Executive Editor: Peter Trafton

Authors: Raymond White, Matthew Camuso

Tibial shaft Wedge fracture, intact wedge

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Glossary

General considerations

42-B2

Fractures sustained by bending injuries tend to require more energy than those caused by twisting injuries, and also tend to be associated with more soft tissue damage. Bending injuries cause more transverse wedge fragments, twisting injuries result in a more spiral wedge configuration. In addition, the longer fractures have a greater surface area. For these reasons, fractures with a more transverse configuration are more likely to have more problems with healing and are likely to benefit from operative treatment with closed intramedullary nailing, or possibly plate fixation.

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

Nonoperative (casting)
Main indication Skill Equipment
Satisfactory reduction; risks of surgery exceed benefits Basic surgical experience, no specialized skills Basic equipment only

Indications

  • Satisfactory reduction
  • Risks of surgery exceed benefits

Contraindications

  • Open fractures
  • Unacceptable alignment after initial reduction or developing later
  • Excessive shortening
  • Soft-tissue condition

Advantage

  • Surgical risks avoided

Disadvantages

  • Risk of secondary displacement
  • Cast immobilization required until healed (less oblique fractures tend to heal more 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 - Bridge plating
Main indication Skill Equipment
Reducible intact wedge 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 - Lag screws with protection plate
Main indication Skill Equipment
Fracture geometry suitable for insertion of lag screw with plate Some specialized surgical experience Simple surgical and imaging resources

Indications

  • Fracture displacement and/or instability that requires surgical fixation
  • Fracture less suitable for IM nail fixation

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
ORIF - Compression plating
Main indication Skill Equipment
Intact wedge fractures where plating is preferable to IM nailing Some specialized surgical experience Basic equipment only

Indications

  • Intact wedge fractures where plating is preferable to IM nailing
  • Configuration suitable for use of a compression plate with added lag screw
  • Displaced and/or unstable fracture

Contraindications

  • Poor soft-tissue condition
  • Risks of surgery and anesthesia exceed benefits
  • Compression plating requires stabilization of the wedge fragment with a lag screw so that interfragmentary compression does not produce shortening

Advantages

  • Provides the most stable plate fixation, if the wedge fragment can be lagged successfully
  • Open reduction usually successful
  • 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