After studying the anatomy of the lower limbs of fresh cadavers, Nelson and Kelly [
20,
21] proposed that the blood supply to the tibia can be divided into three parts; the epiphyseal artery, nutrient artery, and periosteal artery. After entering the medullary cavity, the nutrient artery is divided into ascending and descending medullary artery trunks. The branches of the medullary artery near the inner surface of the bone cortex enter into the bone cortex [
22]. Part of the capillary network radiating from the ascending and descending branches can pass through the bone cortex, and anastomose with the capillaries of the periosteal artery [
23]. In the current study the structure of ascending and descending medullary arteries in pig tibia was similar to that in humans. The peripheral branches entered the bone cortex, and some of them penetrated the bone cortex and anastomosed with the periosteal artery to form a circular structure. The nutrient artery plays an important role in the blood supply of the tibial shaft. Levack et al. [
24] performed quantitative magnetic resonance imaging (MRI) of 8 fresh frozen lower limbs and confirmed that the bone cortical area of the tibial shaft was dominated by intraosseous blood supply. If the intraosseous blood vessels are injured, the probability of nonunion after fracture is increased. At present, the commonly used clinical tibial fracture fixation instruments can easily cause damage to intraosseous blood vessels. According to a retrospective study of 105 patients with tibial fractures treated with external fixators by Almansour et al. [
25], at least 38% of the patients had damaged tibial nutrient arteries, which may be conservative given that damage to the nutrient arteries itself cannot be detected by computed tomography. This view is also supported by Brinker et al. [
26], who reported a similar situation in patients treated with tibial intramedullary nailing. After recognition of the importance of blood supply for fracture healing, existing instruments have been redesigned to avoid damaging intraosseous blood vessels during implantation; but in practice, considering factors such as operation time and firm fixation of the fracture, surgeons still tend to use methods they are familiar with in an effort to avoid intra-operative complications. There is now a consensus among most surgeons that retaining the residual periosteum as much as possible during the operation is desirable [
27], but it is difficult to popularize and implement the concept of protecting intraosseous vessels.