Closed Tibial Fracture



Most common long bone fracture




Young patients / sports


Elderly / simple falls


MVA - often compound


Anatomical Classification



- proximal metaphysis


Shaft / Middle


Tibial Midshaft Fracture



- distal metaphysis


Tibial Fracture AP


Tscherne Soft Tissue Classification


Grade 0

- nil ST injury


Grade 1

- superficial abrasion / contusion

- ST injury from pressure from within


Grade 2

- deep contusion / abrasion

- due to direct trauma


Grade 3

- extensive contusion and crush

- subcutaneous tissue avulsion

- severe muscle injury




Acceptable alignment


No scientific data

- can probably accept a reasonable amount of deformity

- up to and including 10o without risk knee / ankle OA


Usually don't accept this


Operative v Non operative


Littenberg et al JBJS Am 1998

- meta-analysis of 19 papers

- non operative prevents infection

- ORIF more likely to result in union


Sarmiento 1000 patients closed treatment

- 60% lost to follow up

- non union rate 1.1%

- 10% short > 1 cm

- 5% > 8o varus

- comminution longer to unite

- intact fibula more rapid union but increased risk angular deformity


IMN v cast


Hooper et al JBJS 1998

- IMN more rapid union, less malunion and earlier RTW

- improved outcome when > 50% displacement or angulation > 10o


Puno et al Clin Orthop 1986

- 200 closed tibial fractures

- IMN union 98%, malunion 0%, infection 3%

- cast 90%, malunion 4%


Advantages cast

- no infection

- no knee pain

- no hardware to removed


Advantage IMN

- faster union

- reduced non union

- reduced malunion

- earlier ROM

- able to weight bear early


Non Operative Treatment / Plaster Cast




Low energy injury

Minimal ST injury

Stable fracture / minimal / acceptable displacement




Coronal < 5o

Sagittal < 10o

Rotation < 10o

Shortening < 1cm

> 50% apposition




Gavity assist over edge of bed

Application SL initially

Extend with knee slightly flexed


Union rate 




Tibial Shaft Fracture Non Operative Treatment BeforeTibial Shaft Fracture Non Operative Treatment After


Operative Treatment




1.  IM Nail

2.  Plate

3.  External Fixation


1.  IMN Nail


Tibial Midshaft Fracture IMN APTibial Midshaft Fracture IMN Post op


A.  IMN Tibial Shaft




Provides rotatory stability

- required with spiral / comminution / metaphyseal

- may not be necessary with transverse fractures




Larsen et al J Orthop Trauma 2004

- RCT of reamed v unreamed

- significantly longer time to union in unreamed



- reaming also bone grafts fracture site

- large nail provides greater stability


SPRINT trial JBJS Am 2008

- multicentred trial of over 1000 tibial IMN

- demonstrated a possible benefit for reaming


B.  IMN Proximal tibial fractures




High incidence malunion

- typically valgus 

- flexion / procurvatum

- posterior translation of distal segment


Proximal Tibial Fracture Poorly Nailed




Standard medial and anterior entry points

- mismatch to distal canal 

- canal becomes triangular

- pushes fracture into the above deformities


Surgical Points


1.  Change entry point

- match entry point to distal IM canal

- lateral and posterior

- in line with lateral tibial spine

- through or lateral to PT

- entry with knee semi-extended


2.  Blocking screws

- also lateral and posterior

- functionally narrow IM canal

- on concave side of deformity

- same positions as entry point

- posterior in proximal segment

- lateral in proximal segment


C.  IMN Distal tibial fractures


Distal Tibial FractureDistal Tibial Nail APDistal Tibial Nail Lateral




Distal tibial nails

- multiple distal screws

- some within 5 mm of end of nail

- usually 2 medial-lateral and 1 AP




Most important is to centre guide wire over talus

- in lateral and AP


1.  Use finger reduction tools and pass across fracture site

2.  Use temporary external fixator

3.  Pins in distal tibia / calcaneum to control distal fragment

4.  Plate fibula

5.  Blocking screws


2.  ORIF with plate



- metaphyseal / periarticular fractures

- tibial fractures in children


A.  Midshaft tibial ORIF


Tibial Midshaft PlateTibial Midshaft Plate Lateral



- poor skin / blood supply / muscle cover

- high risk of wound breakdown

- must strip bone to apply plate



- minimally invasive

- indirect reduction techniques





- excessive soft tissue stripping

- inability for fracture to compress


Distal Tibial ORIF Nonunion


B.  Distal Tibial ORIF



- too distal to nail



- may need initial external fixation

- hold reduction

- enable swelling to reduce

- ORIF as per tibial plafond fracture


Distal Tibial Fracture DisplacedDistal Tibial Fracture External FixationDistal Tibial Fracture ORIF


3.  External fixation




Contaminated wound

Vascular injury

Damage Control Orthopedics

Segmental bone loss - Ilizarov





- 4 or 5 mm half pin

- predrill to decrease thermal necrosis

- 2 near fracture and 2 far from cortex

- 2 bars / close to skin (2 cm)




Compartment syndrome


5 - 15 %

- pain from nerve ischaemia first symptom

- pain with passive stretch first sign


Normal compartment pressures

- > 30 mm Hg less than DBP

- < 30 mm Hg



- 3%


Delayed / non union


SPRINT trial JBJS Am 2008

- incidence of non union of 4%




Most common in proximal and distal tibial fracture


Anterior Knee Pain after IMN


Most common complication


Vaisto et al J Trauma 2008

- RCT of paratendinous v transtendinous nail insertion

- no difference in incidence of knee pain


Nail removal

- resolves in 1/2 after removal of nail

- improves in 1/4

- no improvement in 1/4




Infected Tibial Nonunion



History of infection post op

Chronic non healing draining sinus

Non responsive to oral ABx

Non union




Inflammatory markers

- persistantly raised



- non union



- confirm non union

- look for sequestrum / dead bone



- abscess


Culture sinus fluid


Management Options


Manage patient factors

- cease smoking

- maximise nutrition

- optimise medical care for co-morbities


1.  Ilizarov Technique


A.  Remove metal work / IMN

- take multiple cultures


B.  Ream / Irrigate +++


C.  Apply Ilizarov


D.  Manage non union


Option 1

- fibular osteotomy

- acute compression over next 10 days

- wait bear as tolerated

- watch for union


Option 2

- excise dead bone / non union

- acutely shorten and compress distally

- proximal corticotomy and bone transport


E.  Treat Infection


Appropriate IV ABx 6 weeks

Monitor inflammatory markers


Case 1


12 months of persistant sinus drainage

- nail removed

- Ilizarov applied with fibular osteotomy and compression of non union

- 6/52 IV Abx


Infected Tibial Non Union XrayInfected Tibial Nonunion CT


Infected Tibial Non Union Ilizarov APInfected Tibial Non Union Ilizarov Lateral


Case 2


Persistent Infected Nonunion post distal tibial nail

- nail removed

- irrigation +++

- ilizarov frame with immediate weight bearing

- union obtained, infection eradicated


Distal tibial infected non union with Ilizarov APDistal tibial infected non union with Ilizarov Lateral


2.  IM Abx rod


A.  Remove Metal work / Ream and Irrigate


B.  Make Abx rod

- use chest tube with guide wire in it

- pour PMMA with Abx (3G vanco, 3G Fluclox)

- cut off plastic sleeve

- insert rod


C.  Treat infection

- 6/52 of appropriate Abx


D. Definitive management of non union

- return at 6/52 for exchange nail / Ilizarov / BG





Segmental Bone Defects


- acute trauma

- resection of dead / contaminated bone

- resection infected bone

- resection infected non union




1.  Acute shortening

- up to 1 cm


2.  Autologous non-vascularised BG

- up to 3 cm


3.  Bone transport distraction osteogenesis

- up to 10 cm


4.  Free vascularised fibula transfer

- up to 12 cm


5.  Bulk structural Allograft 


6.  Amputation

- 10 - 30 cm


Acute shortening



- allows healing to begin immediately

- improves stability

- relaxes soft tissues

- may allow primary closure



- create LLD

- can address at later stage


Autologous bone grafting



- 6 weeks



- slow and variable incorporation

- not ideal for large defects


Donor site

- posterior iliac crest

- enough for 4 cm defect



- traditionally posterolateral for distal & middle tibia

- may need to raise muscle / free flap

- determine which way pedicle is running

- if to anterior tibial artery, posteromedial

- if to posterior tibial artery, anterolateral



- debride all avascular scar

- recanalise medullary canal for blood supply

- longitudinal troughs in cortex with burr to bleeding bone

- pack in BG, overlapping cortical bone by at least 1 cm


Bone Transport Distraction Osteogenesis


Technique 1

- proximal metaphyseal corticotomy

- 5 day latency period

- 1 mm/day distraction

- bridge diaphyseal segment

- bone graft docking site at second OT

- await consolidation (2 x transport times)


Technique 2

- acute shortening

- proximal leg lengthening


Free Vascularised Fibula Graft



- fibula segment 4cm longer than defect

- allows overlap 2 cm each end

- must leave 5 cm fibula distally, 7 cm fibula proximally

- vascular anastomosis performed

- secured with screws and external fixator

- early change to plate fixation



- technically demanding

- bone needs to hypertrophy

- risk of fracture




Cavadus et al Plastic Recon Surg 2010

- 38 free fibula grafts for defects > 4cm

- one graft was lost due to vascular reasons

- all healed

- 3 stress fractures

- time to union 5 - 9 months

- time to FWB 9 - 14 months




Tibial Malunion

Distal Tibial Malunion


Case 1


Distal Tibial Malunion APDistal Tibial Malunion LateralDistal Tibial Malunion CTDistal Tibial Malunion Correction


Case 2


Distal Tibial Malunion



Tibial Nonunion



Delayed union

- difficult to define




- 9/12 since injury

- 3 consecutive months with no signs union

- when the fracture has not healed in what you would expect to be a normal time period




A.  Hypertrophic

- abundant callous

- adequate blood supply, insufficient stability


Tibial Hypertrophic Nonunion


B.  Oligotrophic

- minimal callous

- still have adequate blood supply

- due to inadequate contact between fracture surfaces


Tibial Oligotrophic Nonunion


C.  Atrophic 

- no callous

- deficient biology, adequate stability (too adequate)




1.  Injury factors

- displacement

- bone loss

- comminution

- segmental fractures

- high energy

- compound

- soft tissue injury

- fibula intact

- anatomy i.e. scaphoid, tibia

- vascular injury


2.  Patient factors

- malnutrition

- smoking

- diabetes

- alcoholic

- immunosuppression

- medications

- Paget's

- renal osteodystrophy


3.  Surgeon Factors

- fracture left displaced

- fracture left distracted

- excessive soft tissue stripping

- infection

- nil reaming





- continued pain with weight bearing

- > 3/12







Surgical Options (After excludIng infection)



Exchange nailing

Compression plating

Posterolateral bone grafting

Ilizarov technique

Adjuncts - US





- well aligned fracture

- no significant bone loss

- early < 3/12



- simple, day surgery

- minimal risks / complications



- ill defined / variable

- may achieve union in 50%



- take out screws furtherest from fracture


Exchange nailing




1.  Bone defect

- less likely to heal if > 50% cortex missing for > 2cm

- combine with posterolateral bone graft


2.  Malalignment


3.  Presence of infection

- may achieve union but

- up to 25 % risk of disseminated infection




Remove old nail

- ream +++

- insert at least 1mm larger nail

- routinely send reamings for culture

- no preoperative ABx




Court- Brown et al JBJS Br 1995

- union rates of 90% first attempt

- 100% after simple repeat

- Higher than expected rates of infection

- likely incidence of infected tibial nail not recognised preop

- i.e. indolent infection

- recommend no ABx preop and always send reamings for M/C/S

- 6/52 ABx post op if any microbes grown in lab




1.  Fibular Osteotomy

- nil need

- only if fibular malunion preventing tibial compression


2.  Locking

- only lock if distal or proximal fracture


Compression plating



- higher infection rate

- cannot weight bear



- periarticular fractures


Cancellous Bone grafting



- 87 - 100% union rates


Cancellous bone graft

- osteoinductive

- osteoconductive

- osteogenic


Anterolateral approach

- poor skin healing

- limited amount of bone graft


Posterolateral approach



- middle and distal thirds tibia



- patient prone or lateral

- incision medial to fibula

- between FHL and peroneal tendons

- elevate FHL and soleus taken off tibia

- debridement non union

- tissue sent for MCS

- create troughs in bone segments

- apply bone graft

- close fascia over BG and drain


Posteromedial approach



- proximal tibia





- infection

- malunion

- acute shortening for skin loss

- bone transport for large segmental defects



- allows compression

- allows immediate weight bearing







- proven to improve acute tibial fracture union rates



- non invasive



- expensive

- machines $5000


PEMF / Pulsed Electro-Magnetic Frequency



- 2 surgeries to implant and remove wires



- wire fracture

- infections



- 80% union




Friedlaender et al JBJS Am 2001

- tibial IMN with established non union

- as effective as autologous BG in achieving union

- 80%


Govender et al JBJS Am 2002

- early treatment in open fractures with IMN

- multi-centred trial

- IMN wth BMP v IMN alone in open fracture

- recombinant BMP 2 on absorbable collagen sponge at time of wound closure

- prospective randomised trial

- increased union rate

- less secondary interventions

- less infections

- faster wound healing







Ilizarov Frame Proximal Tibia Clinical Photo




Poor soft tissues

- prohibit ORIF


Non union


Infected non uniion


Malunion / deformity


Bone loss / bone transport / LLD




Concept is known as flexible stability


Ilizarov Frame

- controls torsion and shear well

- allows axial compression and controlled micromotion

- this improves bone healing compared to standard external fixation

- tensioned wires tend to loosen over time and improve this situation with further loading


Can compress / lengthen

- lengthen and shorten struts

- allows compression of non union

- allows distraction osteogenesis of corticotomies




1.  High tension wires

- straight or olive

- 90 - 130 kg

- 90o to each other


Olive wires

- used to aid indirect reduction



- fix one end, tighten the other


Offset wires from rings

- using posts


2.  Pins


Use in conjunction to wires

- never at same level as each other to avoid stress riser

- 90o to each other

- 4, 5 or 6 mm

- connected to ring via rancho cubes with centering sleeves


At least 2 planes of wires / half pins in each major bone segment

- very normal to use 1 tensioned wire and two HA coated half pins

- if have 3-4 wires / half pins can remove 1 (i.e. from loosening or infection) without loosing stability of construct


3.  Rings


Various sizes

- always need extra room posteriorly

- 2-3cm space to skin circumferentially

- proximal ring open posteriorly to allow flexion

- always 2 level fixation in each level for control

- can be one ring, but wires & half pins above and below





- spread wires

- thicker wires (1.5-1.8)

- increase number of wires

- closer to fracture site

- increase tension

- smaller rings (only 2cm gap)

- olive wires


Wire placement


Anatomic Safe Zones


Aim is to avoid NV structures

- start on side containing critical structures

- push in to bone, drill through cortices

- wet gauze square to stabilise wire

- tap through soft tissue on other side

- muscles on maximus stretch to prevent impalement

- parallel to each other and to ring

- two rings in each segment


Proximal Tibia


Structures at risk

- popliteal artery and tibial nerve

- saphenous nerve


Wires Proximal to TT

- safe arco degrees

- 3 wires

- one wire anterior to fibular head angled anteriorly

- one wire through fibular head straight across posterior tibia

- one wire through medial posterior tibia angled anteriorly

- creates a triangle of bone between wires

- always 10 - 15 mm distal to joint line to avoid proximal joint capsule

- can supplement one wire with two half pins below (HA coated) in the medial cortex


Wires Distal to TT

- safe arc 140o

- not safe to go through fibula

- direct wire transversely


Schatzker 6 Proximal TibiaIlizarov Proximal TibiaIlizarov Proximal Tibia Lateral


Distal Tibia


Structures at risk


- DPN and anterior tibial artery

- posterior tibial artery and tibial nerve

- saphenous nerve



- one wire through fibula head angled anteriorly

- one through posterior medial tibia, angled anteriorly

- one straight across

- again supplement with half pins above and below


Ilizarov Distal Tibia ClinicalIlizarov Distal TibiaIlizarov Distal Tibia Lateral




Good pin site care is aided by avoiding loosening

- pin site complications are frequently related to loosening


Pin site infection


Reduce by

- subcutaneous (don't go through muscle)

- away from zone of injury

- adequate skin incisions

- predrill to avoid thermal necrosis

- manually insert pins

- HA coating

- regular pin site cleaning 

- early oral Abx


New self drilling pins are designed for motorised insertion

- avoids problem of "wobble " with hand insertion


HA coating

- improves fixation and decreases infection / loosening


Tapered pins

- increase preload and decrease loosening

- cannot back the pin up or become loose


Pin site care

- motion of skin is most deleterious

- leave a compressive dressing intact for 1 week

- simple daily showers with soap sufficient


Pin site infection

- must remove if loose

- oral Abx

- more regular cleaning

- topical bactroban (mupirocin)


Soft tissue impalement



- loss of motion

- scarring



- check ROM intraoperatively

- position joint in neutral


Late Malunion / Refracture


Dynamise frame / remove struts

- allow patient to weight bear in frame

- should be non painful




Open Tibial Fractures




Tibial facture with break in skin

- open wound communicating with fracture or haematoma


Patient is immediately at higher risk of deep infection




Wound continuously oozes dark red fracture haematoma




Up to 1/4 of tibia fractures open


Gustilo and Anderson Classification


Grade 1

- wound < 1cm

- usually inside out

- minimal muscle contusion


Grade 2

- skin laceration 1-10 cm


Compound Tibial Fracture Grade 2 Clinical Photo


Grade 3a

- > 10 cm wound, able to be closed primarily


Grade 3b

- require skin graft procedure for coverage


Compound TibiaCompound Tibia


Grade 3c

- vascular injury requiring repair




Immediate / ED Management



- assess and manage entire patient

Assess neurovascular status

Assess wound

- size / site / contamination

- photos very useful to show plastic surgeons

- will it close primarily / will it need plastic surgery

Appropriate Antibiotics

- as per Gustilo Classification


Wound management

- irrigation

- betadine dressing

Stabilise fracture


Wound Debridement < 6 hours


Surgical Technique


Extend wound

- debride contaminated tisue

- 1 mm skin edge excision

- debride subcutaneous tissue 

- deliver and debride bone ends


Assess muscle by 4C's

- Colour

- Consistency

- Contractility

- Capacity to Bleed



- remove avascular fragments unless very large or critically important

- avascular bone in continuity with vascularized bone can be kept



- pulse lavage to decrease bacterial contamination

- 9 litres

- photos


Wound management

- close if able without soft tissue tension and clean

- if needs SSG / muscle flap / free flap

- alert plastics immediately

- needs closure within 5 days for good outcome


Skeletal Stabilization


A.  Cast

- increased non and mal union in cast groups


B.  Temporary unilateral external fixator




1.  Vascular repair

- apply swiftly

- place out of way of vascular repair approach


2.  Highly contaminated wound

- inappropriate for metal work

- multiple debridements / skin closure

- eliminate infection

- delayed  definitive management


3.  Multiple injuries patient / Damage control orthopedics

- temporary external fixator

- convert to nail day 5


C.  Tibial nail



- fracture configuration suitable for nailing



- of benefit in closed fractures

- may be no difference in open fractures

- as the ST injury worsens the benefits of reaming decreases


Swiontkowski JBJS Am 2008

- SPRINT trial

- no difference in outcome in compound fractures between reamed and unreamed nails


Bhandari et al JBJS Br 2001

- systemic review of treatment for open tibial fractures

- compared unreamed nails and external fixators

- unreamed nails decreased reoperations / superficial infections / malunions


D.  Ilizarov frame



- bone defects which will need addressing


Soft Tissue Envelope


Godina Yugoslavia 1986

- 532 patients free flaps


Gp 1 -  within 72hrs

Gp 2  - 72hrs - 3/12

Gp 3  - 3/12 - 12.6yrs (average 3.4 years)


  Flap Failure Infection Union
Group 1 0.75% 1.5% 7 months
Group 2 12% 17.5% 12 months
Group 3 9.5% 6% 29 months

Management of Soft Tissue


Definitive coverage within 7 days


Type 1, 2, 3a close with DPC


Type 3b

- 94% will require plastics

- 71% require flap cover


Skin Cover Options (see separate article)

- SSG if muscle present over wound

- proximal third gastrocneumius local muscle flap

- middle third soleus muscle local flap

- distal third / gastrocneumius or soleus damaged - free gracilis muscle flap


Management Bone defects


Priniciple is to decrease dead space


ABx beads

- may decrease infection from 16% to 4% (OTA)

- prevent haematoma and scar

- can place flap over top


Can place segmental Abx cement

- new French technique

- at 6/52 there is a periosteal sleeve about the cement

- aids in bone grafting techniques


Delayed bone reconstruction options

- see Complications / Segmental Bone Loss


Union Rates


Court-Brown JBJS 1991


Type 1

- good union rates


Type 2, 3a

- high union rates but slower

- 6 - 7 months to unite

- deep infection 3.5%


Type 3b

- union time 1 year

- infection rates 17-23%

- not affected by reaming

- not affected by nail v external fixator

- very dependent on ST coverage



- a lot of effort has gone into assessing the mechanics of fracture management

- it is the treatment of ST that governs prognosis


Indications for Amputation


Absolute indications (Lange) with arterial injury

1.  Crush injury with warm ischaemia > 6 hours

2.  Anatomic division of the tibial nerve


Scoring Systems


- NISSA (nerve, ischaemia, shock, soft tissue, age)

- shown not to be predictive


Leap Study

- plantar parasthesia non predictive of outcome

- doesn't predict function of tibial nerve

- many will recover over time


See Principles of Trauma / Amputation






No progression of union over 3/12

Rule out infection



1.  Dynamise

2.  Exchange nail

3.  Bone Graft

4.  Fib Osteotomy

5.  Ring fixator


Deep Infection




1.  Reamed exchange nail


2.  Excision dead bone and necrotic tissue / Ilizarov frame

- elimination dead space

- ST coverage

- appropriate Abx

- delayed bone grafting

Skin Cover Options

Basic Concepts


Proximal tibia

- gastrocnemius local muscle flap

- gracilis free muscle flap if gastroc damaged


Middle tibia

- soleus local muscle flap

- gracilis free muscle flap


Distal tibia

- posterior tibial fasciocutaneous local flap

- gracilis free muscle flap


Distal Tibia Skin Graft


Hip / Thigh

- TFL musculocutaneous local flap



- FHB / Abductor Hallucis Longus

- dorsalis pedis fasciocutaneous local island flap

- gracilis free muscle flap


Types of coverage


1.  Split skin grafts


2.  Local flaps

- muscle (gastrocneumius / soleus / T Anterior / EDB)

- musculocutaneous (gastroc / TFL)

- fasciocutaneous (dorsalis pedis /


3.  Free flaps

- muscle

- fasciocutaneous


1.  SSG



- on bed of healthy muscle

- must not be infected



- graft taken with harvestor

- set desired thickness

- usually from anterior thigh

- meshing increase coverage

- stitched to rim of wound

- pressure dressing applied

- takes 5 - 7 days to take


2.  Local Flaps


A.  Muscle Flaps 



- high blood supply 

- deliver ABx to fight infection

- excellent bulk for eliminating dead space




Type 1 

- single pedicle, easiest to transfer

- tensor fascia lata, gastrocnemius


Type 2 

- one or more dominant pedicles, plus minor pedicles

- soleus


Type 3 

- 2 dominant pedicles




The muscle flap mobilises about the vascular pedicle, not the muscle itself


Preserving the neuro pedicle can be disadvantageous

- muscle twitching can compromise the flap

- however this can be advantageous i.e. in bracial plexus surgery


These never have an independent blood supply and are always dependent on the pedicle

- can raise the flap

- must be aware of and preserve pedicle

- check old notes

- plastics review

- ultrasound


Gastrocnemius flaps




Lateral and medial

- Workhorse of the leg

- Cover between the knee prox tibia

- Need to check sufficient muscle bulk and that muscle has not been damaged in accident



- most commonly used

- close to anterior tibia & larger



- can use, but must remove fibula and tunnel under anterior compartment

- putts pedicle at risk


Blood supply

- each head is supplied by a single sural artery 

- branch of the popliteal artery just below the joint line

- need only do angio if severe trauma, knee dislocation or previous vascular procedure




Type 2 flap

- Useful for the middle third of the tibia

- More difficult to raise as must beware the posterior tibial artery

- Muscles can easily be damaged by the tibia in high velocity trauma


Tibialis Anterior 


Occasionally used if not too damaged




Local to ankle


B.  Musculocutaneous flap



- skin is taken also to extend the flap

- SSG used to cover skin defect of donor site

- Gastrocenumius / TLF



- TFL, skin and deep fascia

- Pedicle is branch of lateral femoral circumflex

- Used for hip and thigh

- Need SSG to skin defect


C.  Fasciocutaneous flap


These have independent blood supply after 2 weeks


Posterior tibial artery flap

- Distal Tibia but greater than 10 cm from ankle

- Based on Great saphenous vein for drainage


Dorsalis Pedis Island Flap

- Used to cover heel


Sural artery flap


3.  Free Flaps


- taking tissue with vascular pedicle 

- transferring it to a distal site and re-anastomosing it

- select flaps that have a long pedicle for ease of reimplantation and positioning



- 95 - 98% success with good surgeons

- Nil evidence that smoking or age affect flap

- CRF / DM / atherosclerosis do


A. Muscle


For when muscle is required to bony cover or to fill dead space



- For defects 10 - 15 cm

- Based on medial circumflex artery

- Reasonable thin


Latissmus dorsi

- Workhorse

- For larger defects up to 25 x 40 cm 

- Based on thoracodorsal artery


Rectus Abdominus

- Less commonly used as hernias are a problem


Serratus anterior

- Used for small defects


B. Fasciocutaneous


For when skin cover only is required, not muscle bulk i.e. over ankle joint


Radial free flap

- Workhorse flap

Taylor Spatial Frame

Taylor Spatial FrameTSR Clinical Photo 2




Deformity correction


TSF Deformity Correction Proximal Tibial Fracture Preop




Apply proximal and distal rings

- choose size

- 2 cm from skin all around

- leg will often swell

- most often compression is posterior

- can use an open ring proximally to aid knee flexion


Apply proximal rings

- Centre / Master Tab anterior to tibial crest

- important for calculations


Apply Distal ring


6 x adjustable struts

- come in 3 lengths (short / medium / long)

- need to ensure that are long enough for any correction

- otherwise will have to adjust strut later

- numbered 1 - 6

- no 1 always to right of proximal strut


TSR Clinical Photo Struts


Intra-operative Correction

- can perform

- new computer program

- struts can be of different lenths

- i.e. the rings do not have to start perpendicular to shaft


Record numbers of each strut

- important for computer calculation


TSR Strut Measurements Pre Correction


Post operative Xray Measurements


Xray of entire tibia and rings

- xray centred on proximal tab of proximal ring

- AP and Lateral all in one film

- the entire diameter of the rings must be on the film


Set reference fragment


Proximal tibia

- usually the proximal fragment is reference fragment

- distal fragment is moving fragment


TSF Reference and Moving Fragment


Opposite for Distal Tibial Fractures


Set Origin / Corresponding Point on AP and Lateral



- reference fragment


Corresponding point

- on moving fragment


TSF Origin and Corresponding Point


Measure AP and Lateral View Axial Frame Offset


The tibia is not in the centre of the rings

- usually anterior

- need to tell computer where the proximal fragment is in reference to the rings


TSF AP View Frame OffsetTSF Lateral View Frame Offset


Estimate Rotatory Offset


If Proximal Ring Tab not centred over anterior border of tibia

- need to clinically estimate the difference

- i.e. 5o


Characterise the skeletal deformity


6 measurements required


AP View Angulation + Translation


TSF AP View Angulation and Translation


Lateral View Angulation + Translation


TSF Lateral View Angulation and Translation


Axial Translation (Shortening)


TSF Axial Translation


Axial View Angulation



- is the foot externally rotated

- if so, how much


Total Residual Correction


Enter details

- ring size

- strut length

- reference fragment / origin

- frame offset

- 6 measurements


Tell rate of correction

- usually 10 days to 2 weeks


Computer will calculate correction

- assumes correct to neutral

- print daily strut changes requires




TSF Proximal Tibial Fracture Pre CorrectionTSF Proximal Tibial Fracture Post Correction


TSF Proximal Tibia Union APTSF Proximal Tibia Union Lateral

Tibial Plafond

IssuesSevere Tibial Plafond


Complex / High energy injuries


Management of soft tissues critical

- restore length with external fixation

- await swelling to dissipate


Restoration of alignment / Joint surface imperative


Outcome guarded

- can still develop arthritis with good joint surface restoration

- initial injury to chondral surfaces



French for Pestle


Fracture of tibial weight bearing surface due to axial compression




35 - 40 years

Males 3 x


Up to 50% incidence of associated injuries




Rapid axial load

- very high energy




Soft tissues very poor

- thin skin

- absence of muscle and adipose tissue

- lack of deep veins


Especially vunerable over anteromedial tibia


Reudi Classification


1.  Undisplaced

2.  Displaced Simple

3.  Displaced Complex


CT scan


Critical to planning

- helps to guide surgical approach

- minimise dissection

- main fracture configuration

- plating configuration


Tibial Plafond External Fixator




1.  Soft tissue algorithm


Management of the soft tissues is the key to a good outcome


Long delays

- wait until swelling down

- wrinkled skin, blisters resolved

- wait 3 weeks plus if needed

- operating early can be a disaster


Spanning external fixation

- holds out length

- helps soft tissues recover

- patient can mobilise

- allows surgery on planned elective list


Tibial Plafond Pre External Fixator APTibial Plafond Pre External Fixator Lateral


Tibial Plafond Post External Fixator APTibial Plafond Post External Fixator Lateral


2.  Surgical Algorithm


A.  Restore fibula length

- holds fracture out to length

- prevents fracture malunion


B.  Varied surgical approach

- anterolateral / anteromedial / posterolateral

- depends on fracture configuration

- posterolateral if large posterior tibial fragment requiring buttress


C. Reduce articular surface


D. Restore bony alignment


1.  Anterolateral +/- medial plate

- percutaneous proximal fixation with indirect reducture

- restore alignment and length / provide stability


2.  Ilizarov Frame


E.  Graft any defect

- often as a delayed procedure at 6 weeks


Techniques to minimise complications


1.  Long delays until definitive surgical treatment using initial spanning external fixation 


2.  The use of small, low-profile implants 


3.  Avoidance of incisions over the anteromedial tibia 


4.  The use of indirect reduction techniques minimizing soft tissue stripping / MIPO


5.  Careful surgical management of the soft tissues at all times


Surgical Technique Plating



- supine on radiolucent table

- IV ABx

- tourniquet for 2 hours then release


ORIF fibula

- holds fracture out to length

- via posterolateral incision

- need wide skin bridge from anterior incision


Anterior skin incision

- small longitudinal incision centred over jont line

- 10 cm long

- usually anteromedial (between T Ant and EHL)

- must be 7 cm from posterolateral incision

- expose distal tibia

- minimise stretch on wound edges at all times


Anatomical reduction joint surface

- open fracture site

- open joint

- washout haematoma

- apply femoral distractor to view joint surface

- pins in tibia and calcaneus

- examine talar dome using periosteal elevator

- open joint and inspect

- ORIF small osteochondral fragments with modular hand screws / 1.5 - 2 mm


Attach metaphysis to diaphysis

- anatomically contoured low profile locking plate

- MIPO techniques

- anterolateral L shaped plate via anterior wound

- small incisions proximally to insert screws

- 4 cortices above fracture

- small medial incision to insert medial plate percutaneously


Early ROM


Bone graft defects at 6/52






Devastating wound complications

- 0% to 6% in four recent series

- with best practice


Tibial Plafond Wound Breakdown


Deep Infection






Excellent results rare


Fair to good are the norm

- develop AKJ OA over time (50%)

- related to cartilage injury at time of trauma

- AKJ arthrodesis rare



- most have some pain

- most return to work

- cannot run or play sports

- pain continues to improve for long times (up to 92 months)

- delay arthrodesis

- x-ray appearances not always related to clinical picture


Case Examples


Example 1


Fracture configuraiton

- characteristic Tillaux fragment

- otherwise lateral column mostly intact

- large medial fragment / medial column disruption



- small anterolateral approach

- joint reduction and cannulated screw from Tillaux fragment medially

- medial percutaneous plate


Tibial Plafond CT AxialTibial Plafond CT SagittalTibial Plafond CT Axial


Tibial Plafond ORIF APTibial Plafond ORIF Lateral


Example 2


Severe plafond

- large medial fragment

- characteristic Tillaux / syndesmotic fragment

- articular fragments driven up into joint

- both columns disrupted



- anterolateral approach

- use femoral distractor

- remove fragments from joint

- restore articular fragments with screws

- anterolateral plate (separate proximal incision for proximal screws)

- percutaneous medial plate (leg was ultimately too swollen, percutanous screws inserted)


Severe Tibial Plafond CT CoronalSevere Tibial Plafond CT SagittalSevere Tibial Plafond CT Axial


Severe Tibial Plateau Post Op


Case 3


In this case can alter incision

- anterolateral

- anterolateral plate only required


Tibial Plafond Fracture


Case 4


Distal tibial fracture with fibular fracture

- fibular ORIF for additional stability and improved alignment


Tibial Plafond with Fibular Fracture PreTibial Plafond with Fibular Fracture Post ORIF

Tibial Plateau


Schatzker Classification


1.  Lateral Spilt 

- seen in young patient

- lateral meniscus can be incarcerated in fracture


Tibial Plateau Schatzker 1


2.  Lateral Split Depression

- often seen in young patients with high energy injuries

- vary in severity


Tibial Plateau Joint DepressionSchatzker 2 Split DepressionSchatzker 2 Split Depression CT


3.  Lateral Depression 

- central depression usually seen in elderly

- have to create lateral cortical window in order to elevate fragment


Tibial Plateau Depression


4.  Medial plateau & intercondylar eminence 

- high velocity injury associated with ACL / LCL / CPN injury

- can be low injury / osteoporotic and often unreconstructable


Schatzker 4 Tibial Plateau


5.  Bi-condylar + intact metaphysis

- unstable

- requires ORIF


Schatzker 5 Bicondylar0001Schatzker 5 Bicondylar0002Schatzker 5 Bicondylar CT


6  Bi-condylar + metaphyseal fracture

- fracture separating metaphysis from diaphysis

- highest incidence of vascular injury


Schatzker VISchatzker 6 Schatzker 6 CT




Most common is Type II / split depression

- 80%


Type IV

- medial plateau involved

- 10 - 20%


Type V, VI

- both condyles involved

- 10 - 20%




Medial plateau larger than lateral

- medial is concave in sagittal plane (golf tee)

- Lateral is convex & more proximal (golf ball)


Creates 3o of varus proximal tibia


Knee Normal AP


Lateral plateau is covered by meniscus

- tolerates incongruity better than medial plateau


Normal posterior slope

- 10o




Lateral plateau more commonly fractures


1.  Medial plateau more resistant to fracture

- due to its larger surface and increased weight bearing

- thicker stronger subchondral bone

- any fracture of medial plateau indicates high energy 

- high incidence of soft tissue complications & poor outcomes


2.  Valgus alignment of leg


Type of fracture


1.  Young people splits / wedges

2.  Older people joint depression


Associated Injures


1.  56% incidence of ligamentous instability 

- ACL and LCL seen with medial plateau fracture


2.  20% incidence meniscal injury


3.  CPN

- again seen with medial plateau fracture


4.  Compartment syndrome

- seen in type 5 and 6


5.  Popliteal artery damage


Factors affecting outcome


1.  Step > 5mm


Blokker et al Clin Orthop 1984

- >5 mm step 0% G/E

- <5 mm 75% G/E

- < 2 mm 85% G/E


2.  Alignment


Rasmussen Acta Orthop Scand 1972

- valgus > 10o 80% OA

- valgus < 10o 14% OA

- accept only < 5o varus /  valgus


3.  Meniscus


Jensen et al JBJS 1990

- 70% OA with meniscectomy


4.  Instability


Honkonen J Orthop Trauma 1995

- M/L instability > 10o 70% OA


Indications for surgery closed fracture


1.  Step > 2mm

2.  Malalignment

3.  Mensical injury

4.  ML laxity






NV examination

Soft tissue examination

- Tscherne / closed soft tissue injury classification

- Gustillo / open soft tissue injury classification

Exclude compartment syndrome


CT scan


Sssess joint line

- predetermine fracture pattern before fixation


Temporary Spanning External Fixation


Knee Spanning Ext Fix


Tibial Plateau Temporary External Fixator APTibial Plateau Temporary External Fixator Lateral



- open fracture

- complex pattern / shortening / malalignment

- poor soft tissues / extreme swelling



- pulls out to length with ligamentotaxis

- allows soft tissues to settle / swelling resolves

- subsequent surgery easier and safer



- 2 x 5 mm half pins anterior / AL femur

- 2 x 5mm half pins anterior tibia far from incision

- apply under II guidance / reduce / apply traction

- 2 x anterior rods

- slight flexion


Definitive Management


1.  ORIF


Tibial Plateau ORIF



- blisters epithelialised

- skin wrinkled

- 2-3 weeks


Set up

- prone on radiolucent table

- knee flexed over bolster or triangle

- tourniquet, antibiotics

- remove frame, scrub leg and apply sterile dressings to pin sites to remove from operative field

- some surgeons leave frame on to aid reconstructive surgery

- may need to use femoral distractor




1. Lateral longitudinal incision

- split ITB proximally

- open anterior fascia distally

- elevate tibialis anterior from tibia

- incise coronary ligament

- elevate capsule and ligament via 1 vicryl stay sutures

- inspect joint and lateral meniscus via varus force


2.  Posteromedial approach

- 1 cm from posterior border tibia

- between medial gastrocneumius and pes anserinus

- buttress or antiglide 4 hole DCP / T plate

- may be indicated for Schatzker IV / V / VI



- elevate and restore joint line (may need cortical window and punch)

- compress with bone reduction forcep

- stabilise joint line with 2 x 6.5 mm cannulated partially threaded screws

- check II

- restore alignment via application anatomically contoured 4.5 mm locking plate

- can use MIPO if required (long fracture, Type VI)

- often use BG or substitutes under depression fractures laterally (Norian)



- must assess at end of operation




Type 1

- can reduce and screw percutaneously

- beware trapped lateral meniscus

- consider arthroscopic inspection initially

- difficult to see because of haematoma 

- also risk of compartment syndrome so need careful fluid management


Tibial Plateau Schatzker 1 Percutaneous ScrewsTibial Plateau Schatzker 1 Percutaneous screws Lateral


Posterolateral Tibial Plateau Fractures

- fracture in posterior half of lateral tibial plateau

- very difficult to access / transfibular approach

- expose / release / protect CPN

- predrill fibula head

- osteotomy above CPN

- reflect fibular head posteriorly on biceps / LCL attachments

- ORIF lateral plateua

- fibular osteotomy secured with 6.5 mm partially threaded cancellous screw


Type IV

- medial plate alone

- address lateral instability


Schatzker 4 Medial Plate0001Schatzker 4 Medial Plate0002


Type V

- single lateral plate

- double plating with medial buttress / LCP / T plate

- may wish to reduce lateral side first for anatomy

- apply medial plate second for stability

- may be a coronal split in medial plateau or TT requiring AP screws

- may need ORIF ACL bony avulsion


Tibial Plateau Bicondylar ORIF APTibial Plateau Bicondylar ORIF Lateral


Tibial Plateau Type VTibial Plateau Type V ORIF APTibial Plateau Type V ORIF Lateral


Type VI

- long locking plate minimally invasive with locking jig

- proximal lag screws

- ensure correct alignment

- often use small medial buttress plate


Tibial Plateau Schatzker 6 ORIF APTibial Plateau Schtazker 6 ORIF LateralSchatzker 6 ORIF APSchatzker 6 ORIF Lateral.jpg


2.  External Fixation



- poor soft tissues

- compound



- pins 14 from joint surface

- use olive wires to compress fracture fragments


Schatzker VI Ilizarov




Hinged Brace

NWB 8 weeks minimum




Collapse / Malunion


Tibial Plateau Collapse Malunion Tibial Plateau Collapse Malunion


Tibial Plateau MalunionTibial Plateau Malunion 2




1. Distal femoral varus osteotomy and fresh osteochondral allograft


Lateral Tibial Plateau MalunionValgus MalunionDFVO and osteochondral allograft


2. TKR


Tibial Plateau OA TKR0001Tibial Plateau OA TKR0002

Tibial Stress Fracture

EpidemiologyTibial Stress Fracture


Athletic / high impact exercises




First described in ballet dancers (Burrows 1956)

- tension side of bone / lateral side

- progression to complete fracture has been well documented in athletes




Point tenderness

- lateral aspect of tibia


Over time develop bony lump


X- ray


Often narrow medullary canal & thickened periosteum

- proximal third in adolescents

- runners typically at junction of middle and distal 1/3 


Tibial Stress FractureTibial Stress Fracture 2


Dreaded black line / fracture


Tibial Stress Fracture




Posteromedial Tibial Stress Fracture


On compression side

Better prognosis for healing


Posteromedial Tibial Stress Fracture




Granulation tissue, fibrous vascular periosteum, underlying new bone formation




Osteoid Osteoma


Osteogenesis Imperfecta






Can take a long time to heal

- up to 1 year


Can fracture

- which can go on to non union




Non operative Management




PTB / Rest




Operative Management




Bone graft

Percutaneous drilling


Anterior Plating


IM Nail


Chang et al 1996 Am J Sports Med

- five cases of chronic tibial stress fractures

- army recruits with minimum 1 year non-op treatment

- reamed IM nail

- 3 proximally locked, 2 percutaneous corticotomies

- 1 lost to follow up

- 2 excellent results (unlimited pain free running)

- 3 good results (occasional pain with vigorous exercise)

- conclusions: safe, effective / no need to lock proximally / corticotomy not needed


Varner et al Am J Sports Med 2005

- 7 athletes treated with IM reamed nail

- united by 3 months

- return to sport by 4 months

- one patient developed bursitis at nail insertion site which settled with HCLA

- one patient developed a distal tibial traumatic fracture which healed non operatively


Anterior Plating


Borens et al J Orthop Trauma 2006

- 4 world class female athletes

- treated with anterior tension band plate

- no complications

- all healed and return to full sports at 10 weeks