General considerations

Intact segmental fractures usually have fracture planes which are transverse or short oblique. Associated fibular fractures are common. These are high energy injuries with significant soft-tissue damage. Whether closed or open, there is an elevated risk of compartment syndrome, skin envelope damage, and nerve or vessel injury.
These are unstable injuries, which are usually considered as good candidates for operative treatment, but the possibility of skin and subcutaneous tissue damage may require delay or modified operative approach. Intramedullary nailing or minimally invasive plating, or even initial external fixation are generally preferred to an extensive open procedure. If intramedullary nailing is chosen, take care to ream the intermediate segment gently, to preserve soft- tissue attachments.
Bridge plating is applicable to all multifragmented long-bone fractures where intramedullary nailing or conventional plate fixation is not suitable.
These fractures have a significant risk of delayed or non-union, with deformity, if they are treated nonoperatively. Surgical fixation is thus preferred, unless its risks are excessive. Temporary external fixation can maintain length to aid delayed reduction and fixation, as well as provide stability.
Nonoperative (casting) | ||
Main indication | Skill | Equipment |
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Risks of surgery exceed benefits | ![]() |
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Indications
- Risks of surgery exceed benefits
- Acceptable alignment after reduction
Contraindications
- Open fractures
- Unacceptable alignment after initial reduction or developing later
- Soft-tissue condition
- Operative treatment available and acceptable
Advantage
- Surgical risks avoided
Disadvantages
- Risk of secondary displacement
- Cast immobilization required until healed (intact segmental fractures heal slowly, especially if initial displacement is severe)
- Increased follow-up exams and x-rays•
Modular external fixator | ||
Main indication | Skill | Equipment |
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Soft-tissue compromise, limited resources, urgency | ![]() |
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The modular external fixator is optimal for temporary use. It is rapidly applied without need for intraoperative x-rays and can be adjusted later. It allows the surgeon to reduce the fracture by manipulation and to hold the reduction.
Further indications
- Open fractures involving bone loss
- Compartment syndrome (after or before fasciotomy)
- Local or systemic contraindications to internal fixation
Advantages
- Allows for subsequent definitive fixation
- Free pin placement to avoid nerves, vessels, or damaged soft-tissues
- Useful for stabilizing open fractures
- Good option in situations with risk of infection
- Requires less experience and surgical skill than standard ORIF
Disadvantages
- Pin-track infection (increases over time)
- Healing time may be prolonged
- Cumbersome and not always well tolerated
Uniplanar external fixator | ||
Main indication | Skill | Equipment |
---|---|---|
Definitive external fixation | ![]() |
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When external fixation is used for definitive treatment of a fracture, it may be useful to do this with a uniplanar fixator. It requires anatomical reduction and precise application.
The advantage is that fewer clamps and rods have to be used than in the application of a modular external fixator. The disadvantage, however, is that the reduction cannot be corrected after two pins have been placed in each fragment. In order to adjust the position, the single rod must be exchanged for a modular external fixator with multiple rods.
Further indication
- Local or systemic contraindications to internal fixation
Contraindication
- Only temporary external fixation is needed (modular external fixation preferred)
Advantage
- More stable than modular external fixation
Disadvantages
- Accurate reduction required before application of the fixator
- C-arm required for reliable application
- Pin-track infection (increases over time)
- Risk of nerve / vascular injury
- Healing time may be prolonged
- Fixator remains until fracture is healed
- Cumbersome and not always well tolerated
Ring fixator (Ilizarov) | ||
Main indication | Skill | Equipment |
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Significant bone loss; definitive treatment | ![]() |
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Indications
- Bone loss
- Late presentation with deformity
- Need for surgical stabilization (potentially adjustable)
- Local or systemic contraindications to internal fixation
Contraindication
- Patient can be treated safely with internal fixation
Advantages
- Definitive minimally invasive surgical stabilization
- Offers options for reconstruction of bone loss and/or deformity
Disadvantages
- Highly complex, requires experience
- Pin-track infection
- Reduction adjustment may be difficult
- X-ray imaging difficult with complex frame
Intramedullary nailing | ||
Main indication | Skill | Equipment |
---|---|---|
Any diaphyseal fracture with a normal medullary canal | ![]() |
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Indications
- Any tibial diaphyseal fracture with a normal medullary canal and sufficient length of end segments
- Need for surgical stabilization
Contraindications
- Deformed medullary canal (old fracture; hardware)
- Risks of surgery and anesthesia exceed benefits
- Medullary infection (late presentation)
- Proximal or distal fracture compromising IM nail use
- Lack of appropriate nail size and configuration
Advantages
- Good stability and durability
- Little damage to soft-tissue envelope
- Early weight bearing and rehabilitation are often possible
Disadvantages
- Requires appropriate equipment
- Requires experienced surgeon
- Technical difficulties with proximal and distal fractures
MIO - Compression plating | ||
Main indication | Skill | Equipment |
---|---|---|
Proximal or distal fractures; alternative to IM nail | ![]() |
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Indications
- Proximal and distal fractures
- If intramedullary nailing is contraindicated
- Displaced and/or unstable fracture
- Closed reduction possible
Contraindications
- Inability to do closed reduction (may need to open)
- Risks of surgery and anesthesia exceed benefits
Advantages
- Offers absolute stability
- Limited surgical trauma
Disadvantages
- Requires accurate reduction
- Might injure overlying skin envelope
- Demanding procedure
- Weight bearing should be delayed
MIO - Bridge plating | ||
Main indication | Skill | Equipment |
---|---|---|
Reducible intact segmental fracture with suitable soft tissues; If bridge plating is preferred to IM nailing | ![]() |
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Indications
- Minimally invasive reduction is possible
- Soft tissues overlying plate are healthy
- Displaced and/or unstable fracture
- If bridge plating is preferred to IM nailing
Contraindications
- Irreducible fractures
- Poor soft-tissue condition
- Risks of surgery and anesthesia exceed benefits
- Lack of proper equipment
Advantages
- Limited surgical trauma
- Fixation with relative stability
- May be advantageous for fracture healing
Disadvantages
- Requires accurate reduction
- Might injure overlying skin envelope
- Demanding procedure
- Weight bearing should be delayed
- Risk of delayed or nonunion
ORIF - Compression plating | ||
Main indication | Skill | Equipment |
---|---|---|
Transverse or short oblique fracture patterns, unable to reduce closed | ![]() |
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Indications
- Transverse or short oblique fracture patterns at one or both levels
- Inability to reduce closed
- Displaced and/or unstable fracture
- If plate is preferred to IM nail
- Lack of instruments, implants, image intensifier, and/or experience for CRIF
Contraindications
- Risks of surgery and anesthesia exceed benefits
- Poor soft-tissue condition
- IM nailing is feasible and available
Advantages
- Open reduction usually successful
- Lag screw (optional) improves stability
- Absolute stability may be possible
- No fluoroscopy needed
Disadvantages
- Risk of infection or impaired wound healing
- Requires fracture exposure
- Requires good plating technique
- Weight bearing should be delayed
ORIF - Lag screws with protection plate | ||
Main indication | Skill | Equipment |
---|---|---|
One or both fracture planes suitable for insertion of lag screw with plate | ![]() |
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Indications
- Segmental tibia fracture with at least one level suitable for a lag screw (oblique fracture at least 30°)
- Fracture displacement and/or instability that requires surgical fixation
- Fracture less suitable for IM nail fixation
- Lack of instruments, implants, image intensifier, and/or experience for CRIF
Contraindications
- Poor soft-tissue condition
- Risks of surgery and anesthesia exceed benefits
Advantages
- Anatomical reduction easier with ORIF
- Internal fixation possible with more limited resources
- No fluoroscopy needed
Disadvantages
- Requires anatomical reduction
- Risk of infection or fixation failure
- Weight bearing should be delayed
- Lag screw placement may be limited by fracture configuration
*Skill | |
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Basic surgical experience, no specialized skills |
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Some specialized surgical experience |
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Highly experienced and skilled surgeon |
*Equipment | |
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Basic equipment only |
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Simple surgical and imaging resources |
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Full specialized surgical and imaging resources |