Executive Editor: Peter Trafton, Michael Baumgaertner

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

Distal tibia Partial articular, depression fracture

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Glossary

General considerations

These fractures involve two or more split fragments, each with possible interfragmentary impaction. As with all partial articular distal tibial fractures, a portion of the articular surface does remain intact.
Each split and/or impacted fragment must be reduced, one after the other to reconstruct the entire distal tibial articular surface. Fragments with ligamentous connections to the distal fibula must be recognized and reduction and fixation of the fibula may be an important component of the procedure. 

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

  • Fracture with slight to moderate instability
  • 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, patients 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
ORIF - Buttress plate and lag screws
Indication summary Skill Equipment
Articular surface deformity and incongruity Highly experienced and skilled surgeon Full specialized 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 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 multifragmentary depression fractures
  • Permits early motion

Disadvantages

  • Adequate exposure may be extensive with increased risk of local surgical complications
  • Requires experienced surgeon
  • Extent of fragmentation may approach limits of possible reduction and fixation
  • 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