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Treatment of the fractured tibia by primary internal fixation is widely practiced but still controversial. There are fundamental principles applicable to the treatment of all fractures — rate and certainty of union, risk of functionally significant residual deformity, and functional result as objectively assessed by such measurable factors as joint stiffness, muscle power and working capacity. Against this must be set the hazards of surgery, not in the hands of the select few (the condition is too common for that) but in the hands of the average competent surgeon. In relation to the results of a prospective survey of 674 consecutive cases in adults treated conservatively, the fact emerges that no case has yet been made out for routine primary internal fixation, but there are certain “high risk” non-union cases in which it could be justified. In such circumstances, the fixation must be meticulous and rigid. There may be exceptional cases where it is justified on social or economic rather than scientific grounds. In general, 5 recognized indications for internal fixation are: open fractures requiring complicated plastic surgery; fracture of femur and other major injuries, paraplegia, segmental fractures with displaced central fragments; missing bone substance.