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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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MIO bridge plating

1. General considerations


Simple pediatric metaphyseal fractures can be managed with closed reduction and medial plate fixation.

Minimally invasive plate fixation of a metaphyseal distal tibial fracture

In fractures with insufficient distal metaphyseal length, it may be necessary to bridge the physis.

The epiphyseal screw must be removed as soon as bone healing allows to prevent growth arrest and deformity.

Minimally invasive plate fixation of a metaphyseal distal tibial fracture

Initial reduction and stabilization with external fixation

Consider external fixation as a preliminary treatment, especially when associated with a significant soft-tissue injury or open fractures.

Associated fibular fracture

A fibular fracture often reduces with reduction and fixation of the tibial fracture and does not require separate consideration.

If the alignment and stability of the fibular fracture are unsatisfactory after fixation of the tibial fracture, surgical treatment of the fibular fracture is also required.

If the distal tibial fracture is highly comminuted, fixation of the fibular fracture may add to overall stability.

Size and type of implant

2.0–4.5 mm plates are typically used in pediatric practice.

The age and weight of the patient, the anatomical site, and the load to which they will be subjected dictate the size of the implant.

Plates are available for use with locking and/or nonlocking screws and can be used for dynamic compression.

The plate should be long enough to insert at least two to three screws on each side of the fracture.

A straight plate can be used in more proximal metaphyseal fractures.

A T-shaped plate can be used in more distal metaphyseal fractures.

Adult anatomic plates for the distal tibia are contoured for periarticular placement. These may be appropriate for patients with a closing physis or, in rare cases, where stable fracture fixation requires bridging the physis. If they are used to manage fractures proximal to the physis, an angular deformity may result.

Plate types for fixation of distal tibial fractures

2. Preoperative planning

Preoperative planning is an essential part of the treatment of all distal tibial fractures because of the variability of the fracture pattern and patient characteristics.

This involves:

  • Careful study of the x-rays
  • Assessment of physis and growth remaining
  • Definition of the fracture fragments and the desired result. This may be achieved with appropriate imaging software
  • Choice of implants
Preoperative planning for plate fixation of a metaphyseal fracture of the distal tibia

3. Patient preparation and approach

Patient positioning

Place the patient in a supine position on a radiolucent table.

Pediatric patient placed supine on a radiolucent table


A minimally invasive medial approach to the distal tibia is used for this procedure.

Confirm the location of the physis with an image intensifier.

Medial approach for minimally invasive plating of the distal tibia

4. Reduction

Reduction of distal tibial and fibular fractures may be difficult. Support from at least one assistant, providing countertraction and stabilizing the proximal leg, may be helpful.

With the knee flexed and stabilized, apply longitudinal traction through the foot.

Correct translation and angulation of the fracture and confirm reduction clinically and with an image intensifier if available.

Application of longitudinal traction through the foot with the knee flexed and stabilized

Reduction aids

The gastrocnemius muscle can be relaxed by flexing the knee and the ankle.

Reduction can be performed with:

  • Pointed reduction forceps
  • A Hohmann retractor, used as a lever to correct translation
  • K-wires, used as a joystick to control the distal fragment
  • Tibial distractor or temporary external fixator, used to achieve and maintain fracture reduction
Distraction of a simple transverse metaphyseal fracture of the distal tibia

Hold the reduction with a temporary K-wire. This must not interfere with subsequent plate placement.

Consider holding the fracture with a large, pointed reduction forceps applied percutaneously.

Temporary K-wire stabilization of a metaphyseal fracture of the distal tibia

5. Plate contouring

If locking screws are used, the plate will not be compressed to the bone and does not need to be anatomically contoured.

If a straight plate is used, the distal end should be contoured to match the internal torsion of the distal tibia.

Contouring of an LCP for application to the distal tibia

6. Plate fixation

Plate insertion

Apply the plate using a minimally invasive technique.

The plate is usually positioned on the anteromedial aspect of the tibia unless this is prevented by the fracture configuration.

Create a submuscular tunnel using the plate or a blunt dissector.

Plate insertion for minimally invasive plating of a metaphyseal fracture of the distal tibia

Use a percutaneous approach to stabilize the plate with a temporary K-wire inserted through the proximal pilot hole.

Insert a second K-wire through the distal pilot hole and confirm plate alignment with an image intensifier.

Temporary fixation of the plate with K-wires during minimally invasive plating of a metaphyseal fracture of the distal tibia

Use the same percutaneous incision to insert he most proximal screw.

Screw insertion during minimally invasive plating of a metaphyseal fracture of the distal tibia

Screw insertion

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.

If an anatomical plate is selected, locking screws should be used adjacent to the physis to prevent compression of the perichondral ring.

Insert the screws into the distal fragment and complete proximal screw insertion.

The dissector or elevator is removed after screw fixation.

An elevator may be used to protect the perichondral ring during minimally invasive plating of a metaphyseal fracture of the distal tibia

Check the final construct with an image intensifier.

Minimally invasive plate fixation of a metaphyseal distal tibial fracture

7. Fibular fracture management

Most fibular fractures do not require treatment. Indications for fixation include:

  • Augmentation of the stability of tibial fracture fixation
  • Significant displacement of the fibular fracture

The type of fracture pattern dictates the method of fixation of the fibular fracture.

In a younger child, these fractures may be fixed with K-wires in a standard manner. Multiple passes of the K-wire through the physis should be avoided.

In an older patient with a closing physis, these fractures may require plate fixation.

If screws are inserted on both sides of the physis, compression should be avoided and the periosteum and perichondral ring not be disturbed. To protect the perichondral ring, a dissector or elevator may be used to offset the plate during screw insertion. The plate should be removed soon after the fracture has healed.

K-wire and plate fixation of an associated distal fibular fracture

8. 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.

9. 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

10. 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.

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.

Note: If the physis has been bridged, the epiphyseal screws should be removed as soon as bone healing allows.