Executive Editor: Peter Trafton, Michael Baumgaertner

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

Distal tibia Complete simple articular, simple 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 simple distal tibial fractures involve only two large fragments each bearing articular surface. Adequate preoperative imaging is essential for preoperative planning.

Nonoperative treatment - Definitive cast
Indication summary Skill Equipment
Undisplaced stable closed fractures, patient's general condition unsuitable for surgery Basic surgical experience, no specialized skills Basic equipment only

Further indications

  • Undisplaced stable closed fracture
  • Significant comorbidities (excessive risk of surgery and anesthesia)
  • Reducible deformity judged to be stable in a suitable cast

Contraindications

  • Open fractures
  • Compartment syndrome
  • Uncorrected fracture malalignment

Advantages

  • Avoids risks of surgery
  • Does not require advanced resources

Disadvantages

  • Risk of secondary fracture displacement
  • Unsatisfactory reduction may require change of treatment
  • Cast immobilization may be prolonged
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

  • Significant local soft-tissue swelling
  • 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
Hybrid external fixation
Indication summary Skill Equipment
Severe soft-tissue injury, unstable reducible fracture Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Further indication

  • Definitive stabilization in patients with compromised soft tissues

Contraindications

  • Inability to obtain satisfactory reduction or stability
  • Soft-tissue injuries, or fracture configuration prevent adequate pin or wire placement

Advantages

  • Minimal soft-tissue disruption of the fracture zone
  • Offers surgical stability without open reduction and internal fixation
  • May be combined with open reduction and partial internal fixation
  • Reduction and stability to aid soft-tissue recovery
  • Rapid initial stabilization
  • Allows staged surgical management

Disadvantages

  • Potential for loss of reduction
  • Risk of pin-track infection
  • Possible compromise of future surgical exposures
Full ring external fixation (Ilizarov)
Indication summary Skill Equipment
Severe soft-tissue injury, unstable reducible fracture, optimal stability desired Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Further indications

  • Severe soft-tissue injury preventing other forms of definitive stabilization
  • Ability to obtain satisfactory reduction and distal wire/pin placement
  • Displaced, unstable fracture

Contraindications

  • Unfamiliarity with technique
  • Inability to obtain satisfactory reduction or stability
  • Injuries and fracture patterns preventing adequate pin or wire placement

Advantages

  • Minimal soft-tissue disruption of the fracture zone
  • Many variations in technique and frame design possible
  • Most stable external fixation construct 
  • May permit early weight bearing, particularly if extended to foot
  • May be combined with open reduction and partial internal fixation
  • Allows staged surgical management

Disadvantages

  • Ring fixators offer limited potential for reduction and stabilization of articular surface fractures
  • Unexpected severe swelling may require premature ring removal
  • Risk of pin-track infection 
  • Possible compromise of future surgical exposures
MIO - Intramedullary nail
Indication summary Skill Equipment
Simple complete articular fracture with two large fragments that can be reduced and lagged to allow for interlocked IM nail placement, rarely indicated Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Contraindications

  • Short distal segment after reconstruction
  • Associated ipsilateral total knee joint replacement
  • Risks of surgery exceed expected benefits because of patient's general condition

Advantage

  • Minimal fracture site exposure may be possible 

Disadvantages

  • Requires preliminary reduction and fixation of distal tibial articular segment
  • Distal lag screws must leave room for nail insertion
ORIF - Plate and screws
Indication summary Skill Equipment
Articular surface deformity and incongruity Highly experienced and skilled surgeon Simple 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.

Contraindications

  • Soft tissues unsatisfactory for direct surgical exposure
  • Adequate preoperative assessment of injury is required before surgery
  • Risks of surgery exceed expected benefits because of patient's general condition 

Advantages

  • Direct anatomical reduction of articular surface fracture and associated impaction
  • Best biomechanical stabilization for simple complete articular fractures
  • Permits early motion

Disadvantages

  • Adequate exposure may be extensive with increased risk of local surgical complications
  • 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