Executive Editor: Peter Trafton, Michael Baumgaertner

Authors: Martin Hessmann, Sean Nork, Christoph Sommer, Bruce Twaddle

Distal tibia Complete, multifragmentary articular and metaphyseal fracture

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Glossary

General considerations

These are complete articular injuries. In addition to articular surface fractures, there is complete detachment of the distal fragments from the proximal tibia.

Treatment must restore the articular surface and joint congruity, and correct axis malalignment. Sufficient stability for early motion is strongly recommended.

These severe distal tibial fractures involve multiple fragments of both articular surface and metaphysis. Adequate preoperative imaging is essential for preoperative planning. This may require provisional traction reduction and external fixation before obtaining CT-scans.

Nonoperative treatment - Temporary traction
Indication summary Skill Equipment
Significant local soft-tissue swelling, patient's general condition satisfactory for maintained bed rest Basic surgical experience, no specialized skills Basic equipment only

Further indications

  • Other injuries in the same extremity that require provisional traction 
  • Patient can tolerate constant bed rest
  • Medical conditions expected to improve enough for surgical treatment

Contraindications

  • Untreated open fractures or compartment syndrome 
  • No reason to delay definitive surgery
  • Better stability necessary

Advantages

  • Continuous traction may improve alignment
  • Better stability than cast 
  • Possibility for stabilizing other ipsilateral lower extremity injuries

Disadvantages

  • Less stable than external fixation 
  • Requires bed rest 
  • Risk of pin-track infection
Temporary joint-bridging modular external fixation
Indication summary Skill Equipment
Fracture with significant injury or expected severe swelling Some specialized surgical experience Simple surgical and imaging resources

With an external fixator, the joint can be reduced and stabilized temporarily in an adequate position, allowing the soft tissues to settle. The modular external fixator maintains the length and holds the foot in a neutral position without a tibiotarsal transfixation.

Further indications

  • Damage control in the polytraumatized patient
  • Compartment syndrome
  • Associated vascular repair

Contraindication

  • Injury patterns or associated injuries where no distal pin placement is possible

Advantages

  • Rapid preliminary stability
  • Permits patient transfer without loss of immobilization
  • Effective fracture stabilization aids soft-tissue recovery
  • Allows exposure and care of open wounds

Disadvantages

  • Pin-track infection risk, possibly delaying definitive surgery
  • Nerve or artery injury from pins
Temporary joint-bridging triangular external fixation
Indication summary Skill Equipment
Fracture with significant injury or expected severe swelling Some specialized surgical experience Simple surgical and imaging resources

With an external fixator, the joint can be reduced and stabilized temporarily in an adequate position, allowing the soft tissues to settle. This requires a tibiocalcaneal frame to maintain the length and a tibiotarsal fixation to hold the foot in a neutral position.

Further indications

  • Damage control in the polytraumatized patient
  • Compartment syndrome
  • Associated vascular repair

Contraindication

  • Injury patterns or associated injuries where no distal pin placement is possible

Advantages

  • Rapid preliminary stability
  • Permits patient transfer without loss of immobilization
  • Effective fracture stabilization aids soft-tissue recovery
  • Allows exposure and care of open wounds

Disadvantages

  • Pin-track infection risk, possibly delaying definitive surgery
  • Nerve or artery injury from pins
ORIF - Plate and screws through anterolateral approach
Indication summary Skill Equipment
Deformity and instability of articular surface and metaphyseal zone. Fracture pattern and/or condition of soft tissues favors anterolateral approach Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Distal tibial fractures have significant risk of wound healing problems after open reduction and internal fixation. Waiting until the tissues have recovered or using a less invasive technique are ways of avoiding wound breakdown in this dangerous region. In any case the gentlest possible soft-tissue handling, and avoidance of unnecessary dissection are important principles.

Further indications 

  • Anterolateral approach preferred if anterior joint fracture line is more lateral
  • Initial valgus displacement of pilon
  • May be safer than medial approach, depending upon soft-tissue condition in both locations

Contraindications

  • Soft tissues unsatisfactory for direct surgical exposure
  • Risks of surgery exceed expected benefits because of patient's general condition 
  • Previous fibular incision too close to anterolateral incision site

Advantages

  • Anterolateral incisions less likely to break down
  • Anterolateral plate resists valgus deformity
  • Permits early motion 

Disadvantages

  • Adequate exposure may be extensive with increased risk of local surgical complications
  • Neurovascular structures at risk in proximal part of incision 
  • Lateral incision limits access to anteromedial tibia for reduction and fixation
  • Requires experienced surgeon
  • Delayed weight bearing required
ORIF - Plate and screws through anteromedial approach
Indication summary Skill Equipment
Deformity and instability of articular surface and metaphyseal zone. Fracture pattern and/or condition of soft tissues favors anteromedial approach Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Distal tibial fractures have significant risk of wound healing problems after open reduction and internal fixation. Waiting until the tissues have recovered or using a less invasive technique are ways of avoiding wound breakdown in this dangerous region. In any case the gentlest possible soft-tissue handling, and avoidance of unnecessary dissection are important principles.

Further indications 

  • Displaced multifragmentary fracture with appropriate soft-tissue envelope
  • Anteromedial approach preferred if anterior joint fracture line is more anterior or medial
  • Initial varus displacement of pilon

Contraindications

  • Soft tissues unsatisfactory for direct surgical exposure
  • Risks of surgery exceed expected benefits because of patient's general condition 

Advantages

  • Medial plate resists varus deformity
  • Permits early motion 

Disadvantages

  • Medial soft-tissues may be more at risk of wound break down
  • Adequate exposure may be extensive with increased risk of local surgical complications
  • Difficult to see anterolateral tibial fracture lines
  • Requires experienced surgeon
  • Delayed weight bearing required
*Skill
Basic surgical experience, no specialized skills Basic surgical experience, no specialized skills
Some specialized surgical experience Some specialized surgical experience
Highly experienced and skilled surgeon Highly experienced and skilled surgeon
*Equipment
Basic equipment only Basic equipment only
Simple surgical and imaging resources Simple surgical and imaging resources
Full specialized surgical and imaging resources Full specialized surgical and imaging resources

v2.0 2018-11-12