Executive Editor: Ernst Raaymakers, Joseph Schatzker, Rick Buckley

Authors: Matthias Hansen, Rodrigo Pesantez

Proximal tibia Extraarticular fracture, metaphyseal wedge or multifragmentary

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1 Principles top


General consideration

In unstable fractures it is helpful to consider the tibia as having a medial and lateral column. A lateral plate on its own is often not sufficient, and the medial side may be supported by a posteromedial small fragment plate.


High degree of medial comminution

If there is a high degree of medial comminution combined with a bad soft-tissue injury do not use conventional plates. This is an indication for the use of the LISS locking plate.

If the LISS plate is unavailable to you then consider a lateral bridge plate plus a medial external fixator (temporary 6 weeks). The disadvantage of the external fixator is the risk of sepsis with the use of periarticular Schanz screws.

In these x-rays the position of the proximal Schanz screw is dangerously close to the joint. The preferred position for this screw is at least 14 mm below the joint line.


This shows the lateral projection.

Compartment syndrome

Monitor the neurovascular status of the limb carefully not to miss a compartment syndrome.

2 Patient preparation top


This procedure is normally performed with the patient in a supine position. By allowing the limb to lie in a externally rotated position, access may be gained through a posteromedial approach.

If a posterior approach is preferred the patient should be placed in a prone position.

3 Approaches top

For this procedure the following approaches may be used:

4 Reduction top

Place distractor opposite of planned fixation device enlarge

Place distractor opposite of planned fixation device

For extraarticular tibial fractures (metaphyseal wedge or multifragmentary) the large or femoral distractor may be used during the fixation of the medial or lateral side depending on where the fixation device will be placed. Eg, the distractor is placed on the medial side if the fixation device will be applied onto the lateral side.

5 Fixation top

Medial Column Fixation enlarge

Medial Column Fixation

Reduction and fixation of the medial column is obtained by a one-third tubular plate through a separate posteromedial approach.

Lateral column fixation enlarge

Lateral column fixation

The lateral side is reduced through a standard lateral approach. Reduction and fixation was obtained with a lateral L-plate 4.5 which functions here as a bridge plate.

The medially applied disctactor may interfere with screw insertion, but the distractor should be kept until both sides are stabilized to prevent loss of reduction.

Removal of medial distractor
The medial distractor should be kept as long as possible and be removed only after application of both plates.

v2.0 2010-05-15