1 Principles topenlarge
Transverse fractures of the tibial diaphysis can be treated nonoperatively if the initial displacement is small, there is <1cm shortening, and there is at least 50% bone contact between the fragments.
Furthermore, satisfactory closed reduction of any initially displaced transverse fracture, with adequately supportive cast, can provide good stability. These higher-energy fractures may heal slowly, possibly with delayed secondary loss of alignment.
Operative treatment with a nail
Nailing is usually a good option for tibial shaft fractures. It allows fixation, usually with minimal additional fracture-site trauma.
Operative treatment with plate and screws
For the treatment of simple transverse fractures in the diaphyseal area, absolute stability is recommended. For this, anatomical reduction and interfragmentary compression are necessary. This requires open exposure with increased risk of wound-healing complications.
Axial compression plating
The objective of axial compression plating is to produce absolute fracture stability, by pre-loading the fracture to eliminate interfragmentary motion.
Axial compression plating is useful in two-part transverse fracture patterns, where the bone fragments can be compressed. The fracture orientation prevents use of a lag screw. Compression of the fracture is usually achieved by eccentric screw placement through one or more of the dynamic compression plate holes. The sides of these holes are inclined so that the screw head can translate the plate to produce compression.
Compression can also be applied with the AO articulated tension device.
2 Preoperative planning topenlarge
Planning the plate position
The center of the plate should be over the fracture line. Choose an 8-hole narrow 4.5 mm DCP that allows 4 screws in each fragment.
Overbending the plate
To compress the opposite cortex, the plate should be slightly overbent (more convex) at the fracture, so there is a small gap between plate and bone. This causes the cortex opposite the plate to be compressed first, as the eccentrically placed plate screws are tightened. With further tightening, the near cortex of the fracture subsequently becomes compressed. This short, convex (away from the bone) bend can be made with the handheld bending pliers, or a pair of bending irons.
If axial compression is applied in a transverse fracture with a plate that is not overbent, compression first occurs at the cortex under the plate. This causes a gap in the fracture opposite the plate, with resulting instability. Such a gap must be avoided.
3 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.
Reduction of the fracture
As the fracture is reduced by pointed reduction forceps, it is also rotated into anatomic position.
Noncomminuted transverse fractures are often stable enough for the plate to be applied without provisional fracture fixation. Make sure that the reduction remains satisfactory before drilling and inserting screws for the plate.
4 Fixation topenlarge
Insert the first screw
Drill with a 3.2 mm drill bit and drill guide centrically through the plate hole as close as possible to the fracture line. Measure for screw length, tap with a 4.5 mm tap and a protective sleeve and insert the first screw, but do not fully tighten it yet.
An alternative is to drill this hole in the optimal pre-planned location without the overlying plate.
Axial compression with eccentric screw
With the plate properly positioned, drill eccentrically for the second screw
in the opposite fragment, using the eccentric drill guide (gold ring). Measure
and tap, as above.
Insert the eccentric screw and alternately tighten both screws. Confirm adequate compression and reduction.
Insert second eccentric screw
To increase axial compression, a second screw can be placed eccentrically
next to the first (neutral) screw.
When the second eccentric screw is tightened, the first (neutral) screw needs to be loosened to allow the plate to slide on the bone.
Insertion of remaining screws
All other screws are inserted centrically (drill sleeve with green ring). They will not add to compression. Insert the screws alternating between the proximal and distal fragments. Start with the screws closest to the fracture plane and work your way outwards.
At least 4 screws should be used on either fragment.
Using cortical screws for the diaphysis, with the following steps:
- Drill both cortices using drill sleeve with green ring 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.
5 Alternative: Compression with the ATD topenlarge
Adequate compression of the fracture can also be achieved with the help of the articulated tension device (ATD). The ATD can also be reversed to push on the plate and regain length, if needed.
If too much tension is applied and/or the plate has not been prebent, there is a risk of causing the opposite side of the fracture to open, with instability and/or angulation.