Executive Editor: Peter Trafton

Authors: Raymond White, Matthew Camuso

Tibial shaft Multifragmentary frature, fragmentary segmental

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Glossary

General considerations

42-C3

Fragmentary segmental fractures are very high energy injuries, often with associated fibular fractures and definitely with significant soft-tissue damage. Whether closed or open, there is a high risk of compartment syndrome, skin envelope injury, muscle crushing, 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. Soft-tissue attachments to the intercalary fragments are at least partially disrupted. Surgical treatment should make great effort to preserve the remaining soft-tissues and thus blood supply to the fracture site.

Bridge plating is applicable to all multifragmented long-bone fractures where intramedullary nailing or conventional plate fixation is not suitable.

Modular external fixator
Main indication Skill Equipment
Soft-tissue compromise, limited resources, urgency Basic surgical experience, no specialized skills Basic equipment only

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 Basic surgical experience, no specialized skills Basic equipment only

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
Significant bone loss; definitive treatment Some specialized surgical experience Simple surgical and imaging resources

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 Highly experienced and skilled surgeon Full specialized surgical and imaging resources

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 - Bridge plating
Main indication Skill Equipment
Reducible C3 fracture with suitable soft tissues; If bridge plating is preferred to IM nailing Highly experienced and skilled surgeon Full specialized surgical and imaging resources

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 - Bridge plating
Main indication Skill Equipment
Reducible fragmentary segmental fracture with suitable soft tissues; If bridge plating is preferred to IM nailing Highly experienced and skilled surgeon Simple surgical and imaging resources

Indications

  • Soft tissues overlying plate are healthy
  • Displaced and/or unstable fracture
  • If bridge plating is preferred to IM nailing or external fixation
  • Fracture fragments threatening overlying soft-tissues (in need of urgent reduction)
  • MIO equipment and skills not available

Contraindications

  • Poor soft-tissue condition
  • Risks of surgery and anesthesia exceed benefits
  • Lack of proper equipment

Advantages

  • With careful protection of soft-tissue attachments and use of indirect reduction techniques benefits of MIO may be approachable
  • Fixation with relative stability
  • May be better tolerated than an external fixator

Disadvantages

  • Risk of devascularizing fracture site, with impaired healing
  • Operative wound may have healing problems
  • Demanding procedure
  • Weight bearing should be delayed
  • Risk of delayed or nonunion and infection
*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 2012-05-13