Executive Editor: Peter Trafton

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

Distal tibia

back to skeleton

Glossary

Basic treatment techniques

Basic technique: Modular external fixation

Surgical procedures sorted by fracture type

Use this menu to jump directly into a specific classification (optional):
A1 A2 A3 B1 B2 B3 C1 C2 C3
A1

Extraarticular fractures, metaphyseal simple

Please select a treatment option:
Treatment Indication summary Skill Equipment
Nonoperative treatment; casting for definitive treatment Undisplaced stable closed fractures, patient's general condition unsuitable for surgery Basic surgical experience, no specialized skills Basic equipment only
Nonoperative treatment; traction (initial provisional stabilization) Significant local soft-tissue swelling, patients general condition satisfactory for maintained bed rest Basic surgical experience, no specialized skills Basic equipment only
Closed reduction; temporary joint-bridging modular external fixation Damage control, significant soft-tissue injury Some specialized surgical experience Simple surgical and imaging resources
Closed reduction; temporary joint-bridging triangular external fixation Damage control, significant soft-tissue injury Some specialized surgical experience Simple surgical and imaging resources
Closed reduction; hybrid external fixation Severe soft-tissue injury, unstable reducible fracture Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Closed reduction; full ring fixation (Ilizarov) Severe soft-tissue injury, unstable reducible fracture, optimal stability desired Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Closed reduction; intramedullary nailing (reamed) (MIPO) Adequate distal fragment, suitable entry site available, unstable fracture, segmental fracture, loss of closed reduction Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Closed reduction; compression plating (MIPO) Fracture with appropriate pattern, closed reduction possible soft-tissues suitable Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Open reduction; compression plating with or without lag screw Displaced, unstable fracture with appropriate pattern, soft-tissues suitable Highly experienced and skilled surgeon Simple surgical and imaging resources
A2

Extraarticular wedge fractures

Please select a treatment option:
Treatment Indication summary Skill Equipment
Nonoperative treatment; casting as initial temporary treatment Temporary splintage necessary, cast provides this adequately without compromising soft tissues Basic surgical experience, no specialized skills Basic equipment only
Nonoperative treatment; traction (initial provisional stabilization) Significant local soft-tissue swelling, patient's general condition satisfactory for maintained bed rest Basic surgical experience, no specialized skills Basic equipment only
Closed reduction; temporary joint-bridging modular external fixation Damage control, significant soft-tissue injury Some specialized surgical experience Simple surgical and imaging resources
Closed reduction; temporary joint-bridging triangular external fixation Damage control, significant soft-tissue injury Some specialized surgical experience Simple surgical and imaging resources
Closed reduction; hybrid external fixation Severe soft-tissue injury, unstable reducible fracture Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Closed reduction; full ring fixation (Ilizarov) Severe soft-tissue injury, unstable reducible fracture, optimal stability desired Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Closed reduction; intramedullary nailing (reamed) (MIPO) Adequate distal fragment, suitable entry site available, unstable fracture, segmental fracture, loss of closed reduction Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Closed reduction; bridge plating (MIPO) Fracture with appropriate pattern, closed reduction possible, soft-tissues suitable Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Open reduction; lag screw and protection plate fixation Displaced, unstable fracture with appropriate pattern, soft-tissues suitable Highly experienced and skilled surgeon Simple surgical and imaging resources
A3

Complex metaphyseal fractures

Please select a treatment option:
Treatment Indication summary Skill Equipment
Nonoperative treatment; casting as initial temporary treatment Temporary splintage necessary, cast provides this adequately without compromising soft tissues Basic surgical experience, no specialized skills Basic equipment only
Nonoperative treatment; traction (initial provisional stabilization) Significant local soft-tissue swelling, patient's general condition satisfactory for maintained bed rest Basic surgical experience, no specialized skills Basic equipment only
Closed reduction; temporary joint-bridging modular external fixation Damage control, significant soft-tissue injury Some specialized surgical experience Simple surgical and imaging resources
Closed reduction; temporary joint-bridging triangular external fixation Damage control, significant soft-tissue injury Some specialized surgical experience Simple surgical and imaging resources
Closed reduction; hybrid external fixation Severe soft-tissue injury, unstable reducible fracture Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Closed reduction; full ring fixation (Ilizarov) Severe soft-tissue injury, unstable reducible fracture, optimal stability desired Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Closed reduction; intramedullary nailing (reamed) (MIPO) Adequate distal fragment, suitable entry site available, unstable fracture, segmental fracture, loss of closed reduction Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Closed reduction; bridge plating of 43-A3.1/3.2 fractures (MIPO) Fracture with appropriate pattern, closed reduction possible, soft-tissues suitable Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Closed reduction; bridge plating of 43-A3.3 fracture (MIPO) Fracture with appropriate pattern, closed reduction possible, soft-tissues suitable Highly experienced and skilled surgeon Full specialized surgical and imaging resources
B1

Partial articular fractures – “pure split fractures"

Please select a treatment option:
Treatment Indication summary Skill Equipment
Nonoperative treatment; casting for definitive treatment Undisplaced stable closed fractures, patient's general condition unsuitable for surgery Basic surgical experience, no specialized skills Basic equipment only
Nonoperative treatment; traction (initial provisional stabilization) Significant local soft-tissue swelling, patients general condition satisfactory for maintained bed rest Basic surgical experience, no specialized skills Basic equipment only
Closed reduction; temporary joint-bridging modular external fixation Damage control, significant soft-tissue injury Some specialized surgical experience Simple surgical and imaging resources
Closed reduction; temporary joint-bridging triangular external fixation Damage control, significant soft-tissue injury Some specialized surgical experience Simple surgical and imaging resources
Open reduction; buttress plating and lag screws Articular surface deformity and incongruity, undisplaced, but unstable articular surface fracture Highly experienced and skilled surgeon Simple surgical and imaging resources
B2

Partial articular fractures – “split-depression fractures”

Please select a treatment option:
Treatment Indication summary Skill Equipment
Nonoperative treatment; casting as initial temporary treatment Temporary splintage necessary, cast provides this adequately without compromising soft tissues Basic surgical experience, no specialized skills Basic equipment only
Nonoperative treatment; traction (initial provisional stabilization) Significant local soft-tissue swelling, patients general condition satisfactory for maintained bed rest Basic surgical experience, no specialized skills Basic equipment only
Closed reduction; temporary joint-bridging modular external fixation Damage control, significant soft-tissue injury Some specialized surgical experience Simple surgical and imaging resources
Closed reduction; temporary joint-bridging triangular external fixation Damage control, significant soft-tissue injury Some specialized surgical experience Simple surgical and imaging resources
Open reduction; buttress plating and lag screws Articular surface deformity and incongruity Highly experienced and skilled surgeon Simple surgical and imaging resources
B3

Partial articular fracture, multifragmentary depression

Please select a treatment option:
Treatment Indication summary Skill Equipment
Nonoperative treatment; casting as initial temporary treatment Temporary splintage necessary, cast provides this adequately without compromising soft tissues Basic surgical experience, no specialized skills Basic equipment only
Nonoperative treatment; traction (initial provisional stabilization) Significant local soft-tissue swelling, patients general condition satisfactory for maintained bed rest Basic surgical experience, no specialized skills Basic equipment only
Closed reduction; temporary joint-bridging modular external fixation Damage control, significant soft-tissue injury Some specialized surgical experience Simple surgical and imaging resources
Closed reduction; temporary joint-bridging triangular external fixation Damage control, significant soft-tissue injury Some specialized surgical experience Simple surgical and imaging resources
Open reduction; plating and screws Articular surface deformity and incongruity Highly experienced and skilled surgeon Full specialized surgical and imaging resources
C1

Complete articular fracture, articular simple, metaphyseal simple

Please select a treatment option:
Treatment Indication summary Skill Equipment
Nonoperative treatment; casting as definitive treatment Undisplaced stable closed fractures, patient's general condition unsuitable for surgery Basic surgical experience, no specialized skills Basic equipment only
Nonoperative treatment; traction (initial provisional stabilization) Significant local soft-tissue swelling, patient's general condition satisfactory for maintained bed rest Basic surgical experience, no specialized skills Basic equipment only
Closed reduction; temporary joint-bridging modular external fixation Damage control, significant soft-tissue injury Some specialized surgical experience Simple surgical and imaging resources
Closed reduction; temporary joint-bridging triangular external fixation Damage control, significant soft-tissue injury Some specialized surgical experience Simple surgical and imaging resources
Closed reduction; hybrid external fixation Severe soft-tissue injury, unstable reducible fracture Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Closed reduction; full ring fixation (Ilizarov) Severe soft-tissue injury, unstable reducible fracture, optimal stability desired Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Closed reduction; intramedullary nailing (reamed) (MIPO) C1 distal tibial fracture with two large articular fragments that can be prepared for IM nailing after initial reduction and lag screw fixation, rarely indicated Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Open reduction; plating and screws Articular surface deformity and incongruity, best available treatment for most type C1 distal tibial fractures Highly experienced and skilled surgeon Simple surgical and imaging resources
C2

Complete articular fracture, articular simple, metaphyseal multifragmentary

Please select a treatment option:
Treatment Indication summary Skill Equipment
Nonoperative treatment; traction (initial provisional stabilization) Significant local soft-tissue swelling, patient's general condition satisfactory for maintained bed rest Basic surgical experience, no specialized skills Basic equipment only
Closed reduction; temporary joint-bridging modular external fixation Damage control, significant soft-tissue injury Some specialized surgical experience Simple surgical and imaging resources
Closed reduction; temporary joint-bridging triangular external fixation Damage control, significant soft-tissue injury Some specialized surgical experience Simple surgical and imaging resources
Open reduction; plating and screws Articular surface deformity and incongruity, best available treatment for type C2 distal tibial fractures Highly experienced and skilled surgeon Simple surgical and imaging resources
C3

Complete articular fractures, multifragmentary

Please select a treatment option:
Treatment Indication summary Skill Equipment
Nonoperative treatment; traction (initial provisional stabilization) Significant local soft-tissue swelling, patient's general condition satisfactory for maintained bed rest Basic surgical experience, no specialized skills Basic equipment only
Closed reduction; temporary joint-bridging modular external fixation Damage control, significant soft-tissue injury Some specialized surgical experience Simple surgical and imaging resources
Closed reduction; temporary joint-bridging triangular external fixation Damage control, significant soft-tissue injury Some specialized surgical experience Simple surgical and imaging resources
Open reduction; screws and plate fixation through anterolateral approach (complex) Deformity and instability of articular surface and metaphyseal zone. Satisfactory soft tissues. Fracture pattern and/or condition of soft tissues favors anterolateral approach, with additional intraarticular fragements addressed as necessary. Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Open reduction; screw and plate fixation through anterolateral approach (3-part) Deformity and instability of articular surface and metaphyseal zone. Satisfactory soft tissues. Fracture pattern and/or condition of soft tissues favors anterolateral approach. Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Open reduction; screws and plate fixation through anteromedial approach Deformity and instability of articular surface and metaphyseal zone. Satisfactory soft tissues. 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

v1.0 2016-11-22