M.E.Müller: Atlas: Fracture 42-C3

Tibia/Fibula, Diaphysis,
complex fracture, irregular
0,31% of the total
1,62% of the tibia
2,90% of the segment

64 fractures
37,4% group
82%M, 18%F

47 fractures
27,5% group
83%M, 17%F

60 fractures
35,1% group
84%M, 16%F

With two or three intermediate fragments +Q With limited shattering (< 4 cm) +Q With extensive shattering ( >= 4 cm) +Q

These are complex fractures with several irregular intermediate fragments involving 4 cm or more (extensive shattering) of the tibial diaphysis. These are the most serious of the tibial fractures. Although the center of the fracture site is in the diaphysis, the fracture line often extends to the metaphyseal-epiphyseal segments. Ref. Manual of Internal Fixation:
200 - 207. 232 - 251. 574 - 587.
Surgeon. RO.

Since these are high-energy fractures, they are often associated with soft tissue damage that establishes the indication for provisional or definitive treatment with external fixators. Interlocking nailing may be a good alternative in some cases.

The illustrated case demonstrates some of the treatment difficulties. If an external fixator had been used, the distal pin fixation would have had to be talo-calcaneal, with all of its disadvantages. If an interlocking nail had been chosen, the nail insertion would have split open the slitted large proximal fragment, making the reduction of the distal fragment impossible and the interlocking ineffective.

The use of a plate involves skin difficulties but allows anatomic reduction, compression and neutralization of the whole diaphyseal fracture, although it is insufficient at the distal end where it coincides with the level of the fibular fracture, a factor of greater focal instability. The consequences are evident: the perfectly reduced and stabilized proximal fracture lines heal “per primam” while the distal fracture line, unstable, heals by a hyper-trophic callus.

The distal tibial joint line is in valgus because of the shortening of the fibula. This probably was the only, but nonetheless important, mistake in the preoperative planning of the case. The fibula should have been reduced and fixed with a plate, similar to what we would have done with a pilon fracture.

preoperative postoperative + 4 months + 8 months

Ref. Manual of Internal Fixation:
152 - 157. 200 - 207. 232 - 251.
574 - 587.
Surgeon. RO.

Throughout this book we show several different treatment techniques for internal fixation of closed fractures, first and second degree open fractures and occasionally in third and fourth degree open fractures. As an exception we illustrate this case of a tibial fracture with bone and soft tissue loss, that had been infected for three weeks and with a generalized sepsis when the patient came under our care. The fracture had been immobilized with an external fixator and its appereance is shown in the images marked -1.

Once the long process of healing of the infection was over, grafting of the areas with skin loss but muscle preservation was performed with meshed skin. The second operative procedure was the coverage of the fracture site with a vascularized latissimus dorsi muscle graft covered with a free skin graft. Once the wounds healed, double plating internal fixation was performed

through the vascularized graft, filling the bone loss with autologous iliac crest bone graft (marked 1W). Eight months after the accident the patient was able to walk without crutches. One year later, one of the plates was removed. The images show the process of bone remodelling up to the 3 years landmark.

At present, many authors propose the Ilizarov-like bone transport techniques for reconstruction of segmental bone loss. This case demonstrates the possibility of obtaining a stable fixation and early function with two plates. The plate applied to the lateral aspect of the tibia is of the lengthening type (without central holes) and the medial plate is of the semitubular design. One of the plates must allways be removed (the semitubular one) in order to favour the process of corticalization of the diaphysis and prevent refractures.

preoperative preoperative + 1 weak + 1 month

+ 4 months + 4 months + 1 year + 3 years




						Tibia/Fibula, Diaphysis, complex fracture, irregular	0,31% of the total 1,62% of the tibia 2,90% of the segment






These are complex fractures with several irregular intermediate fragments involving 4 cm or more (extensive shattering) of the tibial diaphysis. These are the most serious of the tibial fractures. Although the center of the fracture site is in the diaphysis, the fracture line often extends to the metaphyseal-epiphyseal segments.		Ref. Manual of Internal Fixation: 200 - 207. 232 - 251. 574 - 587. Surgeon. RO.

Since these are high-energy fractures, they are often associated with soft tissue damage that establishes the indication for provisional or definitive treatment with external fixators. Interlocking nailing may be a good alternative in some cases. The illustrated case demonstrates some of the treatment difficulties. If an external fixator had been used, the distal pin fixation would have had to be talo-calcaneal, with all of its disadvantages. If an interlocking nail had been chosen, the nail insertion would have split open the slitted large proximal fragment, making the reduction of the distal fragment impossible and the interlocking ineffective.	The use of a plate involves skin difficulties but allows anatomic reduction, compression and neutralization of the whole diaphyseal fracture, although it is insufficient at the distal end where it coincides with the level of the fibular fracture, a factor of greater focal instability. The consequences are evident: the perfectly reduced and stabilized proximal fracture lines heal “per primam” while the distal fracture line, unstable, heals by a hyper-trophic callus. The distal tibial joint line is in valgus because of the shortening of the fibula. This probably was the only, but nonetheless important, mistake in the preoperative planning of the case. The fibula should have been reduced and fixed with a plate, similar to what we would have done with a pilon fracture.






		Ref. Manual of Internal Fixation: 152 - 157. 200 - 207. 232 - 251. 574 - 587. Surgeon. RO.

Throughout this book we show several different treatment techniques for internal fixation of closed fractures, first and second degree open fractures and occasionally in third and fourth degree open fractures. As an exception we illustrate this case of a tibial fracture with bone and soft tissue loss, that had been infected for three weeks and with a generalized sepsis when the patient came under our care. The fracture had been immobilized with an external fixator and its appereance is shown in the images marked -1. Once the long process of healing of the infection was over, grafting of the areas with skin loss but muscle preservation was performed with meshed skin. The second operative procedure was the coverage of the fracture site with a vascularized latissimus dorsi muscle graft covered with a free skin graft. Once the wounds healed, double plating internal fixation was performed	through the vascularized graft, filling the bone loss with autologous iliac crest bone graft (marked 1W). Eight months after the accident the patient was able to walk without crutches. One year later, one of the plates was removed. The images show the process of bone remodelling up to the 3 years landmark. At present, many authors propose the Ilizarov-like bone transport techniques for reconstruction of segmental bone loss. This case demonstrates the possibility of obtaining a stable fixation and early function with two plates. The plate applied to the lateral aspect of the tibia is of the lengthening type (without central holes) and the medial plate is of the semitubular design. One of the plates must allways be removed (the semitubular one) in order to favour the process of corticalization of the diaphysis and prevent refractures.