lag screws is
      advisable to ensure maintenance of reduction. For isolated injuries,
      generally nonoperative management is selected. A splint is applied, and
      the leg is elevated for the first 24 to 48 hours. Knee aspiration is
      carried out if a significant hemarthrosis is present, and knee motion
      may be started with continuous passive motion (CPM) if available. As
      soon as the patient is comfortable and the range of motion is
      increasing, he or she can be followed up as an outpatient. Follow-up
      radiographs should be obtained shortly after motion is instituted to
      ensure that the fracture remains nondisplaced. Touch-down weight
      bearing should be maintained for 8 weeks to prevent displacement from
      shear forces.
    • Displaced fractures
      • Split fracture.
        Open reduction and fixation is generally done if there is a significant
        widening (lateral or medial displacement of more than 3–5 mm) of the
        plateau (8,9). The
        internal fixation must be rigid enough to allow movement of the joint
        as soon as there is soft-tissue healing. In this situation, the authors
        prefer to use the Association of the Study of Internal Fixation (ASIF)
        buttress plate (Fig. 25-2) or a dynamic compression or locking plate when the patient is osteoporotic (4).
        Recently, there has been a move toward use of smaller implants for all
        tibial plateau fixation. Specialized 3.5-mm T- and L-buttress plates
        allow the placement of more screws under the articular surface. If the
        patient is young and has dense bone, then multiple percutaneous
        cannulated lag screws can be inserted



        fluoroscopic and/or arthroscopic control. Percutaneous placement of a
        large reduction clamp is often successful in providing reduction of the
        fracture. If open reduction and internal fixation are not feasible,
        then treatment should be as for comminuted fractures.

        Figure 25-1.
        Schatzker’s classification system. I, split; II, split with depression;
        III, depression; IV, medial condyle; V, bicondylar; VI, bicondylar with
        shaft extension. (From Hansen ST, Swiontkowski MF. Orthopaedic trauma protocols. New York: Raven, 1993:315.)
        Figure 25-2.
        Internal fixation of a split depression fracture of the tibial plateau
        using L-buttress plate fixation with bone grafting of the elevated
        segment. (From Hansen ST, Swiontkowski MF. Orthopaedic trauma protocols. New York: Raven, 1993: 318.)
      • Central depression of the plateau.
        If depression is greater than 3 to 5 mm, especially with valgus stress
        instability of the knee greater than 10 degrees in full extension, then
        most authors currently recommend elevation with bone grafting and
        fixation (2,3,9,10).
        More recently, articular reductions have been done with arthroscopic
        visualization with percutaneous technique for elevation of the segment.
        Autogenous bone graft remains the treatment of choice, but allograft
        and cancellous substitutes such as corallin hydroxyapatite and
        calcium-phosphate cements have been successfully used (9).
        Generally, percutaneous lag screws are adequate for support of the
        elevated joint surface and bone graft or graft substitute material.
      • Split-depressed fractures
        with a displacement/depression of more than 3 to 4 mm are treated with
        reduction, fixation, and early motion in most young patients.
        Generally, this reduction is done with an open technique with an
        anterior or anterolateral approach, elevation, and bone grafting using
        buttress or locking buttress plates for older patients (Fig. 25-2)
        and lag screws or 3.5-mm small fragment T- or L-plates or one-third
        tubular plates (as washers) in younger patients. These fractures may be
        managed with arthroscopic reduction in skilled hands. Secure fixation
        is critical so


        early motion with or without CPM can be initiated. Patients are
        generally limited to touch-down weight bearing for 12 weeks to prevent
        late fracture settling. If the patient’s limb is stable to varus and
        valgus stress in an examination under anesthesia shortly after injury,
        then traction treatment with a tibial pin and early motion is an option
        (10,11). The patient is placed in a cast-brace (as described in Chap. 7, III.H) or a hinged knee brace after 3 to 4 weeks (1).
        This treatment is not currently recommended on a routine basis. If the
        instability exceeds 10 degrees, then reduction and fixation as
        described earlier is indicated (11).

      • Fractures with metaphyseal/diaphyseal extension
        are treated similarly to split-depressed fractures if the joint
        extension is significant. Generally, buttress plate fixation and bone
        grafting are required. When the injury is bicondylar, stripping the
        soft tissues off both condyles from an anterior approach should be
        avoided; this results in a high incidence of nonunion and deep
        infection. Instead, the most unstable condyle (usually lateral) is
        selected for the buttress fixation via an anterolateral approach and
        the other condyle is stabilized by percutaneous screw fixation,
        fixation with a posterior medial incision and small buttress plate, or
        neutralization with an external fixator for 4 to 6 weeks while motion
        is limited. With all tibial plateau fractures treated with operative
        stabilization, it is important to examine the knee for ligamentous
        stability after completing the fixation in the operating room to rule
        out ligamentous injury (see II.B) (1). The functional results of treatment
        are often better than the routine radiographs seem to predict. Early
        motion of the knee joint and delayed full weight bearing are the keys
        to maximum restoration of joint function (2,3,4).
        • Apply a cast-brace (as described in Chap. 7, III.H)
          off the self-hinged knee braces, which are lightweight and limit varus
          and valgus stress and are more widely used. The same ambulation
          protocol, touch-down weight bearing, is followed.
        • In special situations, the patient is placed in a long-leg cast
          until the fracture is healed. Then the patient is placed in a
          rehabilitation program to regain full extension and flexion of the knee
          to beyond 90 degrees. The patient is kept on protected weight bearing
          for at least 3 to 4 months. This treatment is generally limited to
          patients with a severe neurologic condition or significant osteopenia.
  • Complications
    • Significant loss of range of motion may occur, particularly if early movement is not instituted.
    • Early degenerative joint changes
      with pain can occur regardless of the degree of joint reconstruction.
      In some instances, the pain may be severe enough to require
      arthroplasty or arthrodesis (8).
    • The infection rate
      following operative treatment is reduced in experienced hands. Most
      infections occur because of excessive soft-tissue stripping.
    • Nerve and vascular injuries that occur at the time of injury or subsequent to treatment are not uncommon (12).
      Nerve injuries are usually traction injuries, and recovery is
      unpredictable. Compartmental syndrome may be present and should be
      treated as described in Chap. 2, III.
II. Extraarticular Proximal Tibial Fractures
  • Classification. Proximal tibial fractures are classified similar to diaphyseal fractures (see III.C).
  • Examination.
    Initial examination should be comprehensive including inspection,
    palpation, and lower extremity neurovascular assessment. The integrity
    and condition of the soft tissues should be carefully inspected. The
    alignment of the lower extremity should also be noted. The compartments
    of the leg should be palpated and passive flexion and extension of the
    toes performed to assess for pain and possible compartment syndrome.
    Distal pulses may be palpable despite ischemia from increased
    compartment pressure. Definitive diagnosis may require measurement of
    intracompartmental pressures (see Chap. 2, III). The diagnosis of a compartment


    syndrome is a surgical emergency and requires prompt release of
    pressure to preserve muscle and nerve viability. A careful examination
    of the extremity pulses is imperative to rule out potential vascular

  • Radiographs.
    Although a tibial diaphyseal fracture may be obvious from clinical
    examination, anteroposterior and lateral radiographs of the tibia
    (including the knee and ankle joints) are needed to plan management.
    Radiographs should be carefully reviewed to ensure fracture lines do
    not reveal intraarticular extension. Computed tomograms or plain
    tomograms can be helpful to identify intraarticular extension when
    plain x-rays are difficult to interpret.
  • Treatment.
    Extraarticular proximal tibial fractures are often the result of high
    energy trauma with displacement and comminution. Most authors agree
    that operative management of such fractures is warranted to optimize
    patient outcomes. However, it remains unclear which surgical option
    (plate, nail, external fixator, or combination) is preferable. The
    rates of nonunion between implants did not appear to differ between
    treatment options (Table 25-1). Infection rates were significantly lower with intramedullary nails than with plates or external fixators (p <0.05) (13). A trend towards increased rates of malunion with intramedullary nails was identified (p
    = 0.06). Pooled results across studies may be limited by heterogeneity
    between studies. Results should be interpreted with caution.
  • Complications.
    Extraarticular fractures of the tibia are prone to infection, malunion
    (i.e., valgus and procurvatum deformities), nonunion, compartment
    syndrome, and implant failure (Table 25-1) (13).
    • Infection: range 8% to 14% (deep infection rates 3%–5%)
    • Malunion: range 2.4% to 20%
    • Nonunion: range 2% to 8%
    • Compartment syndrome: range 2% to 6%
    • Implant failure: 8%
III. Diaphyseal fractures
  • Epidemiology.
    Tibial fractures are the most common long bone fracture. They occur
    commonly in the third decade of life at a rate of 26 diaphyseal
    fractures per 100,000 population annually.
  • Mechanism of injury.
    Five causes of injury include falls, sports related, direct blunt
    trauma, motor vehicle accidents, and penetrating injuries (e.g.,
  • Classification.
    The most comprehensive classification for tibial fractures is the AO
    Association for the Study of Internal Fixation/Orthopaedic Trauma
    Association system that divides injury patterns into three broad
    categories: unifocal, wedge, and complex fractures.
    • Unifocal fractures are further described as spiral, oblique, and transverse fractures (A).
    • Wedge fractures are further described as intact spiral, intact bending, and comminuted wedge fractures (B).
    • Complex fractures (i.e., multiple fragments) can be described as spiral wedge, segmental, and comminuted fractures (C).
  • Examination.
    Initial examination should be comprehensive including inspection,
    palpation, and lower extremity neurovascular assessment. The integrity
    and condition of the soft tissues should be carefully inspected. The
    alignment of the lower extremity should also be noted. The compartments
    of the leg should be palpated and passive flexion and extension of the
    toes performed to assess for pain and possible compartment syndrome.
    The diagnosis of a compartment syndrome is a surgical emergency and
    requires prompt release of pressure to preserve muscle and nerve
    viability (see Chap. 2, III).
  • Radiographs.
    Although a tibial diaphyseal fracture may be obvious from clinical
    examination, anteroposterior and lateral radiographs of the tibia
    (including the knee and ankle joints) are needed to plan management.
    Radiographs can provide information about fracture morphology, quality
    of the bone (i.e., osteopenia, osteoporosis), and gas in the tissues
    suggesting an open wound.
  • Treatment.
    The selection of nonoperative or operative management must involve the
    consideration of many factors, including associated skeletal and



    the degree of soft-tissue injury, injuries to other organ systems, the
    general condition of the patient, the skill and experience of the
    treating physician, and the resources of the facility. Options for
    treatment include: casting/functional bracing (nonoperative), external
    fixation, plate fixation, and intramedullary nailing.

    TABLE 25-1 Proximal Extraarticular Tibial Fractures
      Point estimates and 95% confidence intervals  
    Infection Nonunion Malunion CS Implant failure
    Plate 14% (8%–23%) 2% (0.3%–8%) 10% (5%–18%) 2% (0.3%–8%)
    IM nail 2.5% (0.1%–3%)a 3.5% (1.7%–7%) 20% (1.5%–26%)b 5.5% (3.1%–9.6%) 7.5% (5%–12%)
    Ex-fix 8% (4%–15%)
    DI: 3% (1%–8%)
    8% (4%–15%) 4% (1.5%–10%)
    +12% (5–26%)
    DI: 5% (1%–16%)
    2.4% (0.4%–13%)
    Ex-fix, external fixation; DI, deep infection; CS, compartment syndrome; IM, intramedullary.
    ap >0.05 when compared to plate.
    bp = 0.06 when compared to plate.
    Adapted from Busse J, Bhandari M, Kulkarni A, et al. The effect of low
    intensity, pulsed ultrasound on time to fracture healing: a
    meta-analysis. CMAJ 2002;166:437–441.
    • Nonoperative management
      is commonly reserved for closed tibial diaphyseal fractures with less
      than 1.5 cm of shortening, axially stable transverse fractures, spiral
      oblique of comminuted fractures with less than 12 mm of initial
      shortening, angulations less than degrees initially, and less than 50%
      displacement (15). However, acceptable degrees
      of fracture shortening and translation are highly variable among
      surgeons (<5 mm to >15 mm). Surgeons’ definitions of acceptable
      angular malunions (rotational, varus/valgus, and
      procurvatum/recurvatum) range from less than 5 degrees to 20 degrees (16). Sarmiento (17,18)
      developed a below-the-knee cast [patellar tendon bearing (PTB)] and
      prefabricated functional brace that allows knee motion while
      maintaining stability and length in the affected leg. This PTB cast is
      generally applied after 2 to 3 weeks in the long-leg bent knee cast
      that is applied following a closed reduction. Prefabricated braces are
      the most widely used. One of these two treatment methods should be
      chosen, and the particular technique should be strictly adhered to if
      the same excellent results reported in the literature are to be
      expected. These cast techniques are described in detail in Chap. 4.
      It must be re-emphasized that a below-the-knee total contact cast may
      not be applied immediately after the fracture; one must wait until the
      swelling has diminished. The authors suggest using a modified Robert
      Jones compression long-leg splint during the period of acute swelling.
      When the patient is ready for casting and following an appropriate
      spinal or general anesthetic, nearly all tibial fractures can be
      reduced by placing the leg over the end of the table. Adequate
      reduction and alignment are maintained in this position while the cast
      is applied. If shortening is minimal, then analgesia may suffice. The
      average healing time with closed treatment is approximately 18 weeks
      (range from 14.5–21.0 weeks). One of Sarmiento’s principles is that, in
      general, the amount of final shortening is demonstrated on the initial
      radiograph, and the patient should be so informed. Good functional
      outcomes can be expected in 90% of cases (19,20,21). Closed treatment is recommended for children’s fractures except when the physis or joint is involved (22).
    • Operative management
      is reserved for those fractures deemed unacceptable for nonoperative
      treatment. Most surgeons prefer intramedullary nails in the treatment
      of closed low energy fractures (95.5%), high energy fractures (96%),
      and those closed fractures with associated compartment syndrome (80.4%)
      (23). The majority of surgeons prefer
      intramedullary nails in the treatment of open tibial shaft fractures;
      however, there is a decline in the use of intramedullary nails as the
      severity of the soft tissue injury increases from Types I to IIIb (Type
      I, 95.5%; Type II, 88.1%; Type IIIa, 68.4%; Type IIIb, 48.4%) (23).
      • Closed fractures.
        There have been three published meta-analyses evaluating treatment
        alternatives for closed tibial shaft fractures: two pooling data from
        primarily observational studies and one pooling data from on-use
        randomized trials (21,24,25).
        Littenburg and colleagues, in a comprehensive review of the available
        literature, identified 2005 patients treated with a cast or brace, 474
        patients treated with a plate and screws, and 407 patients treated with
        intramedullary nails (21). Pooled infection
        rates were lower with casts (0%) and intramedullary nails (0%–1%) when
        compared to plates (0%–15%). While plate fixation achieved the fastest
        time to fracture union (0%–15%). when compared to either casts (median
        = 13.7 weeks) or intramedullary nails (median = 20 weeks) there were no
        differences in the ultimate rates of nonunion between groups. Rates of
        deep infection were lower with casts and intramedullary nails than with
        plates (ranges: 0%–2%, 0%–1%, 0%–15%, respectively).
        In a review of prospective studies (eight observational
        and five randomized trials) evaluating treatment alternatives for
        tibial shaft fractures,


        and Gross found plate fixation to result in the lowest nonunion rates
        (2.6%) and highest infection rates (9%) compared to other treatment
        alternatives (24).
        Despite the apparent benefits of plate fixation in decreasing the time
        to fracture healing, only 2.1% to 7.4% of surgeon respondents to a
        survey preferred them in the treatment of closed tibial shaft fractures
        (low energy, high energy, and those with associated compartment
        syndrome). This likely reflects an assessment that the high risk of
        infection with plates outweighs their relative benefit in decreasing
        time to fracture union. It remains unclear whether surgeons from less
        industrialized countries, who prefer plate fixation in closed tibial
        shaft fractures, have similar access to intramedullary nails as those
        surgeons in developed nations.

        A substantial proportion of respondents chose external
        fixation for high energy tibial shaft fractures and those associated
        with compartment syndrome. The role of external fixation in closed
        tibial shaft fractures has been evaluated in an observational study (26).
        Turen and colleagues, in a review of 68 closed fractures, identified a
        longer fracture healing time in fractures with compartment syndrome
        than those without (30.2 weeks versus 17.2 weeks, respectively)(26). Moreover, fracture healing times for closed fractures with compartment syndrome were similar to open fractures.
        There remains considerable variability in their
        preference to ream the intramedullary canal or not. The evidence
        favoring reamed or non-reamed nail insertion is suggestive but not
        definitive. Bhandari and colleagues conducted a systematic review and
        found nine randomized trials (n = 646 patients) comparing reamed and nonreamed intramedullary nail insertion in tibial and femoral fractures (25).
        Reamed nailing resulted in a 56% reduction in the relative risk of
        nonunion compared to nonreamed nailing (95% confidence interval:
      • Open fractures.
        An international survey suggests a progressive decline in the use of
        intramedullary nails as the severity of the soft tissue injury
        increases from Type I to IIIb. This is related to an increased use of
        external fixation with increasing soft tissue injury (3%–51%) (27). Surgeons rarely prefer plates in the treatment of open fractures (0.8%–1.1%). One study (n
        = 56) suggests external fixators that significantly decrease the risk
        of re-operation relative to plates (relative risk 0.13, 95% confidence
        interval 0.03–0.54, p <0.01) (15). A meta-analysis found that nonreamed nails, in comparison to external fixators (five studies, n = 396 patients), reduced the risk of reoperation [relative risk (RR) 0.51, 95% confidence interval 0.31–0.69] (28).
        Nonreamed nails also offered advantages in decreasing the relative risk
        of malunion (RR 0.42, 95% confidence interval 0.25–0.71) and
        superficial infection (RR 0.24, 95% confidence interval, 0.08–0.73).
        While these studies shared methodologic limitations of lack of
        concealment, blinding, and loss to follow-up, the narrow confidence
        intervals make the results more definitive than those of the studies
        comparing reamed versus unreamed nailing. In the open tibial fracture
        trials, reamed nails, when compared to nonreamed nails, showed a trend
        toward decreasing the risk of reoperation (two studies, n = 132; RR 0.75, 95% confidence interval 0.43–1.32) (6).
        Because the confidence interval is very wide, the relative effect of
        reamed and unreamed nails in open tibial fractures remains unresolved.
  • Complications. Most patients experience some residual disability after a tibial fracture (21,24).
    • Compartment syndrome has been discussed previously (see Chap. 2, III).
    • Joint stiffness
      can be largely prevented by aggressive treatment to achieve early
      union. Flexion and extension exercises to the toes must not be
      neglected because these joints frequently stiffen and produce
      considerable postcasting dysfunction.
    • Complex regional pain syndrome (reflex sympathetic dystrophy) can occur in 30% of patients with tibial diaphyseal fractures (29). Vigorous physical therapy and sympathetic may be required (see Chap. 2).
    • P.367

    • Delayed union and nonunion (30)
      • The following factors are related to delayed union or nonunion:
        • Severe initial displacement of the fracture fragments (probably indicating significant soft-tissue injury)
        • Significant comminution
        • Associated soft-tissue injuries or open fractures
        • Infection
        • Open management with inadequate stability
          These complications can be minimized by adequate
          immobilization, early weight bearing (which is often delayed for 2
          months if a dynamic compression plate is used), and early bone grafting
          where delayed union appears certain.
      • Adjunctive therapies. Low-intensity pulsed ultrasound (30 mW/cm2
        given at 20 minutes per day has shown potential benefits in improving
        time to healing. A meta-analysis identified 138 potentially eligible
        studies, of which 6 randomized trials met inclusion criteria (31).
        Three trials, representing 158 fractures, were of sufficient
        homogeneity for pooling. The pooled results showed that time to
        fracture healing was significantly shorter in the groups receiving
        low-intensity ultrasound therapy than in the control groups. The
        weighted average effect size was 6.41 (95% confidence interval
        1.01–11.81), which converts to a mean difference in healing time of 64
        days between the treatment and control groups.
        Figure 25-3.
        Displaced closed fractures of the tibia shaft, when shortened more than
        1 cm or considered to be unstable, are best treated with interlocking
        nails. A and B: Preoperative radiographs of a shortened, unstable segmental fracture of the tibia shaft. C and D:
        The interlocking nail in place. The screws placed through the holes in
        the nail proximal and distal to the fracture provide length and
        rotational stability for the fracture. Nearly all fractures of the
        femoral shaft in skeletally mature individuals are treated with similar
        interlocking nails, allowing mobilization of the patient and early
        range of motion of adjacent joints.
    • P.368

    • Infection is
      a complication of open fractures or the opening of a closed fracture.
      The risk of infection is minimized by efficient surgical technique, by
      the proper use of antibiotics, and by a delayed primary closure for
      open fractures. For the most severe soft-tissue injuries, aggressive
      debridement and coverage with free or rotational muscle flaps minimizes
      this complication. Pin tract infection is common with the use of
      external fixators.
    • Revision surgery.
      An observational study of 192 patients with tibial shaft fractures
      identified three simple predictors of the need for reoperation within 1
      year (32). Three variables predicted
      reoperation: the presence of an open fracture wound (RR 4.32, 95%
      confidence interval 1.76–11.26), lack of cortical continuity between
      the fracture ends following fixation (RR 8.33, 95% confidence interval
      3.03–25.0), and the presence of a transverse fracture (RR 20.0, 95%
      confidence interval 4.34–142.86).
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J, Bhandari M, Kulkarni A, et al. The effect of low intensity, pulsed
ultrasound on time to fracture healing: a meta-analysis. CMAJ 2002;166:437–441.
32. Bhandari
M, Guyatt G, Sprague S, et al. Predictors of re-operation following
operative management of fractures of the tibial shaft. J Orthop Trauma 2003;17:353–361.
Selected Historical Readings
Burwell HN. Plate fixation of tibial shaft fractures. J Bone Joint Surg (Br) 1971;53:258–271.
Clancey GJ, Hansen ST Jr. Open fractures of the tibia. J Bone Joint Surg (Am) 1978;60:118–122.
Dehne E. Treatment of fractures of the tibial shaft fractures. Clin Orthop 1969;66:159–173.
Fernandez-Palazzi F. Fibular resection in delayed union of tibial fractures. Acta Orthop Scand 1969;40:105–118.
Karlstrom G, Olerud S. External fixation of severe open tibial fractures with the Hoffmann frame. Clin Orthop 1983;180:68–77.
Lottes JO. Medullary nailing of the tibial with the triflange nail. Clin Orthop 1974;105:253–266.
Nicoll EA. Fractures of the tibial shaft. J Bone Joint Surg (Br) 1964;46:373–387.
Olerud S, Karlstrom G. Secondary intramedullary nailing of tibial fractures. J Bone Joint Surg (Am) 1972;54:1419–1428.
Pare A. Compound fracture of leg. Pare’s personal care (MII, 328). In: Hamby WB, ed. The case reports and autopsy records of ambrose pare. Springfield, IL: Charles C Thomas Publisher, 1960:82–87.
Sarmiento A. Functional bracing of tibial fractures. Clin Orthop 1974;105:202–219.
Schatzker J, McBroom R, Bruce D. The tibial plateau fractures. The toronto experience. Clin Orthop 1979;138:94–104.
Sorensen KH. Treatment of delayed union and nonunion of the tibia by fibular resection. Acta Orthop Scand 1969;40:92–104.

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