Executive Editor: Peter Trafton, Michael Baumgaertner

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

Distal tibia Extraarticular, simple fracture

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Glossary

General considerations

Extraarticular fractures have a simple 2-part pattern with or without an associated fibular fracture.

The status of the soft tissues is variable and determines the safety of surgical treatment. Delaying definitive open reduction and internal fixation reduces the risk of complications related to severely injured soft tissues.
Fractures with greater displacement are less stable and may heal with deformity unless adequate fixation is maintained through healing.

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

  • 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

Traction is generally the least favorable technique for temporary stabilization.

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 length 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

Hybrid external fixators may be used for selected distal tibial fractures, particularly when soft tissue damage is severe, or if surgical fracture stabilization is necessary but the risks of internal fixation are considered to outweigh the benefits.

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 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
  • 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 simple 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 - Compression plate
Indication summary Skill Equipment
Fracture with appropriate pattern, closed reduction possible, soft-tissues suitable Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Further indications

  • Displaced, unstable fracture 
  • Simple extraarticular distal tibial fractures where MIO technique can be used with compression 
  • 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 absolute stability for articular component and relative stability for metadiaphyseal component
  • 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
ORIF - Compression plate
Indication summary Skill Equipment
Displaced, unstable fracture with appropriate pattern, soft-tissues suitable Highly experienced and skilled surgeon Simple surgical and imaging resources

Distal tibial fractures have significant risk wound healing problems after open reduction and internal fixation. Waiting until the tissues have recovered and using a less invasive technique are ways of avoiding wound breakdown in this dangerous region. Gentle soft-tissue handling, and avoidance of unnecessary dissection are critical techniques.

Further indications

  • Preliminary to planned soft-tissue flap coverage
  • Intramedullary nailing is not an acceptable alternative
  • Fractures where satisfactory closed reduction cannot be achieved

Contraindications

  • Elevated risk factors for impaired healing (diabetes, arteriosclerosis, smoking)
  • Risks of surgery exceed expected benefits because of patient's general condition

Advantage

  • Offers anatomical reduction with absolute stability

Disadvantages

  • Extensive exposure increases risk of healing problems (wound break down, infection, delayed fracture healing)
  • Medial plate may interfere with skin closure
*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