Current Orthopaedics (2003) 17, 200 ^205

c 2003 Published by Elsevier Science Ltd.

doi:10.1016/S0268 - 0890(02)00198 - 6

MINI-SYMPOSIUM:TIBIAL FRACTURES

(v) The long-term complications of tibial shaft

fractures
S. A. Milner and C. G. Moran
Trauma & Orthopaedic Surgery, University Hospital, Nottingham NG7 2UH, UK

KEYWORDS
tibial fractures, fractures,
malunited, osteoarthritis,
compartment syndrome,
outcome assessment
(healthcare)

Abstract The main long-term complications of tibial shaft fractures are ankle osteoarthritis and subtalar stiness, postphlebitic limb, foot and ankle deformities due to
acute compartment syndrome, chronic osteomyelitis, and local discomfort related to
metal implants. Fracture malunion may theoretically result in an increased risk of osteoarthritis but clinically the association is not clear, probably because malunion does
not necessarily move overall lower limb alignment outside of the normal range, and
c 2003
therefore not result in important changes in loading of the knee and ankle joints.
Published by Elsevier Science Ltd.

INTRODUCTION
Fracture of the tibial shaft is the most common long
bone fracture, and there is a large volume of literature
about dierent treatments and short- to medium-termoutcomes. Nicolls paper on cast-treated tibial shaft
fractures, published in 1964, is perhaps the best-known
historical study.1 He studied 705 subjects with tibial shaft
fractures and showed that fracture outcome was predicted by what he called the personality of the fracture,
determined by the severity of fracture, displacement,
comminution and associated soft-tissue injury. He
concluded that the good results obtained with cast
treatment meant that routine operative xation of tibial
shaft fractures was not justied.
Over the succeeding decades, there has been a gradual move away from cast treatment towards operative
intervention, mainly due to the development of interlocking nail systems which can be used to stabilise a wide
range of fracture types. Such devices are undoubtedly a
major advance over cast treatment in the management
of high-energy tibial shaft fractures, because skeletal stability allows optimum management of the associated
soft-tissue injury. However, the majority of tibial shaft
fractures are caused by a lower energy mechanism, and
are associated with a less severe soft-tissue injury. Operative treatment of such fractures usually produces
good results, but cast or brace treatment also produces
Correspondence to: CGM.Tel: +44 (0)115 924 9924 ext 43368; Fax: +44
(0)115 875 4556; E-mail: sushrut@india.com

good results in the majority of these more favourable injuries.1, 2

To date, there has been no randomised, controlled
trial of operative vs non-operative treatment of tibial
shaft fractures with sucient follow-up to test the
hypothesis that operative treatment results in less longterm impairment of joint function. A recent meta-analysis concluded that insucient data exist in the literature
to evaluate any aspect of patient-reported outcome with
dierent treatments.3 In each individual patient, it is important to make a balanced assessment of the risks and
the benets of operative vs non-operative treatment in
order to formulate a treatment plan.The purpose of this
article is to review the long-term complications of tibial
shaft fractures, and to examine how this may be aected
by the original injury and the subsequent treatment.

OSTEOARTHRITIS AND IMPAIRED

JOINT FUNCTION
Prevalence of osteoarthritis and functional
impairment after tibial shaft fracture
Thirty years after a tibial shaft fracture, 34% of subjects
have radiographic osteoarthritis of the ipsilateral knee,
and 5% have sucient knee pain and functional impairment to warrant consideration of knee replacement surgery.4 However, osteoarthritis aects the ipsilateral and
contralateral knees with equal frequency, and is no more
common in former tibial fracture patients than in the

THE LONG-TERM COMPLICATIONS OF TIBIAL SHAFT FRACTURES

201

general population. The commonest pattern of osteoarthritis is isolated patello-femoral disease. Many patients
with radiographic evidence of osteoarthritis report knee
pain and mild impairment of everyday physical activities.
The cause of osteoarthritis is multifactorial, including
genetic predisposition, direct injury to the knee, and abnormal loading as a result of injuries such as a meniscal
tear or anterior cruciate ligament rupture.The inuence
of tibial shaft fracture malunion on the development of
knee osteoarthritis remains uncertain.
Unlike the knee, there is a signicant excess of osteoarthritis of the ankle on the side of a previous tibial shaft
fracture. Ipsilateral ankle osteoarthritis aects around
10% of subjects,4 whereas contralateral ankle osteoarthritis is rare, and when present is almost always associated
with another injury such as fracture. Ankle osteoarthritis
is usually associated with pain and stiness, but symptoms
do not seem to have as much eect on function.
While ipsilateral subtalar osteoarthritis is seen in 6%
of subjects after a tibial shaft fracture, ipsilateral subtalar
stiness aects 32% of subjects.4 Operative xation of
tibial fractures, followed by early, non-weight-bearing
joint mobilisation may reduce the prevalence of subtalar
stiness.5

Malunion after tibial shaft fractures

There are four components to fracture malunion: angulation, rotation, translation and shortening. The coronal
and sagittal plane components of angular malunion can
be measured on the anteroposterior and lateral radiographs, respectively, but the true angle is almost always
greater than either of these values because the plane of
angulation lies somewhere between the two planesF
most commonly a combination of varus and recurvatum
(see Figs 1^3). Fracture angulation has a centre of rotation, which may or may not coincide with the centre of
the fracture. If translation is associated with angulation,
this has the eect of moving the centre of rotation proximally or distally with respect to the fracture site.The incidence of malunion after tibial shaft fractures varies
between studies, but in general is lower with operative
treatment than cast treatment (Table 1).
Operative treatment does not abolish malunion completely. Even with intramedullary nailing, angular malunion can be a problem particularly with proximal and
distal shaft fractures. Achieving correct length and rotational alignment at the time of surgery can also be dicult, particularly if there is severe comminution at the
fracture site.

Biomechanical eects of malunion

There is no consensus in the published literature on what
degree of malunion is signicant. Many authors have

Figure 1 Anteroposterior radiograph of a tibial fracture malunion taken 30 years after the original injury.The coronal plane
malunion measures 12.51 varus. The joints are well preserved,
and the patient reported no knee pain, ankle pain or functional
limitation.

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CURRENT ORTHOPAEDICS

Figure 2 Anteroposterior radiograph of a tibial shaft fracture

malunion taken 30 years after the injury.The fracture had been
plated, but there was a coronal plane malunion of 131 varus.
There was medical compartment osteoarthritis of the knee.

suggested arbitrarily values of 51 or 101 as the limits

of acceptable angulation.6 In the normal lower limb, the
knee centre lies slightly lateral to the hip ^ankle axis, so
that the lower limb alignment (HKA angle) averages 11
varus (normal range 51 valgus to 61 varus). A malunited
tibial fracture alters the HKA angle, and the change
in lower limb alignment depends not only on the size
of the malunion angle but also on its centre of
rotation. Proximal angulation has a greater eect than
distal angulation on overall lower limb alignment. A nomogram has been devised to illustrate this (Fig. 4). It can
be seen that a 101 coronal plane malunion of the distal
third of the tibia produces less than 21 change in overall
lower limb alignment. This may be insucient to move
alignment outside of the normal range. Studies have conrmed that static knee joint loading is aected by limb

Figure 3 Anterososterior radiograph of a midshafttibial shaft

fracture taken 30 years after the injury.The fracture has united
with 1.51 valgus angulation, and there is severe osteoarthritis of
the knee and ankle.

alignment,7 although the dynamic joint loading, which

occurs in real life, is clearly far more complex. In the absence of other factors that promote osteoarthritis, it
may be that the human knee is able to tolerate a small
amount of malalignment without any long-term deleterious eect.

THE LONG-TERM COMPLICATIONS OF TIBIAL SHAFT FRACTURES

203

Table 1 Incidence of malunion after tibial shaft fracture

Component of malunion
Coronal angulation
Sagittal angulation
Rotation
Shortening
Translation

451
4101
451
4101
4101
4201
410 mm
420 mm
433%

Non-operative treatment (%)

Operative treatment (%)

13^32
6^9
10^30
1^6
0^4
2
4^12
2^3
14

0^2
0
3
0^2
4^14
0
1
0
2

Figure 4 A nomogram to calculate the change in lower limb

alignmentdie to coronalplane tibial angulation at a particular site
in the tibia.

shaft fractures are not associated with an increased risk

of subsequent osteoarthritis of the knee, ankle or subtalar joints.This may be because most legs remain normally
aligned in spite of a malunited fracture. The cause of the
observed excess of ankle osteoarthritis on the side of
the fracture remains unclear. One possibility is a direct
injury to the ankle joint at the time of the tibial shaft
fracture, although this has not been proven.
The small number of patients who have lower limb
malalignment after a tibial fracture may have an increased risk of developing medial compartment osteoarthritis of the knee,4 although no study to date has had
sucient power to demonstrate statistical signicance.
However, there is a signicant association between
lower limb malalignment and ipsilateral subtalar stiness.4 Malalignment has also been shown to accelerate
the progression of established osteoarthritis of the
knee.13

Clinical studies of malunion and

malalignment

POSTPHLEBITIC LIMB

Several long-term follow-up studies of tibial fracture subjects have looked at the prevalence of osteoarthritis in
relation to malunion and other fracture factors.4, 8 ^12
Such studies have a number of limitations. With longterm follow-up, it becomes dicult to trace a good proportion of the original cohort, and this may result in a
biased sample. In addition, the number of subjects with
overall lower limb malalignment will be relatively small
because it is uncommon, even after cast treatment.
Comparisons in these circumstances may be subject to
type 2 statistical error (i.e. failure to show a statistically
signicant dierence when one does exist, owing to insucient subject numbers). With increasing subject age
at the time of follow-up, one would expect a parallel increase in the prevalence of idiopathic osteoarthritis of
susceptible joints such as the knees which might obscure
a small number of cases of osteoarthritis due to malunion, if such exist.
Overall, the published studies suggest that malunions
of the severity usually seen after cast treatment of tibial

The reported incidence of clinically apparent deep vein

thrombosis (DVT) after a tibial fracture is 1% in those
treated operatively.14 Venographic studies have shown a
DVT incidence of 45% after tibial fracture treated in
plaster,15 and an incidence of 77% in subjects with a tibial
fracture and an injury severity score of 9 points or higher.16 Hence, most DVTs after a tibial shaft fracture are
asymptomatic and will only be detected with venographic screening.
A DVT can damage the valves in the leg veins that normally prevent retrograde ow when the limb is dependent, resulting in chronic venous hypertension. This may
lead to postphlebitic changes.The clinical features of the
postphlebitic limb are aching, ankle swelling and supercial varicosities (stage I), progressing to brawny oedema
and hyperpigmentation (stage II) and eventually to varicose eczema and frank venous ulceration (stage III). A
follow-up study of subjects at a mean of 6.6 years after a
proven DVTshowed that the prevalence of postphlebitic
limb was 82% (46% stage I, 29% stage II and 7% stage III),

204

and this was more common in subjects with a calf thrombosis, those who were not adequately anticoagulated,
and those with recurrent thromboses.17
Postphlebitic limb is not recognised as a major problem by many orthopaedic surgeons, probably because
it tends to present years after the causal thrombosis,
and most frequently in vascular surgery or dermatology
clinics. Fractures of the femur and the tibia are said to be
associated with subsequent postphlebitic changes in approximately 50% of subjects where no antithrombotic
prophylaxis is given,18 although the majority would probably be stage I and therefore not a cause of appreciable
morbidity. Signs and symptoms of postphlebitic limb may
not appear until more than15 years after a DVT, and this
means that it is hard to attribute them with certainty to
a previous tibial shaft fracture. Some subjects may have
developed a DVT for other, unrelated reasons. Thus, the
role of tibial shaft fractures in producing appreciable
long-term morbidity as a result of an associated DVT
may have been overstated.

LONG-TERM EFFECTS OF
COMPARTMENT SYNDROME
Compartment syndrome is anincreased pressure within
a closed fascial compartment causing local tissue ischaemia. The reported incidence of compartment syndrome
after a tibial shaft fracture is 1^9%, and tibial shaft fractures account for more cases of compartment syndrome
than any other injury. The type of fracture, and the
means by which it is treated, do not seem to aect
the incidence of compartment syndrome.19 Men under
the age of 35 years are at highest risk of developing
compartment syndrome after tibial shaft fracture.
In spite of heightened awareness of compartment syndrome, cases continue to be diagnosed late or missed altogether. Failure of early diagnosis and treatment of
acute compartment syndrome results in ischaemic muscle damage, which in turn may result in nerve damage,
renal failure, infection, amputation, or even death. Damaged muscle heals by brosis, causing shortening of
the musculo-tendinous unit.This may result in ankle stiness or cavus foot deformity with clawing of the toes,
depending on the compartments aected. Such deformities appear within the rst year after injury. Muscle damage associated with the tibial fracture itself will also
heal by brosis; it is important not to assume that the
presence of foot deformities after a tibial shaft fracture
means that a compartment syndrome must have been
missed.
In one series of tibial shaft fractures treated in casts,
6% of subjects at review had foot and ankle stiness, and
in one-third of these stiness was attributed to ischaemic muscle damage.20 The treatment of ischaemic contractures is dicult, although good functional results

CURRENT ORTHOPAEDICS

have been reported following lengthening of exor hallucis longus and exor digitorum longus for clawing of the
toes after a tibial fracture.21

CHRONIC INFECTION
The main determinant of infection after a tibial fracture
is whether or not the original injury was open or closed.
With closed fractures treated in plaster, the infection
rate is negligible. Operative treatment of closed fractures does result in a small but denite infection rate, in
the range 0 ^15% for AO plate xation and 0 ^1% for intramedullary nailing.3 The infection rate after open fractures depends on the severity of the soft-tissue injury.
Using the Gustilo and Anderson classication, infection
is seen after 0 ^2% of grade I injuries, 2^7% of grade II injuries, 7% of grade IIIa injuries, 10 ^50% of grade IIIb injuries and 25^50% of grade IIIc injuries.22 Plate xation of
open tibial fractures seems to give a higher rate of infection than intramedullary nailing or external xation.
Most infections after a tibial fracture are acute, respond to aggressive surgical treatment, and do not lead
to chronic bone infection. Overall, approximately 10% of
deep infections lead to chronic osteomyelitis. Treatment
of this is dicult, involving removal of infected metalwork, excision of dead bone, stable re-xation and antibiotics. Complex reconstructive procedures are often
necessary to treat the resulting bony and soft-tissue defects. If treatment for infection is unsuccessful, belowknee amputation may give the best functional outcome;
however, circular frame techniques have greatly increased the potential for limb salvage in these dicult
cases. Unresolved infection persisting for many years
has a small risk of amyloidosis.

LOCAL SYMPTOMS
Many patients report intermittent aching symptoms at
the site of a previous tibial shaft fracture, whether the
fracture has been treated by operative or non-operative
means. These symptoms probably lessen with time.
Symptoms seem to be worse when the weather is cold,
although the mechanism for this is not known.
Intramedullary nails have a more denite association
with local symptoms. Up to 40% of patients who have a
tibial nail inserted complain subsequently of anterior
knee pain, although this improves with time in half of
these patients. The use of a patellar tendon-splitting approach, and leaving the tibial nail proud of the bone are
two factors that may increase the incidence and severity
of anterior knee pain after tibial nailing. However, a wellburied nail inserted through a medial para-patellar approach still carries a risk of anterior knee pain, and only
about one-half of aected individuals will get better

THE LONG-TERM COMPLICATIONS OF TIBIAL SHAFT FRACTURES

following nail removal. Residual tenderness may be related to the presence of a scar on the front of the knee.

PRACTICE POINTS
K Tibial shaft fracture is associated with subsequent ankle osteoarthritis and subtalar stiness of unknown cause
K Angular malunion which does not cause overall lower limb
malalignment does not have a deleterious eect
K Asymptomatic deep vein thrombosis after a tibial shaft fracture is one possible cause of postphlebitic limb many years
later
K Inadequate treatment of acute compartment syndrome
after a tibial shaft fracture results in foot and ankle stiness
and deformities
K Persistent infection after tibial xation carries a risk of amputation

RESEARCH DIRECTIONS
K Long-term follow-up study of young adults to dene the
range of lower limb alignment that can be tolerated without leading to osteoarthritis
K Elucidation of the mechanism by which tibial shaft fractures
lead to ankle osteoarthritis
K Ecacy of strategies to prevent deep vein thrombosis on
the long-term prevalence of postphlebitic limb

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