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Authors of section


Daniel Green, Philip Henman, Mamoun Kremli

Executive Editor

James Hunter

General Editor

Fergal Monsell

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Open reduction; plate fixation

1. General considerations


In adolescents close to skeletal maturity, these fractures are reduced and stabilized with a plate, using the same principles as adult patients.

The plate is used to keep the fragments aligned but compression should not be applied across the physis. The technique depends on the fracture morphology but generally involves bridge plating.

Plate fixation of a Salter-Harris I and II fracture of the distal fibula

Size and type of implant

The size and type of implant are determined by the size and age of the patient and the fracture pattern. The range of plate sizes in pediatric distal fibular fractures is between 2.4 and 3.5 mm.

Plate types for fixation of distal fibular fractures

2. Patient preparation and approach

Patient positioning

Place the patient in a lateral decubitus position or supine with a bump under the buttock.

Lateral decubitus position of a pediatric patient


Most fibular fractures are treated with a lateral incision to visualize the fracture and remove blocks to reduction.

Skin incision for a lateral approach to the pediatric distal fibula

3. Reduction

It may be necessary to remove interposed soft tissue and periosteum without devitalizing the fracture fragments.

Anatomical reduction may require limited dissection of the periosteum adjacent to the fracture site.

This is performed under direct vision before fracture reduction.

Reduce and temporarily hold the fracture with pointed reduction forceps or K-wire.

Reduction of a Salter-Harris II fracture of the distal fibula stabilized with reduction forceps

4. Plate fixation

Apply the plate in a standard manner.

Plate contouring is often required to conform to the anatomy of the distal fibula.

Ensure that the screws do not penetrate the physis.

The order of screw insertion depends on the fracture configuration.

The periosteum and perichondral ring should not be disturbed. To protect the perichondral ring, a dissector or elevator may be used to offset the plate during screw insertion.

Plate fixation of a Salter-Harris I and II fracture of the distal fibula

5. 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.

6. 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

7. Aftercare

Immediate postoperative care

The patient should get out of bed and begin ambulation with crutches on the day of surgery or the first postoperative day.

In most cases, the postoperative protocol will involve protected weight-bearing in a cast or splint.

Touch weight-bearing with immobilization of the ankle

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 removal

A cast or boot can be removed 2–6 weeks after injury.


After cast removal, graduated 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

Implant removal

Implant removal is not mandatory and requires a risk-benefit discussion with patient and carers.