Executive Editor: Peter Trafton, Michael Baumgaertner

Authors: Martin Hessmann, Sean Nork, Christoph Sommer, Bruce Twaddle

Distal tibia

back to skeleton

Glossary

Basic treatment techniques

Basic technique: Modular external fixation

Extraarticular, simple fracture

Please select a treatment option:
Treatment Indication summary Skill Equipment
Nonoperative treatment - Definitive cast Undisplaced stable closed fractures, patient's general condition unsuitable for surgery Basic surgical experience, no specialized skills Basic equipment only
Nonoperative treatment - Temporary traction Significant local soft-tissue swelling, patient's general condition satisfactory for maintained bed rest Basic surgical experience, no specialized skills Basic equipment only
Temporary joint-bridging modular external fixation Fracture with significant injury or expected severe swelling Some specialized surgical experience Simple surgical and imaging resources
Temporary joint-bridging triangular external fixation Fracture with significant injury or expected severe swelling Some specialized surgical experience Simple surgical and imaging resources
Hybrid external fixation Severe soft-tissue injury, unstable reducible fracture Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Full ring external fixation (Ilizarov) Severe soft-tissue injury, unstable reducible fracture, optimal stability Highly experienced and skilled surgeon Full specialized surgical and imaging resources
MIO - Intramedullary nail Any unstable simple extraarticular fracture of sufficient length to allow for adequate distal locking Highly experienced and skilled surgeon Full specialized surgical and imaging resources
MIO - Compression plate Fracture with appropriate pattern, closed reduction possible, soft-tissues suitable Highly experienced and skilled surgeon Full specialized surgical and imaging resources
ORIF - Compression plate Displaced, unstable fracture with appropriate pattern, soft-tissues suitable Highly experienced and skilled surgeon Simple surgical and imaging resources

Extraarticular, wedge fracture

Please select a treatment option:
Treatment Indication summary Skill Equipment
Nonoperative treatment - Temporary cast Temporary splintage necessary, cast provides this adequately without compromising soft tissues Basic surgical experience, no specialized skills Basic equipment only
Nonoperative treatment - Temporary traction Significant local soft-tissue swelling, patient's general condition satisfactory for maintained bed rest Basic surgical experience, no specialized skills Basic equipment only
Temporary joint-bridging modular external fixation Fracture with significant injury or expected severe swelling Some specialized surgical experience Simple surgical and imaging resources
Temporary joint-bridging triangular external fixation Fracture with significant injury or expected severe swelling Some specialized surgical experience Simple surgical and imaging resources
Hybrid external fixation Severe soft-tissue injury, unstable reducible fracture Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Full ring external fixation (Ilizarov) Severe soft-tissue injury, unstable reducible fracture, optimal stability Highly experienced and skilled surgeon Full specialized surgical and imaging resources
MIO - Intramedullary nail Any unstable extraarticular fracture of sufficient length to allow for adequate distal locking Highly experienced and skilled surgeon Full specialized surgical and imaging resources
MIO - Bridge plate Displaced, unstable fracture where closed reduction is possible, soft-tissues suitable Highly experienced and skilled surgeon Full specialized surgical and imaging resources
ORIF - Lag screw and protection plate Displaced, unstable fracture, soft-tissues suitable Highly experienced and skilled surgeon Simple surgical and imaging resources

Extraarticular, multifragmentary fracture

Please select a treatment option:
Treatment Indication summary Skill Equipment
Nonoperative treatment - Temporary cast Temporary splintage necessary, cast provides this adequately without compromising soft tissues Basic surgical experience, no specialized skills Basic equipment only
Nonoperative treatment - Temporary traction Significant local soft-tissue swelling, patient's general condition satisfactory for maintained bed rest Basic surgical experience, no specialized skills Basic equipment only
Temporary joint-bridging modular external fixation Fracture with significant injury or expected severe swelling Some specialized surgical experience Simple surgical and imaging resources
Temporary joint-bridging triangular external fixation Fracture with significant injury or expected severe swelling Some specialized surgical experience Simple surgical and imaging resources
Hybrid external fixation Severe soft-tissue injury, unstable reducible fracture Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Full ring external fixation (Ilizarov) Severe soft-tissue injury, unstable reducible fracture, optimal stability desired Highly experienced and skilled surgeon Full specialized surgical and imaging resources
MIO - Intramedullary nail Any unstable extraarticular fracture of sufficient length to allow for adequate distal locking Highly experienced and skilled surgeon Full specialized surgical and imaging resources
MIO - Bridge plate Displaced, unstable fracture with closed reduction possible, soft-tissues suitable Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Partial articular, split fracture

Please select a treatment option:
Treatment Indication summary Skill Equipment
Nonoperative treatment - Definitive cast Undisplaced stable closed fractures, patient's general condition unsuitable for surgery Basic surgical experience, no specialized skills Basic equipment only
Nonoperative treatment - Temporary traction Significant local soft-tissue swelling, patients general condition satisfactory for maintained bed rest Basic surgical experience, no specialized skills Basic equipment only
Temporary joint-bridging modular external fixation Fracture with significant injury or expected severe swelling Some specialized surgical experience Simple surgical and imaging resources
Temporary joint-bridging triangular external fixation Fracture with significant injury or expected severe swelling Some specialized surgical experience Simple surgical and imaging resources
ORIF - Buttress plate and lag screws Articular surface deformity and incongruity, or undisplaced, but unstable articular surface fracture Highly experienced and skilled surgeon Simple surgical and imaging resources

Partial articular, split depression fracture

Please select a treatment option:
Treatment Indication summary Skill Equipment
Nonoperative treatment - Temporary cast Temporary splintage necessary, cast provides this adequately without compromising soft tissues Basic surgical experience, no specialized skills Basic equipment only
Nonoperative treatment - Temporary traction Significant local soft-tissue swelling, patients general condition satisfactory for maintained bed rest Basic surgical experience, no specialized skills Basic equipment only
Temporary joint-bridging modular external fixation Fracture with significant injury or expected severe swelling Some specialized surgical experience Simple surgical and imaging resources
Temporary joint-bridging triangular external fixation Fracture with significant injury or expected severe swelling Some specialized surgical experience Simple surgical and imaging resources
ORIF - Buttress plate and lag screws Articular surface deformity and incongruity Highly experienced and skilled surgeon Simple surgical and imaging resources

Partial articular, depression fracture

Please select a treatment option:
Treatment Indication summary Skill Equipment
Nonoperative treatment - Temporary cast Temporary splintage necessary, cast provides this adequately without compromising soft tissues Basic surgical experience, no specialized skills Basic equipment only
Nonoperative treatment - Temporary traction Significant local soft-tissue swelling, patients general condition satisfactory for maintained bed rest Basic surgical experience, no specialized skills Basic equipment only
Temporary joint-bridging modular external fixation Fracture with significant injury or expected severe swelling Some specialized surgical experience Simple surgical and imaging resources
Temporary joint-bridging triangular external fixation Fracture with significant injury or expected severe swelling Some specialized surgical experience Simple surgical and imaging resources
ORIF - Buttress plate and lag screws Articular surface deformity and incongruity Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Complete simple articular, simple metaphyseal fracture

Please select a treatment option:
Treatment Indication summary Skill Equipment
Nonoperative treatment - Definitive cast Undisplaced stable closed fractures, patient's general condition unsuitable for surgery Basic surgical experience, no specialized skills Basic equipment only
Nonoperative treatment - Temporary traction Significant local soft-tissue swelling, patient's general condition satisfactory for maintained bed rest Basic surgical experience, no specialized skills Basic equipment only
Temporary joint-bridging modular external fixation Fracture with significant injury or expected severe swelling Some specialized surgical experience Simple surgical and imaging resources
Temporary joint-bridging triangular external fixation Fracture with significant injury or expected severe swelling Some specialized surgical experience Simple surgical and imaging resources
Hybrid external fixation Severe soft-tissue injury, unstable reducible fracture Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Full ring external fixation (Ilizarov) Severe soft-tissue injury, unstable reducible fracture, optimal stability desired Highly experienced and skilled surgeon Full specialized surgical and imaging resources
MIO - Intramedullary nail Simple complete articular fracture with two large fragments that can be reduced and lagged to allow for interlocked IM nail placement, rarely indicated Highly experienced and skilled surgeon Full specialized surgical and imaging resources
ORIF - Plate and screws Articular surface deformity and incongruity Highly experienced and skilled surgeon Simple surgical and imaging resources

Complete simple articular, multifragmentary metaphyseal fracture

Please select a treatment option:
Treatment Indication summary Skill Equipment
Nonoperative treatment - Temporary traction Significant local soft-tissue swelling, patient's general condition satisfactory for maintained bed rest Basic surgical experience, no specialized skills Basic equipment only
Temporary joint-bridging modular external fixation Fracture with significant injury or expected severe swelling Some specialized surgical experience Simple surgical and imaging resources
Temporary joint-bridging triangular external fixation Fracture with significant injury or expected severe swelling Some specialized surgical experience Simple surgical and imaging resources
Hybrid external fixation Severe soft-tissue injury, unstable reducible fracture Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Full ring external fixation (Ilizarov) Severe soft-tissue injury, unstable reducible fracture, optimal stability desired Highly experienced and skilled surgeon Full specialized surgical and imaging resources
MIO - Intramedullary nail Complete articular fracture with two large articular fragments that can be reduced and lagged to allow for interlocked IM nailing placement, rarely indicated Highly experienced and skilled surgeon Full specialized surgical and imaging resources
ORIF - Plate and screws Articular surface deformity and incongruity Highly experienced and skilled surgeon Simple surgical and imaging resources

Complete, multifragmentary articular and metaphyseal fracture

Please select a treatment option:
Treatment Indication summary Skill Equipment
Nonoperative treatment - Temporary traction Significant local soft-tissue swelling, patient's general condition satisfactory for maintained bed rest Basic surgical experience, no specialized skills Basic equipment only
Temporary joint-bridging modular external fixation Fracture with significant injury or expected severe swelling Some specialized surgical experience Simple surgical and imaging resources
Temporary joint-bridging triangular external fixation Fracture with significant injury or expected severe swelling Some specialized surgical experience Simple surgical and imaging resources
ORIF - Plate and screws through anterolateral approach Deformity and instability of articular surface and metaphyseal zone. Fracture pattern and/or condition of soft tissues favors anterolateral approach Highly experienced and skilled surgeon Full specialized surgical and imaging resources
ORIF - Plate and screws through anteromedial approach Deformity and instability of articular surface and metaphyseal zone. Fracture pattern and/or condition of soft tissues favors anteromedial approach Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Special considerations

Principles of management of open fractures
Complications
Infection
Compartment syndrome
*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 2018-11-12