1. Home
  2. Skeleton
  3. Diagnosis
  4. Indications
  5. Treatment

Authors of section


Daniel Green, Philip Henman, Mamoun Kremli

Executive Editor

James Hunter

General Editor

Fergal Monsell

Open all credits

Open reduction; screw fixation

1. General considerations


The physeal fragment is fixed with a retrograde intramedullary screw. This risks growth arrest and is only recommended in adolescents.

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

Open reduction and screw 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

Appropriately sized cannulated or noncannulated screws can be used.

The following equipment is used:

  • Screw set
  • Drill
  • Image intensifier
Drill, cannulated, partially threaded screw, and guide wire

3. Patient preparation and approach

Patient positioning

Place the patient in a supine position on a radiolucent table with a block under the lower leg proximal to the heel.

Patient and leg position for treatment of distal fibular fractures


Perform a lateral incision from just distal to the tip of the fibula to the level of the fracture.

Skin incision for open reduction and screw fixation of a Salter-Harris I fracture of the 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 a screw in a standard manner.

Screw fixation of a distal fibular fracture

Confirm reduction, fracture stability, and screw placement with an image intensifier.

Screw fixation of a distal fibular fracture

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.

Younger children may require a period of bed rest followed by mobilization in a wheelchair.

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.