Executive Editor: Ernst Raaymakers, Joseph Schatzker, Rick Buckley

Authors: Matthias Hansen, Rodrigo Pesantez

Proximal tibia Complete articular fracture, simple aricular, multifragmentary metaphyseal

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Glossary

General considerations

41-C2

Complete articular fractures, articular simple and metaphyseal multifragmentary. Angular stable fixation is of considerable help in the treatment of these fractures because of their metaphyseal and diaphyseal extension.
Intraarticular fractures should not be immobilized except as a temporizing measure prior to definite surgical treatment.

 

Nonoperative treatment
Indication summary Skill Equipment
Undisplaced/stable, medical compromise, initial temporary splintage, marked osteoporosis Basic surgical experience, no specialized skills Basic equipment only

Nonoperative treatment is only advised as a temporizing measure in these fractures.

Indications

  • Undisplaced or minimally displaced, and stable
  • Patient who cannot tolerate surgery
  • Elderly patient

Contraindication

  • Open injury

Advantage

  • No risks of surgery
Bridging external fixator (temporary)
Indication summary Skill Equipment
Provisional means of fixation in severely traumatized patients Basic surgical experience, no specialized skills Basic equipment only

The main indication for a bridging external fixation is to provide temporary immobilization of the fracture.

Indications

  • Open fractures with severe contamination
  • Joint instability
  • Polytrauma
  • Severe soft-tissue compromise
  • Serious medical co-morbidity

Contraindication

  • Extreme osteoporosis

Advantages

  • Provides temporary immobilization of the fracture
  • Soft-tissue friendly
  • Fast procedure

Disadvantages

  • Bridging of the joint
  • Risk of pin-track infection
  • Risk of muscle scarring
  • Risk of knee stiffness

Hybrid external fixator (definitive)
Indication summary Skill Equipment
Severe open fracture Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Indications

  • Open fractures
  • Major joint instability
  • Severe soft-tissue compromise, not permitting definitive internal fixation
  • Non compliant patient

Note: If the soft tissue envelope prevents conversion to stable internal fixation, the fracture can be treated by changing the hybrid to a double ring fixator until union.


 

Ring external fixator (definitive)
Indication summary Skill Equipment
Severe open fracture Highly experienced and skilled surgeon Full specialized surgical and imaging resources
This is a technically demanding procedure because of the anatomical situation. It should therefore be considered only if no other method is available.

Indications

  • Severe open fracture, particulary with bone loss
  • Fracture with loss of soft tissue cover

Contraindication

  • Stable internal fixation is possible

MIO - Angular stable plate (LISS)
Indication summary Skill Equipment
Simple articular fractures, osteoporosis, minimal soft-tissue compromise, surgeon's preference Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Conventional plating of the major diaphyseal component of these fractures is contraindicated because it requires open direct reduction. Minimally invasive plate osteosynthesis with the aid of plates with locking screws is much less traumatizing to the soft tissue envelope and is therefore the method of choice.

Indications

  • Open fractures
  • Articular, displaced/ unstable fracture
  • Closed fractures with compromised soft- tissue envelope
  • Osteoporosis
  • Compartment syndrome

Contraindications

  • Severe open and contaminated wound
  • Medical co-morbidities

Advantages

  • Less traumatic to soft-tissue
  • Buttress fixation of the metaphysis and bridge plating of the diaphyseal extension which will prevent subsequent displacement and angular deformity
  • Stable
  • Does not require anatomic reduction
  • Minimally invasive surgery
  • Restoration of the correct mechanical axis

Disadvantages

  • Risk of neural  trauma with plating
  • Technically demanding
  • Cost
  • Requires intraoperative imaging
  • Use of complex equipment
  • Difficult to obtain and maintain the reduction
  • Surgical risks
ORIF - Conventional plates
Indication summary Skill Equipment
All displaced operable fractures; knee instability, open fractures, compartment syndrome Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Conventional plating of the major diaphyseal component of these fractures is contraindicated because it requires open direct reduction. Minimally invasive plate osteosynthesis with the aid of plates with locking screws is much less traumatizing to the soft tissue envelope and is therefore the method of choice.

Indications

  • Open fractures
  • Displaced/ unstable fracture
  • Unstable knee
  • Good soft-tissue envelope
  • Good bone quality
  • Compartment syndrome

Contraindications

  • Severe soft-tissue damage
  • Open fracture with severe contamination
  • Several serious medical co-morbidities
  • Extreme osteoporosis

Advantages

  • Open direct anatomical reduction of articular surface
  • Buttress fixation of the metaphysis and bridge plating of the diaphyseal extension which will prevent subsequent displacement and angular deformity
  • Stable internal fixation
  • Stable fixation promotes articular cartilage healing
  • Immediate functional after-treatment
  • Compression osteosynthesis

Disadvantages

  • Soft-tissue dissection
  • Devitalization of bone
  • Large skin incision
  • Surgical risks
*Skill
Basic surgical experience, no specialized skills Basic surgical experience, no specialized skills
Some specialized surgical experience Some specialized surgical experience
Highly experienced and skilled surgeon Highly experienced and skilled surgeon
*Equipment
Basic equipment only Basic equipment only
Simple surgical and imaging resources Simple surgical and imaging resources
Full specialized surgical and imaging resources Full specialized surgical and imaging resources

v2.0 2010-05-15