Stabilization procedures in large soft-tissue and bone defects

When stabilizing fractures with large soft tissue and bone defects, the primary concern is to avoid additional vascularization damage. Therefore, external fixation is still the standard method. In metaphysical fractures, joint transfixation should be avoided if possible. Concerning closed comminuted fractures of femoral and tibial shaft fractures, interlocking nailing shows the lowest complication rate. The introduction of unreamed nailing of open fractures shows the same low infection rate as external fixation, so it can be considered an alternative method. Early plate fixation is applied for fractures of the upper extremities as well as the proximal and distal femur, if secure covering with vital tissue can be provided. As this is not guaranteed in the case of the tibial shaft, plate fixation remains the absolute last resort. Concerning distal and proximal fractures of the tibial pylon and tibia head, plate fixation is very often applied for definitive stabilization. However, the secondary application represents a considerably lower infection and fracture-healing risk.