By Thad Jackson & Deborah Blades
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Extra resources for Radiography of the cervical spine in trauma
This explains the mechanical problems caused by other nail designs, which use small screws in this kind of fracture [3, 4]. Distal Fractures Distal tibia fractures can be easily treated with IM locking nails  because closed procedures are particularly indicated in this area for soft tissue reasons. We know that open procedures are riskier and that the complication rate is often high after plating techniques used in open fractures, for example. When using locking nailing techniques in distal fractures, the two distal screws have to be inserted downstream of the fracture line.
When one considers that the first successful free tissue transfer was performed in 1962  and that fasciocutaneous flaps were only described in the early 1980s , it is obvious that the importance of plastic surgery in the management of open fractures is a relatively recent phenomenon. The role of fixation in open fractures has also increased in recent years. The first book detailing the techniques of fracture fixation was published by Brenger-Fraud in 1870 , but until Lister's work with antisepsis and the later introduction of antibiotics, the use of internal fixation in the management of open fractures was not widespread.
Lateral Malleolar Fractures These fractures can be treated by open procedures with plates or by closed procedures by IM pinning. The important point is to give the fibula the correct length and/or to repair the inferior tibiofibular joint. Posterior (or Third) Malleolar Fractures This fracture must be treated by an antero-posterior screw after reduction of the frontal fracture line. The reduction of this fracture is obtained by putting the ankle in the talus situation. Again, it is very important to place the screw as distal as possible to avoid any contact with the distal tip of the nail.