Executive Editor: Peter Trafton

Authors: Raymond White, Matthew Camuso

Tibial shaft Simple fracture, oblique

back to skeleton

Glossary

General considerations

42-A2

Oblique tibial shaft fractures tend to be higher energy injuries with increased risk of displacement if treated nonoperatively.

If the fibula is fractured, instability is greater, but varus angulation is less likely.

Nonoperative treatment is an option, if reduction is easily obtained and maintained. Operative fixation with closed nailing or occasionally plating is the best way to deal with malalignment. 

Nonoperative (casting)
Main indication Skill Equipment
Minimal displacement Basic surgical experience, no specialized skills Basic equipment only

Indications

  • Minimal displacement after reduction (less than 1cm shortening; < 5-10° angulation or rotation)
  • Risks of surgery and anesthesia exceed benefits

Contraindications

  • Open fractures
  • Excessive displacement on initial x-ray
  • Unacceptable alignment after initial reduction or developing later

Advantage

  • Surgical risks avoided

Disadvantages

  • Cast immobilization required until healed
  • 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
Short oblique fractures, especially proximal and distal Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Indications

  • 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
ORIF - Lag screws through protection plate
Main indication Skill Equipment
Oblique fractures oriented suitably and long enough for lag screw through plate Some specialized surgical experience Basic equipment only

Indications

  • Oblique fracture (>30°)
  • Fracture displacement and/or instability that requires surgical fixation
  • Fracture less suitable for IM nail fixation (distal, proximal, or difficult to reduce)

Contraindications

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

Advantages

  • Anatomical reduction easier with ORIF
  • Stability
  • 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
ORIF - Lag screws outside protection plate
Main indication Skill Equipment
Oblique fractures oriented suitably and long enough for lag screw outside plate Some specialized surgical experience Simple surgical and imaging resources

Indications

  • Oblique fracture (>30°)
  • Fracture displacement and/or instability that requires surgical fixation
  • Fracture less suitable for IM nail fixation (distal, proximal, or difficult to reduce)

Contraindications

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

Advantages

  • Anatomical reduction easier with ORIF
  • Stability
  • 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
ORIF - Compression plate with lag screw
Main indication Skill Equipment
Oblique fracture configuration suitable for use of a compression plate with added lag screw Some specialized surgical experience Simple surgical and imaging resources

Indications

  • Oblique fracture configuration suitable for use of a compression plate with added lag screw
  • Displaced and/or unstable fracture
  • If plate is preferred to IM nail

Contraindications

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

Advantages

  • Lag screw (optional) improves stability
  • Open reduction usually successful
  • Offers absolute stability
  • No fluoroscopy needed

Disadvantages

  • Requires fracture exposure
  • Requires good plating technique
  • Weight bearing should be delayed
  • Risk of 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