Executive Editor: Peter Trafton, Michael Baumgaertner

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

Distal tibia Extraarticular, multifragmentary fracture

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Glossary

General considerations

These extraarticular fractures have a multifragmentary zone between proximal and distal segments. The fibula may be fractured or intact. These fractures are the least stable of the extraarticular distal tibial fractures and require mechanical support to preserve normal alignment. Multifragmentary fractures have absorbed more energy and have a greater damage to both bone and surrounding soft tissue.

The status of the soft tissues determines the safety of surgical treatment. Temporary external fixation, with delay of definitive repair, reduces the risk of complications related to severely injured soft tissues.

Nonoperative treatment - Temporary cast
Indication summary Skill Equipment
Temporary splintage necessary, cast provides this adequately without compromising soft tissues Basic surgical experience, no specialized skills Basic equipment only

Further indications

  • Definitive surgical fixation is planned 
  • As initial treatment until soft-tissue swelling decreases, or to permit patient transfer

Contraindications

  • Fractures with severe soft-tissue compromise (caution: swelling can increase significantly in the first hours after injury!)
  • Impending compartment syndrome

Advantages

  • Temporary reduction and immobilization of the fracture
  • Allows further imaging (e.g., CT) to plan definitive treatment
  • May be applied after debridement of open fracture

Disadvantages

  • Limited stability
  • Soft-tissue evaluation is difficult
  • May need to loosen cast to accommodate soft-tissue swelling or impending compartment syndrome

Note: Temporary joint-bridging external fixation provides higher stability and allows better evaluation of the soft tissues. Therefore, external fixation should always be considered for more severe distal tibial fractures, closed or open.

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
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 limited 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
  • 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 
  • Risk of pin-track infection 
  • Possible compromise of future surgical exposures
  • Unexpected severe swelling may require premature ring removal
MIO - Intramedullary nail
Indication summary Skill Equipment
Any unstable extraarticular fracture of sufficient length to allow for adequate distal locking Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Further indications

  • Loss of reduction after nonoperative treatment
  • Segmental fractures

Contraindications

  • Short distal segment
  • Inability to reduce the fracture by indirect means
  • Severely contaminated open fracture
  • Associated ipsilateral total knee joint replacement
  • Risks of surgery exceed expected benefits because of patient's general condition

Advantages

  • No local open surgical approaches
  • Minimal additional insult to soft-tissue injury
  • May allow earlier weight bearing

Disadvantages

  • Can be difficult to accurately reduce the fracture
  • May require supplementary techniques for adequate stability
  • May require a delay for recovery of pin sites if temporary external fixation has been used before IM nailing
MIO - Bridge plate
Indication summary Skill Equipment
Displaced, unstable fracture with closed reduction possible, soft-tissues suitable Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Further indications

  • Short distal segment not allowing intramedullary nailing
  • Following adequate soft-tissue recovery after provisional external fixation

Contraindications

  • Inability to reduce the fracture by indirect means 
  • Severe open or closed soft-tissue injury
  • Risks of surgery exceed expected benefits because of patient's general condition

Advantages

  • Offers relatively stable fixation
  • Minimal disruption of the soft tissues at the fracture site 

Disadvantages

  • Can be difficult to satisfactorily reduce the fracture 
  • Requires technical precision
  • Medial subcutaneous plate may threaten skin, even with small incisions
*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