Sponsorship provided by Smith & Nephew, Inc. Fragment-Speciﬁc Fixation of Proximal Tibia Fractures: Case Report and Surgical Technique Yelena Bogdan, MD* and Paul Tornetta III, MD† Summary: Proximal tibia and plateau fractures are challenging cases with a high rate of soft-tissue complications. Although precontoured locking plates provide excellent results, they are not always ideally suited for ﬁxation of additional or small fragments, and their prominence can lead to irritation and wound problems. Fragment-speciﬁc ﬁxation for complex fractures has been used extensively in the upper extremity, but the literature on the lower extremity is sparse. The purpose of this article is to illustrate the use of small-fragment plates in the ﬁxation of a complex proximal tibia fracture. Key Words: proximal tibia fracture, plateau fracture, fragment- speciﬁc ﬁxation, small-fragment plating INTRODUCTION The aims of periarticular fracture ﬁxation include restoration of articular congruity, joint stability, and metaphyseal alignment. Locked plating has become more popular in the care of tibial plateau fractures. 1 Their variable-angle screw options, and ability to compress and bridge, have greatly enhanced the surgeon’s armamentarium in approaching these difﬁcult injuries. However, these plates, especially when placed under thin or damaged soft tissue, may compromise wound healing. Plate irritation occurs with a bone–plate distance of as little as 5 mm. 2 Even with staged external ﬁxation and careful soft-tissue handling, complication rates of high-energy proximal tibia fractures range from 10% to 30%. 3,4 One study cited an infection rate of 21%, with 8% being deep infections. Ten percent of patients experienced hardware- related complications, including pain and mechanical symptoms associated with prominent screws and lateral plates. These complications were independent of factors such as age and dia- betes. 3 Additionally, locking plates are precontoured to ﬁt the bone in a speciﬁc place, and thus may not be in an ideal position over the fracture spikes, and are not reliable in stabilizing post- eromedial fragments. 5 In contradistinction to precontoured plating, fragment-speciﬁc ﬁxation involves using thinner, more malleable small or mini plates in the most biomechanically optimal position to support fracture fragments. These plates can be used in 3 ways: as provisional ﬁxation, as supplementary ﬁxation in addition to large plates, and as the sole ﬁxation in smaller joints, such as the ankle. 6 In subcutaneous bones like the clavicle, these low-proﬁle plates enjoy a lower implant removal rate, 7 a signiﬁcant advan- tage particularly in traumatized soft tissue. Further advantages include ease of contouring, multiple points of ﬁxation, and the ability to capture smaller fragments using smaller and more clus- tered screw options. Fragment-speciﬁc ﬁxation has been successfully used in the upper extremity, including the distal humerus, 8 Monteggia elbow fracture–dislocations, 9 and the distal radius. 10 Lower extremity literature, on the other hand, is limited. One study used small 3.5 T- plates and atraumatic soft-tissue handling to ﬁx tibial plateau fractures in 17 patients. In unicondylar fractures, the plate was used on its own; in bicondylar C-type fractures, it was supplemented with a medial external ﬁxator. The authors cited their ability to place screws very proximally, allowing for better support of the fracture fragments. All fractures united without infection, and no patient experienced irritation during knee motion; however, 4 thin From the *Department of Orthopaedic Surgery, Geisinger Holy Spirit, Camp Hill, PA; and †Department of Orthopaedic Surgery, Boston Univer- sity Medical Center, Boston, MA. P. Tornetta: intellectual property, Smith and Nephew; intellectual prop- erty, Wolters Kluwer. The remaining author reports no conﬂict of interest. Reprints: Paul Tornetta III, MD, Boston University Medical Center, Bos- ton, MA 02118 (e-mail: ptornetta@gmail.com). The views and opinions expressed in this case report are those of the authors and do not necessarily reﬂect the views of the editors of Journal of Orthopaedic Trauma or Smith & Nephew, Inc. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/BOT.0000000000001253 J Orthop Trauma  2018 www.jorthotrauma.com e1 Copyright Ó 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.