- BACKGROUND: Extra-articular proximal tibial fractures are often the result of high-energy trauma with displacement and comminution. Most authors agree that operative management of these fractures is warranted to optimize patient outcomes. It is unclear, however, which surgical option (plate, nail, external fixator, or combination) is preferable. (1-17) OBJECTIVE: To evaluate the effect of alternative operative techniques in the management of extra-articular proximal third tibial fractures on rates of nonunion, malunion, infection, compartment syndrome, and implant failure. HIGHEST AVAILABLE EVIDENCE: 1. Intramedullary nail (level 3 prospective case series). 2. Plates (level 3 prospective case series). 3. External fixator (level 4 case series). STUDY IDENTIFICATION: 1. Cochrane Database: 0 articles. 2. PubMed Search: Proximal tibial fractures: 568 hits; And external fixation: 69 hits; And plate: 103 hits; And intramedullary nail: 77 hits. Clinical queries search: proximal tibial fracture (specificity/therapy): 1 hit; proximal tibial fracture (sensitivity): 24 hits. Systematic reviews: 3 hits (none relevant). 3. OTA website abstract database: 8 abstracts. Total number potentially relevant articles: 29 (following review of all study titles and abstracts). Total number included after review: 17 (1-17) .