Executive Editor: Ernst Raaymakers, Joseph Schatzker, Rick Buckley

Authors: Matthias Hansen, Rodrigo Pesantez

Proximal tibia Extraarticular fracture, metaphyseal wedge or multifragmentary

back to skeleton

Glossary

General considerations

41-A3

This fracture type is an indication of high energy trauma and soft tissue damage is the rule. Therefore expect marked swelling and delay the definitive procedure to avoid soft tissue complications.

While awaiting definitive treatment, it is best to provide temporary fixation with a bridging anterior external fixator frame.

Nonoperative treatment
Indication summary Skill Equipment
Undisplaced or minimally displaced, stable Basic surgical experience, no specialized skills Basic equipment only

Indications

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

Contraindication

  • Severe soft-tissue damage
  • Severe obesity
  • Open injury

Advantage

  • No risks of surgery

Note: The fracture is usually displaced as it is usually high velocity and there is no place for a hinged brace. The brace is usually only a temporizing measure.

Bridging external fixator (temporary)
Indication summary Skill Equipment
Provisional means of fixation in severely traumatized patients Some specialized surgical experience Simple surgical and imaging resources

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

Indications

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

Contraindication

  • Extreme osteoporosis

Advantages

  • Provides temporary immobilization of the fracture
  • Soft-tissue friendly
  • Fast procedure
  • Also important for use with polytraumatized patients

Disadvantages

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

Non-bridging external fixator (definitive)
Indication summary Skill Equipment
Sufficiently large fragment and the fracture does not communicate with the joint Some specialized surgical experience Simple surgical and imaging resources

Nonbridging external fixation is a means of definitive treatment.


Indications

  • Severe soft-tissue compromise
  • Proximal fragment sufficiently large
  • Fracture does not communicate with the joint
  • Austere environments

Contraindication

  • Extreme osteoporosis

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

Indications

  • Open fractures
  • Severe soft-tissue compromise, not permitting definitive internal fixation
  • Non compliant patients

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 fixation (definitive)
Indication summary Skill Equipment
Severe soft-tissue injury or bone loss 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
Displaced/unstable, short proximal fragment, open fractures, intact fibula, compartment syndrome, osteoporosis Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Indications

  • Open fractures
  • Displaced/ unstable fracture
  • Intact fibula
  • Closed fractures with compromised soft- tissue envelope
  • Osteoporosis
  • Short proximal fragment
  • Compartment syndrome

Contraindications

  • Severe open and contaminated wound
  • Medical co-morbidities

Advantages

  • Less traumatic to soft-tissue
  • 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 - Plates without angular stability
Indication summary Skill Equipment
Displaced/unstable, good soft tissues, good bone quality, compartment syndrome Highly experienced and skilled surgeon Simple surgical and imaging resources

Indications

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

Contraindications

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

Advantage

  • Stable internal fixation

Disadvantages

  • Soft-tissue dissection
  • Devitalization of bone
  • Large skin incision
  • Surgical risks
  • May necessitate a second plate to obtain stability
*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