Executive Editor: Peter Trafton

Authors: Theerachai Apivatthakakul, Surapong Anuraklekha, George Babikian, Fabio Castelli, Antonio Pace, Vajara Phiphobmongkol, Raymond White, Kodi Kojima, Matthew Camuso

Tibial shaft

back to skeleton

Glossary

Basic treatment techniques

Fracture management with limited resources
Traction and/or cast stabilization
Nailing without image intensification
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

Simple spiral fracture

Please select a treatment option:
Treatment Main indication Skill Equipment
Nonoperative (casting) Minimal displacement Basic surgical experience, no specialized skills Basic equipment only
CREF - Modular external fixator Soft-tissue compromise, limited resources, urgency Basic surgical experience, no specialized skills Basic equipment only
CREF - Uniplanar external fixator Definitive external fixation Basic surgical experience, no specialized skills Basic equipment only
CREF - Ring fixator (Ilizarov) Significant bone loss; definitive treatment Some specialized surgical experience Simple surgical and imaging resources
CRIF - Intramedullary nailing Any diaphyseal fracture with a normal medullary canal Highly experienced and skilled surgeon Full specialized surgical and imaging resources
ORIF - Lag screws through protection plate Spiral fracture oriented suitably for lag screw through plate Some specialized surgical experience Simple surgical and imaging resources
ORIF - Lag screws outside protection plate Spiral fracture oriented suitably for lag screw outside plate Some specialized surgical experience Simple surgical and imaging resources
A2

Simple oblique fracture

Please select a treatment option:
Treatment Main indication Skill Equipment
Nonoperative (casting) Minimal displacement Basic surgical experience, no specialized skills Basic equipment only
CREF - Modular external fixator Soft-tissue compromise, limited resources, urgency Basic surgical experience, no specialized skills Basic equipment only
CREF - Uniplanar external fixator Definitive external fixation Basic surgical experience, no specialized skills Basic equipment only
CREF - Ring fixator (Ilizarov) Significant bone loss; definitive treatment Some specialized surgical experience Simple surgical and imaging resources
CRIF - Intramedullary nailing Any diaphyseal fracture with a normal medullary canal Highly experienced and skilled surgeon Full specialized surgical and imaging resources
MIO - Compression plating Short oblique fractures, especially proximal and distal Highly experienced and skilled surgeon Full specialized surgical and imaging resources
ORIF - Lag screws through plate Oblique fractures oriented suitably and long enough for lag screw through plate Some specialized surgical experience Basic equipment only
ORIF - Lag screws outside protection plate Oblique fractures oriented suitably and long enough for lag screw outside plate Some specialized surgical experience Simple surgical and imaging resources
ORIF - Compression plate with lag screw Oblique fracture configuration suitable for use of a compression plate with added lag screw Some specialized surgical experience Simple surgical and imaging resources
A3

Simple transverse fracture

Please select a treatment option:
Treatment Main indication Skill Equipment
Nonoperative (casting) Minimal displacement after reduction Basic surgical experience, no specialized skills Basic equipment only
CREF - Modular external fixator Soft-tissue compromise, limited resources, urgency Basic surgical experience, no specialized skills Basic equipment only
CREF - Uniplanar external fixator Definitive external fixation Basic surgical experience, no specialized skills Basic equipment only
CREF - Ring fixator (Ilizarov) Significant bone loss; definitive treatment Some specialized surgical experience Simple surgical and imaging resources
CRIF - Intramedullary nailing Any diaphyseal fracture with a normal medullary canal Highly experienced and skilled surgeon Full specialized surgical and imaging resources
MIO - Compression plating Proximal or distal fractures; alternative to IM nail Highly experienced and skilled surgeon Full specialized surgical and imaging resources
ORIF - Axial compression plating Any 42-A3 diaphyseal fracture Some specialized surgical experience Simple surgical and imaging resources
B1

Spiral wedge fracture

Please select a treatment option:
Treatment Main indication Skill Equipment
Nonoperative (casting) Satisfactory reduction; risks of surgery exceed benefits Basic surgical experience, no specialized skills Basic equipment only
CREF - Modular external fixator Soft-tissue compromise, limited resources, urgency Basic surgical experience, no specialized skills Basic equipment only
CREF - Uniplanar external fixator Definitive external fixation Basic surgical experience, no specialized skills Basic equipment only
CREF - Ring fixator (Ilizarov) Significant bone loss; definitive treatment Some specialized surgical experience Simple surgical and imaging resources
CRIF - Intramedullary nailing Any diaphyseal fracture with a normal medullary canal Some specialized surgical experience Simple surgical and imaging resources
MIO - Bridge plating Reducible B1 fracture with suitable soft tissues; If bridge plating is preferred to IM nailing Highly experienced and skilled surgeon Full specialized surgical and imaging resources
ORIF - Lag screws through protection plate Fracture geometry suitable for insertion of lag screw outside plate Some specialized surgical experience Simple surgical and imaging resources
ORIF - Lag screws outside protection plate Fracture geometry suitable for insertion of lag screw through plate Some specialized surgical experience Simple surgical and imaging resources
B2

Bending wedge fracture

Please select a treatment option:
Treatment Main indication Skill Equipment
Nonoperative (casting) Satisfactory reduction; risks of surgery exceed benefits Basic surgical experience, no specialized skills Basic equipment only
CREF - Modular external fixator Soft-tissue compromise, limited resources, urgency Basic surgical experience, no specialized skills Basic equipment only
CREF - Uniplanar external fixator Definitive external fixation Basic surgical experience, no specialized skills Basic equipment only
CREF - Ring fixator (Ilizarov) Significant bone loss; definitive treatment Some specialized surgical experience Simple surgical and imaging resources
CRIF - Intramedullary nailing Any diaphyseal fracture with a normal medullary canal Highly experienced and skilled surgeon Full specialized surgical and imaging resources
MIO - Bridge plating Reducible B2 fracture with suitable soft tissues; If bridge plating is preferred to IM nailing Highly experienced and skilled surgeon Full specialized surgical and imaging resources
ORIF - Lag screws with protection plate Fracture geometry suitable for insertion of lag screw with plate Some specialized surgical experience Simple surgical and imaging resources
ORIF - Compression plating B2 fractures where plating is preferable to IM nailing Some specialized surgical experience Basic equipment only
B3

Fragmented wedge fracture

Please select a treatment option:
Treatment Main indication Skill Equipment
Nonoperative (casting) Satisfactory reduction; risks of surgery exceed benefits Basic surgical experience, no specialized skills Basic equipment only
CREF - Modular external fixator Soft-tissue compromise, limited resources, urgency Basic surgical experience, no specialized skills Basic equipment only
CREF - Uniplanar external fixator Definitive external fixation Basic surgical experience, no specialized skills Basic equipment only
CREF - Ring fixator (Ilizarov) Significant bone loss; definitive treatment Some specialized surgical experience Simple surgical and imaging resources
CRIF - Intramedullary nailing Any diaphyseal fracture with a normal medullary canal Highly experienced and skilled surgeon Full specialized surgical and imaging resources
MIO - Bridge plating Reducible B3 fracture with suitable soft tissues; If bridge plating is preferred to IM nailing Highly experienced and skilled surgeon Full specialized surgical and imaging resources
C1

Complex spiral fracture

Please select a treatment option:
Treatment Main indication Skill Equipment
Nonoperative (casting) Risks of surgery exceed benefits Basic surgical experience, no specialized skills Basic equipment only
CREF - Modular external fixator Soft-tissue compromise, limited resources, urgency Basic surgical experience, no specialized skills Basic equipment only
CREF - Uniplanar external fixator Definitive external fixation Basic surgical experience, no specialized skills Basic equipment only
CREF - Ring fixator (Ilizarov) Significant bone loss; definitive treatment Some specialized surgical experience Simple surgical and imaging resources
CRIF - Intramedullary nailing Any diaphyseal fracture with a normal medullary canal Highly experienced and skilled surgeon Full specialized surgical and imaging resources
MIO - Bridge plating Reducible C1 fracture with suitable soft tissues; If bridge plating is preferred to IM nailing Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Open bridge plating C1 fracture with suitable soft tissues; if bridge plating is preferred to IM nailing; MIO equipment and skills not available Highly experienced and skilled surgeon Simple surgical and imaging resources
C2

Complex segmental fracture

Please select a treatment option:
Treatment Main indication Skill Equipment
Nonoperative (casting) Risks of surgery exceed benefits Basic surgical experience, no specialized skills Basic equipment only
CREF - Modular external fixator Soft-tissue compromise, limited resources, urgency Basic surgical experience, no specialized skills Basic equipment only
CREF - Uniplanar external fixator Definitive external fixation Basic surgical experience, no specialized skills Basic equipment only
CREF - Ring fixator (Ilizarov) Significant bone loss; definitive treatment Some specialized surgical experience Simple surgical and imaging resources
CRIF - Intramedullary nailing Any diaphyseal fracture with a normal medullary canal Highly experienced and skilled surgeon Full specialized surgical and imaging resources
MIO - Compression plating Proximal or distal fractures; alternative to IM nail Highly experienced and skilled surgeon Full specialized surgical and imaging resources
MIO - Bridge plating Reducible C2 fracture with suitable soft tissues; If bridge plating is preferred to IM nailing Highly experienced and skilled surgeon Full specialized surgical and imaging resources
ORIF - Compression plating Transverse or short oblique fracture patterns, unable to reduce closed Some specialized surgical experience Simple surgical and imaging resources
ORIF - Lag screws with protection plate One or both fracture planes suitable for insertion of lag screw with plate Some specialized surgical experience Simple surgical and imaging resources
C3

Complex irregular fractures

Please select a treatment option:
Treatment Main indication Skill Equipment
CREF - Modular external fixator Soft-tissue compromise, limited resources, urgency Basic surgical experience, no specialized skills Basic equipment only
CREF - Uniplanar external fixator Definitive external fixation Basic surgical experience, no specialized skills Basic equipment only
CREF - Ring fixator (Ilizarov) Significant bone loss; definitive treatment Some specialized surgical experience Simple surgical and imaging resources
CRIF - Intramedullary nailing Any diaphyseal fracture with a normal medullary canal Highly experienced and skilled surgeon Full specialized surgical and imaging resources
MIO - Bridge plating Reducible C3 fracture with suitable soft tissues; If bridge plating is preferred to IM nailing 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 2016-10-17