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Authors of section


Daniel Green, Philip Henman, Mamoun Kremli

Executive Editor

James Hunter

General Editor

Fergal Monsell

Open all credits

Open reduction; K-wire fixation

1. General considerations


Reduction and stabilization of a tibial fracture will frequently reduce the fibula such that fixation is not required.

These fibular fractures may require temporary internal fixation across the physis to produce adequate stability.

Open reduction is necessary if it is not possible to obtain or maintain adequate reduction by closed manipulation.

The following should be considered to minimize secondary damage to the physis:

  • Manipulation of the fracture must be gentle
  • Multiple passes across the physis with a K-wire should be avoided
  • Select smooth, appropriately sized K-wires

The K-wire may be inserted retrogradely from the epiphysis into the medullary canal.

Open reduction and K-wire fixation of a Salter-Harris I and II fracture of the distal fibula

Treatment goals

The main treatment goals are:

  • Stabilize the fracture
  • Minimize further physeal injury

2. Instruments and implants

The following equipment is used:

  • K-wires of appropriate sizes
  • Drill or a T-handle for manual insertion
  • Wire cutting instruments
  • Standard orthopedic instrument set
Instruments for K-wire fixation

3. Patient preparation and approach

Patient position

Place the patient in a supine position on a radiolucent table with a block under the heel.

Patient and leg position for treatment of distal fibular fractures


A small lateral approach is typically used with an incision that provides sufficient exposure to visualize and reduce the fracture.

Skin incision for a lateral approach to the pediatric distal fibula

4. Reduction

It may be necessary to remove interposed soft tissue and periosteum before reducing the fracture under direct vision, without devitalizing the fracture fragments.

5. Fixation

Insert the K-wire from the tip of the fibula retrograde across the physis into the medullary canal.

Insertion of a K-wire for fixation of a Salter-Harris II fracture of the distal fibula

K-wire cutting and dressing

Bend the K-wire approximately 1 cm from the skin to allow for swelling.

Cut the K-wire and apply a dressing to protect the skin.

A K-wire inserted through the tip of the fibula can be buried if there is adequate soft-tissue coverage.

Open reduction and K-wire fixation of a Salter-Harris II fracture of the distal fibula

Release tethered skin around the K-wire by extending the incision.

Release of tethered skin around the K-wire by extending the incision

Alternatively, the K-wire may be placed under the skin with the bent end on the surface of the bone.

6. Final assessment

Recheck the fracture alignment and implant position clinically and with an image intensifier before anesthesia is reversed.

Confirm stability of the fixation by moving the ankle through a range of dorsi/plantar flexion.

7. Immobilization

A molded below-knee cast or fixed ankle boot is recommended for a period of 2–6 weeks as the strength of fixation may not provide sufficient stability for unrestricted weight-bearing.

Pediatric patient walking with crutches and a short leg cast for immobilization of the ankle

8. Aftercare

Immediate postoperative care

Weight-bearing is encouraged.

Older children may be able to use crutches or a walker.

Pain control

Patients tend to be more comfortable if the limb is splinted.

Routine pain medication is prescribed for 3–5 days after surgery.

Neurovascular examination

The patient should be examined frequently to exclude neurovascular compromise or evolving compartment syndrome.

Discharge care

Discharge follows local practice and is usually possible within 48 hours.


The first clinical and radiological follow-up is usually undertaken 5–7 days after surgery to check the wound and confirm that reduction has been maintained.

Cast and K-wire removal

Distal tibial and fibular fractures heal rapidly. Cast and K-wires are typically removed 3–6 weeks after injury, depending on the age and weight of the patient.


Once K-wires and cast are removed, gradual weight-bearing is usually possible.

Patients are encouraged to start range-of-motion exercises. Physiotherapy supervision may be required in some cases but is not mandatory.

Sports and activities that involve running and jumping are not recommended until full recovery of local symptoms.

Range-of-motion exercises of the ankle