44=OutcomesThe prognosis after tibial fracture depends on the extent of bone and soft tissue damage. Most low-energy closed tibial fractures achieve union by 10 to 13 weeks. High energy fractures often can require as much as 20 weeks to achieve union 20. The expected union rate for tibial diaphyseal fractures (in the absence of extensive soft tissue damage) is approximately 95% or greater 16. Even among patients with high-energy tibial fractures, 76% who were working at the time of injury eventually returned to work in an average of 11 months 2. Despite high general healing rates and good return to function,tibial shaft fractures still pose a surgical challenge. Complications of closed tibial shaft fractures include vascular injury, fat embolism, and compartment syndrome. Two studies reported rates of compartment syndrome in AO Type A fractures from 5.8% to 15.6%, in Type B from 11.4% to 16.7%, and in Type C from 9.6% to 28.6% 1, 13. Infection is a rare complication in closed fractures, with an incidence less than 1% 19. Intramedullary fixation generally is well tolerated, but can be complicated by nonunion, malunion, and implant failure 4. Anterior knee pain is not uncommon after tibial nailing 5, an observation that should be conveyed to the patient early during treatment. Although the exact cause of knee pain is unknown, it can lead to substantial functional impairment. In one study, 33.7% of patients reported pain at rest, 57% with running, and 92% with kneeling 5.=44 20. Skoog A, Soderqvist A, Tornkvist H, Ponzer S. One year outcome after tibial fractures: results of a prospective fracture registry. J Orthop Trauma. 2001;15:210–215. 16. Sarmiento A, Sharpe FE, Ebramzadeh E, Normand P, Shankwiler J. Factors influencing the outcome of closed tibial fractures treated with functional bracing. Clin Orthop Relat Res. 1995;315:8–24. 2. Arangio GA, Lehr S, Reed JF 3rd. Reemployment of patients with surgical salvage of open, high-energy tibial fractures: an outcome study. J Trauma. 1997;42:942–945. 1. Al-Dadah OQ, Darrah C, Cooper A, Donell ST, Patel AD. Continuous compartment pressure monitoring vs. clinical monitoring in tibial diaphyseal fractures. Injury. 2008;39:1204–1209 13. Park S, Ahn J, Gee AO, Kuntz AF, Esterhai JL. Compartment syndrome in tibial fractures. J Orthop Trauma. 2009;23:514–518. 19. Shuler FD, Obremskey WT. Tibial shaft fractures. In: Stannard JP, Schmidt AH, Kregor PJ, eds. Surgical Treatment of Orthopaedic Trauma. New York, NY: Thieme; 2007:742–66. 4. Cannada LK, Anglen JO, Archdeacon MT, Herscovici D Jr, Ostrum RF. Avoiding complications in the care of fractures of the tibia. J Bone Joint Surg Am. 2008;90:1760–1768. 5. Court-Brown CM, Gustilo T, Shaw AD. Knee pain after intramedullary tibial nailing: its incidence, etiology, and outcome. J Orthop Trauma. 1997;11:103–105. 62=Medical problems such as cardiopulmonary disease, vascular disease, and immune disorders need to be considered as well as social factors such as addiction and homelessness. Factors that have been shown to affect the outcome of fracture treatment include multiple medical problems. Cardiopulmonary problems may delay mobilization, metabolic problems such as diabetes affect healing and increase the risk of infection,4 and vascular disease in the extremities slows healing of bone and soft tissue. Osteoporotic bone is associated with implant failures. Altered immune states and poor nutrition can lead to wound breakdown and secondary infection.5 Neurologic problems such as paralysis slow ambulation, an aid to healing. Psychiatric diseases may result in decreased patient compliance.6 Social factors also affect outcome. Use of tobacco slows fracture healing.7,8=62 4. Kwon PT, Rahman SS, Kim DM, Kopman JA, Karimbux NY, Fiorellini JP. Maintenance of osseointegration utilizing insulin therapy in a diabetic rat model. J Peridontol 2005;76:621–6.5. Patel GK. The role of nutrition in the management of lower extremity wounds. Int J Low Extrem Wounds 2005;4:12–22.6. Karlstrom G, Olerud S. The management of tibial fractures in alcoholics and mentally disturbed patients. J Bone Joint Surg Br 1974;56:730–4.7. Castillo R, Bose M, MacKenzie E, Patterson B. The impact of smoking on fracture healing and risk of complications in limbthreatening open tibial fractures. J Orthop Trauma 2005;19:151–7.8. Gullihorn L, Karpman R, Lippiello L. Differential effects of nicotine and smoke condensate on bone cell metabolic activity. J Orthop Trauma 2005;19:17–22.