Extraarticular, wedge fracture

 

 

Temporary splintage necessary, cast provides this adequately without compromising soft tissues

Further indications

• Fracture with slight to moderate instability
• Definitive surgical fixation is planned
• As initial treatment until soft-tissue swelling decreases, or to permit patient transfer

Contraindications

• Fractures with severe soft-tissue compromise (caution: swelling can increase significantly in the first hours after injury!)
• Impending compartment syndrome

Advantages

• Temporary reduction and immobilization of the fracture
• Allows further imaging (e.g., CT) to plan definitive treatment
• May be applied after debridement of open fracture

Disadvantages

• Limited stability
• Soft-tissue evaluation is difficult
• May need to loosen cast to accommodate soft-tissue swelling or impending compartment syndrome

Note: Temporary joint-bridging external fixation provides higher stability and allows better evaluation of the soft tissues. Therefore, external fixation should always be considered for more severe distal tibial fractures, closed or open.

 

 

Significant local soft-tissue swelling, patient's general condition satisfactory for maintained bed rest

Further indications

• Other injuries in the same extremity that require provisional traction
• Patient can tolerate constant bed rest
• Medical conditions expected to improve enough for surgical treatment

Contraindications

• Untreated open fractures or compartment syndrome
• No reason to delay definitive surgery
• Better stability necessary

Advantages

• Continuous traction may improve alignment
• Better stability than cast
• Possibility for stabilizing other ipsilateral lower extremity injuries

Disadvantages

• Less stable than external fixation
• Requires bed rest
• Risk of pin-track infection

 

 

Fracture with significant injury or expected severe swelling

With an external fixator, the joint can be reduced and stabilized temporarily in an adequate position, allowing the soft tissues to settle. The modular external fixator maintains the length and holds the foot in a neutral position without a tibiotarsal transfixation.

Further indications

• Damage control in the polytraumatized patient
• Compartment syndrome
• Associated vascular repair

Contraindication

• Injury patterns or associated injuries where no distal pin placement is possible

Advantages

• Rapid preliminary stability
• Permits patient transfer without loss of immobilization
• Effective fracture stabilization aids soft-tissue recovery
• Allows exposure and care of open wounds

Disadvantages

• Pin-track infection risk, possibly delaying definitive surgery
• Nerve or artery injury from pins

 

 

Fracture with significant injury or expected severe swelling

With an external fixator, the joint can be reduced and stabilized temporarily in an adequate position, allowing the soft tissues to settle. This requires a tibiocalcaneal frame to maintain the length and a tibiotarsal fixation to hold the foot in a neutral position.

Further indications

• Damage control in the polytraumatized patient
• Compartment syndrome
• Associated vascular repair

Contraindication

• Injury patterns or associated injuries where no distal pin placement is possible

Advantages

• Rapid preliminary stability
• Permits patient transfer without loss of immobilization
• Effective fracture stabilization aids soft-tissue recovery
• Allows exposure and care of open wounds

Disadvantages

• Pin-track infection risk, possibly delaying definitive surgery
• Nerve or artery injury from pins

 

 

Severe soft-tissue injury, unstable reducible fracture, optimal stability

Further indications

• Severe soft-tissue injury preventing other forms of definitive stabilization
• Ability to obtain satisfactory reduction and distal wire/pin placement
• Displaced, unstable fracture

Contraindications

• Unfamiliarity with technique
• Inability to obtain satisfactory reduction or stability
• Injuries and fracture pattern preventing adequate pin or wire placement

Advantages

• Minimal soft-tissue disruption of the fracture zone
• Many variations in technique and frame design possible
• Most stable external fixation construct
• May permit early weight bearing, particularly if extended to foot
• May be combined with open reduction and partial internal fixation
• Allows staged surgical management

Disadvantages

• Ring fixators offer limited potential for reduction and stabilization of articular surface fractures
• Risk of pin-track infection
• Possible compromise of future surgical exposures
• Unexpected severe swelling may require premature ring removal

 

 

Any unstable extraarticular fracture of sufficient length to allow for adequate distal locking

Further indications

• Loss of reduction after nonoperative treatment
• Segmental fractures

Contraindications

• Short distal segment
• Inability to reduce the fracture by indirect means
• Severely contaminated open fracture
• Associated ipsilateral total knee joint replacement
• Risks of surgery exceed expected benefits because of patient's general condition

Advantages

• Fracture site not exposed
• Minimal additional insult to soft-tissue injury
• May allow earlier weight bearing

Disadvantages

• Can be difficult to accurately reduce the fracture
• May require supplementary techniques for adequate stability
• May require a delay for recovery of pin sites if temporary external fixation has been used before IM nailing

 

 

Displaced, unstable fracture where closed reduction is possible, soft-tissues suitable

Further indications

• Short distal segment not allowing intramedullary nailing
• Following adequate soft-tissue recovery after provisional external fixation

Contraindications

• Inability to reduce the fracture by indirect means
• Severe open or closed soft-tissue injury
• Risks of surgery exceed expected benefits because of patient's general condition

Advantages

• Offers relatively stable fixation
• Minimal disruption of the soft tissues at the fracture site

Disadvantages

• Can be difficult to satisfactorily reduce the fracture
• Requires technical precision
• Medial subcutaneous plate may threaten skin, even with small incisions

 

 

Displaced, unstable fracture, soft-tissues suitable

Distal tibial fractures have significant risk wound healing problems after open reduction and internal fixation. Waiting until the tissues have recovered or using a less invasive technique are ways of avoiding wound breakdown in this dangerous region. In any case the gentlest possible soft-tissue handling, and avoidance of unnecessary dissection are important principles.

Further indications

• Preliminary to planned soft-tissue flap coverage
• Intramedullary nailing is not an acceptable alternative
• Fractures where satisfactory closed reduction cannot be achieved

Contraindications

• Soft tissues unsatisfactory for direct surgical exposure
• Elevated risk factors for impaired healing (diabetes, arteriosclerosis, smoking)
• Risks of surgery exceed expected benefits because of patient's general condition

Advantage

• Offers anatomical reduction with absolute stability

Disadvantages

• Extensive exposure can increase risk of healing problems (wound break down, infection, delayed fracture healing)
• Judgement necessary to balance benefits and risks of open surgery
• Medial plate may interfere with skin closure