Executive Editor: Peter Trafton

Authors: Raymond White, Matthew Camuso

Tibial shaft Multifragmentary frature, intact segmental

back to skeleton

Glossary

General considerations

42-C2

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
Risks of surgery exceed benefits Basic surgical experience, no specialized skills Basic equipment only

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
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 - Compression plating
Main indication Skill Equipment
Proximal or distal fractures; alternative to IM nail Highly experienced and skilled surgeon Full specialized surgical and imaging resources

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 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 - Compression plating
Main indication Skill Equipment
Transverse or short oblique fracture patterns, unable to reduce closed Some specialized surgical experience Simple surgical and imaging resources

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 Some specialized surgical experience Simple surgical and imaging resources

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
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