Introduction: Paediatric tibial fractures, unlike femoral fractures do not have much potential for overgrowth. In simple factures of the tibial shaft treated non-operatively the major problems are shortening and malunion.

In complex injuries with extensive soft tissue disruption and bone loss, the long-term aim of reconstruction is to achieve union with a fully functional limb without limb-length inequality.

Methods: Four children who sustained high-energy grade III open fractures of the tibia were treated with acute shortening and bone transport. Any soft tissue reconstructive and secondary grafting procedures for delayed union were recorded. The children were prospectively followed up to fracture union. Distraction ostegenesis proceeded until limb length equality was achieved and the regenerate allowed to consolidate.

Discussion: Despite achieving equal limb lengths at the end of distraction osteogenesis the injured tibia overgrew by 1–2cm at three years post injury. This would suggest that even in the presence of extensive soft tissue trauma, as seen in these high energy injuries, the increased blood flow associated with metaphyseal corticotomy stimulates epiphyseal activity resulting in overgrowth. The value of stopping adjustments just short of achieving limb length equality to allow for expected overgrowth in the injured tibia merits further investigation.