Tibial shaft fractures are a heterogeneous group of lesions, the treatment of which requires adequate knowledge of managing both soft tissues and bony injuries for optimal outcome. The incidence of tibial shaft fractures has been recently quoted around 16.9/100,000 year, with an incidence among males almost twice that in women. Surgical or conservative treatment should always turn to accurate soft tissue management to reduce wound problems and avoid infections, together with fracture management to stabilize the lower limb, aiming at fracture healing and restoring good function, possibly with a quick return to everyday activities. In order to achieve these goals, the vast majority of adult tibial shaft fractures are treated surgically. The gold standard has been intramedullary nailing for several years, and this is probably the best treatment for most patients and fractures, but there are still some patterns that can require a different approach. The authors' aim is to produce a simple 10-step pathway that can be used as a decision making from the initial fracture pattern and soft tissue status evaluation in emergency department, passing across the choice of surgical or conservative treatment, to the final stage of tailoring the operative procedure.