1 Principles top
Oblique fractures of the tibial diaphysis can be treated nonoperatively if the initial displacement is small and there is <1 cm shortening.
Operative treatment with a nail
Nailing is usually a good option for tibial fractures, but is technically more difficult for proximal and distal locations.
Operative treatment with plate and screws
For the treatment of simple oblique fractures in the diaphyseal area, absolute stability is recommended.
For this, anatomical reduction and interfragmentary compression are necessary.
Choosing the method of interfragmentary compression
The method of interfragmentary compression is determined by the fracture geometry and the plane of the obliquity.
1. The tip of the fracture is in the center of the anteromedial or anterolateral surface of the tibia
In this case, the fracture can be compressed with an axial compression plate, with a supplementary lag screw through the plate.
The apex of the fracture should be underneath the plate.
2. The tip of the fracture is not in the center of the anteromedial or anterolateral surface, but either posterior or anterior
In this case, compression must be done with a lag screw, usually inserted through the plate. In this case, the plate is used in protection rather than compression mode. The apex of the fracture is not underneath the plate, but either anterior or posterior of it.
3. The tip of the fracture lies on the tibial crest
In this case, a lag screw outside of the plate (protection mode) is usually required.
2 Open reduction topenlarge
As anatomical reduction is necessary, open, or direct, reduction is needed.
Mobilize just enough of the periosteum around the fracture edges to control the reduction. Take care to protect the periosteum wherever possible.
Because they do less damage to the soft tissues, pointed reduction forceps are best used.
In a first step, length and rotation must be restored. This may be possible with manual traction. Otherwise, mechanical aids such as a large distractor, or bone spreader, should be considered.
Reduction of the fracture
In a second step, once length and rotation are restored, pointed reduction forceps are used to compress and anatomically reduce the fracture. The forceps tips should be applied perpendicular to the plane of the fracture, just like a lag screw. Place the forceps outside the intended path of the lag screw.
3 Preoperative planning topenlarge
Confirm fracture plane
Confirm the fracture plane and ensure that the plate can not be applied over the tip of the fracture. If this is possible, use an axial compression plate with a lag screw through the plate instead. If, on the other hand, the tip of the fracture lies on the tibial crest, the lag screw must be inserted outside of a protection plate.
Planning the plate position
Before starting the procedure, the exact position of the plate should be determined according to the position of the lag screw. The screw should be inserted perpendicular to the fracture plane.
However, if this is not possible, at least insert the screw through the center of the fracture.
4 Preparation topenlarge
Plate selection and preparation
The chosen plate (usually a narrow, 4.5 mm DCP) should allow
1. A hole near the middle of the fracture, for the first lag screw to be inserted as perpendicularly as possible to the fracture plane.
2. Sufficient length for at least 4 screws proximal and distal to the fracture zone.
Usually a 9-10 hole straight 4.5 mm DCP is used. Remember that whenever the plate is placed distally, the plate must be twisted and bent to match the shape of the tibia in that region.
5 Fixation topenlarge
Drilling the gliding hole for the lag screw
Using a 4.5 mm drill guide and a 4.5 mm drill bit, drill a gliding hole in
the near cortex.
Ensure that the direction of the drill is as perpendicular to the fracture plane as possible. If this is not possible, ensure that the lag screw will go through the center of the fracture.
Drilling the thread hole
Insert the 4.5 mm / 3.2 mm drill guide through the plate and the gliding hole. Use a 3.2 mm drill bit to drill a thread hole just through the far cortex.
Measure for screw length
Use a depth gauge through the plate to measure for screw length.
Measure the longer side of an oblique drill hole, as shown, to ensure sufficient screw length.
A screw should protrude 1-2 mm through the opposite cortex to ensure thread purchase. However, too long a screw may be tender, or injure soft tissues.
Tap the thread hole
Use a 4.5 mm tap and the corresponding drill sleeve to tap the thread hole.
Insert lag screw
Insert the lag screw and carefully tighten it. Confirm that the fracture is reduced anatomically and compressed.
Insertion of diaphyseal fixation screws
Insert the screws alternating between the proximal and distal fragments. Start with the screws closest to the fracture plane and work your way outwards.
Drill for the fixation screws. At least 3 screws should be used on the proximal fragment, and at least 3 screws on the distal fragment.
For all diaphyseal screws, use cortical screws, observing the following steps:
- Drill both cortices using the appropriate drill guide to ensure a central drill hole with the 3.2 mm drill bit.
- Measure for screw length.
- Tap both cortices using the 4.5 mm tap and appropriate drill sleeve.
- Insert the screw.