Introduction: Closed and open grade I (low energy) tibial shaft fractures are a common and costly event and optimal management for such injuries remains uncertain.

Methods: We explored costs associated with treatment of low energy tibial fractures with either casting, casting with therapeutic ultrasound, or intramedullary nailing (with and without reaming) by use of a decision tree.

Results: From a governmental perspective the mean associated costs were USD $3 365 (standard deviation [SD] ± 1 425) for operative management by reamed intramedullary nailing, $5 041 (SD ± 1 363) for operative management by non-reamed intramedullary nailing, $5 017 (SD±1 370) for casting, and $5 312 (SD±1 474) for casting with therapeutic ultrasound. From a societal perspective the mean associated costs were ($12 449; SD±4 894) for reamed intramedullary nailing, ($13 266; SD±3 692) for casting with therapeutic ultrasound, ($15 571; SD±4 293) for operative management by non-reamed intramedullary nailing, and ($17 343; SD±4 784) for casting alone.

Interpretation: Our analysis suggests that, from an economical standpoint, reamed intramedullary nailing is the treatment of choice for closed and open grade I tibial shaft fractures. There is preliminary evidence, from a societal perspective, that treatment of low energy tibial fractures with therapeutic ultrasound and casting may also be an economically-sound intervention.