A series of 31 segmental tibial fractures is reported. Eighty-four percent of the patients sustained multiple trauma and 80% of these were open fractures. The series includes treatment with 20 external fixators, seven unreamed intramedullary nails, two casts, and two amputations. Complications included a 48% incidence of elevated compartment pressures necessitating fasciotomy. Despite rapid early decompression, there was a 19% incidence of residual motor and sensory deficit. Other complications observed were a 35% incidence of wound infection, nonunion, and malunion. Eighty-one percent of delayed or nonunions occurred at the distal fracture site. Intramedullary nailing produced the fewest complications. The segmental tibial fracture is at high risk for complications. Close observation of the limb for high compartment pressures is advisable. Treatment for compartment syndrome includes prompt decompression and stabilization of the fracture and, as indicated, intramedullary rods without preliminary reaming.