M.E.Müller: Atlas: Fracture 42-C2

Tibia/Fibula, Diaphysis,
complex fracture, segmental
0,59% of the total
3,07% of the tibia
5,51% of the segment

91 fractures
28,1% group
70%M, 30%F

199 fractures
61,4% group
70%M, 30%F

17 fractures
10,8% group
47%M, 53%F

With an intermediate segmental fragment +Q With an intermediate segment. & addtional wedge fragment(s) +Q With two intermediate segmental fragments +Q

These are complex segmental fractures of the tibial diaphysis, with an intermediate segmental fragment, thus without contact between the proximal and distal fragments. Ref. Manual of Internal Fixation:
200 - 207. 232 - 251. 574 - 581.
Surgeon. RO.

Theoretically these fractures can be perfectly stabilized with an intramedullary nail but, in practice, many risks and difficulties become evident. If the nail is to be fitted tight by previous reaming, the free segment will rotate and devascularize. To avoid this problem, the free segment will have to be stabilized by opening the fracture site. If no reaming is performed, then one must use the rigid interlocking nails (the prevailing preference) with the disadvantages that arise from the rigidity and thinness of the nail (iatrogenic fractures, instability) and from the interlocking (neutralization of the dynamic compression, delayed union, screw breakage, prolonged exposure to the X-Rays).

The internal fixation with a plate allows the fixation and compression of the two fracture sites, one after the other, and neutralizes both of them with a single plate. The illustrated case shows healing “per primam” (stability) of both fracture sites as well as the perfect cortical reconstruction, evident after removal of the plate.

preoperative preoperative postoperative postoperative

+ 18 months + 18 months + 30 months + 30 months

preoperative preoperative + 0 months + 10 months

These are complex segmental fractures of the tibial diaphysis, thus without contact between the proximal and distal fragments, with an additional bending wedge fragment of the intermediate segment. Ref. Manual of Internal Fixation:
200 - 207. 232 - 251. 574 - 587.
266 - 267 (2nd ed.).
Surgeon. RO, RO, RO.

All of the statements made in the previous .1 fracture subgroup are valid for the .2 fracture subgroup, as illustrated in the two cases shown in the upper half of the page. If the wedge is fragmented (the case on the right side), autologous cancellous bone graft will have to be added.

In cases with a non-reconstructible multifragmented wedge (the case on the lower half of the page), we consider the old-style nailing treatment option: unreamed intramedullary nailing, supported with external splints. If union is delayed at one or both fracture sites, the nail

is changed for another one of a greater diameter, reamed, through which Herzog wires are inserted in order to avoid rotation of the distal segment.

The conceptual difference between this technique and the interlocking nailing is that, with the former, the stability is based on the thickness and length of the nail while the interlocking technique depends on the locking bolts, which have to bear enormous shear loads; That is the reason why the bolts break with some frequency and this complicates the removal of the nail and of the screw fragments.

preoperative + 1 year

preoperative + 1 year

preoperative + 11 months + 1 year + 2 years

preoperative + 1 months + 1 months + 1 months

+ 4 months + 4 months




						Tibia/Fibula, Diaphysis, complex fracture, segmental	0,59% of the total 3,07% of the tibia 5,51% of the segment






These are complex segmental fractures of the tibial diaphysis, with an intermediate segmental fragment, thus without contact between the proximal and distal fragments.		Ref. Manual of Internal Fixation: 200 - 207. 232 - 251. 574 - 581. Surgeon. RO.

Theoretically these fractures can be perfectly stabilized with an intramedullary nail but, in practice, many risks and difficulties become evident. If the nail is to be fitted tight by previous reaming, the free segment will rotate and devascularize. To avoid this problem, the free segment will have to be stabilized by opening the fracture site. If no reaming is performed, then one must use the rigid interlocking nails (the prevailing preference) with the disadvantages that arise from the rigidity and thinness of the nail (iatrogenic fractures, instability) and from the interlocking (neutralization of the dynamic compression, delayed union, screw breakage, prolonged exposure to the X-Rays).	The internal fixation with a plate allows the fixation and compression of the two fracture sites, one after the other, and neutralizes both of them with a single plate. The illustrated case shows healing “per primam” (stability) of both fracture sites as well as the perfect cortical reconstruction, evident after removal of the plate.






These are complex segmental fractures of the tibial diaphysis, thus without contact between the proximal and distal fragments, with an additional bending wedge fragment of the intermediate segment.		Ref. Manual of Internal Fixation: 200 - 207. 232 - 251. 574 - 587. 266 - 267 (2nd ed.). Surgeon. RO, RO, RO.

All of the statements made in the previous .1 fracture subgroup are valid for the .2 fracture subgroup, as illustrated in the two cases shown in the upper half of the page. If the wedge is fragmented (the case on the right side), autologous cancellous bone graft will have to be added. In cases with a non-reconstructible multifragmented wedge (the case on the lower half of the page), we consider the old-style nailing treatment option: unreamed intramedullary nailing, supported with external splints. If union is delayed at one or both fracture sites, the nail	is changed for another one of a greater diameter, reamed, through which Herzog wires are inserted in order to avoid rotation of the distal segment. The conceptual difference between this technique and the interlocking nailing is that, with the former, the stability is based on the thickness and length of the nail while the interlocking technique depends on the locking bolts, which have to bear enormous shear loads; That is the reason why the bolts break with some frequency and this complicates the removal of the nail and of the screw fragments.