Executive Editor: Peter Trafton, Michael Baumgaertner

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

Distal tibia Partial articular, split fracture

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Glossary

1 Preliminary considerations top

Partial articular distal tibia fracture enlarge

Fracture characteristics

Usually, the soft-tissue injury is minimal and therefore, these fractures can often be fixed in one stage. Timing can be crucial. Optimal time is either in the first six hours after injury, or after 4-6 days depending on the soft-tissue swelling.

The fibula can be intact or not. Additional injury of the syndesmotic ligaments must be detected during the operation. It might be necessary to address these injuries as well by suture and/or syndesmotic fixation.

2 Fracture orientation and choice of approach top

Buttress plating and lag screw to treat pure split fractures of the distal tibia enlarge

Introduction

Many pure split fractures of the distal tibia can be approached minimally invasive using stab incisions for the application of reduction forceps and screw fixation. Depending on the fracture pattern, a smaller open approach can be used for the insertion of an antiglide plate.

This latter approach has to be placed in relation to the position of the proximal end of the fracture and can be placed wherever the fracture ends proximally.

Interfragmentary lag screws should be inserted from the small fragment to the large intact articular segment of the tibia, providing optimal compression force by the long threaded hole. In the illustrated cases with smaller fractured fragments, plate and screws are inserted from the same direction. With a large fragment, it might be necessary to insert the lag screws at the joint level from the opposite direction of the plate, as shown in the following example.


Radiographic example of pure split fracture of the distal tibia enlarge

Fracture assessment

The split fracture can occur in the frontal or sagittal plane, or in between.

The following case demonstrates the surgical management of a partial articular split. The fracture is a large posteromedial fragment of the distal tibia, involving more than 80% of the articular surface. There is a moderate displacement with shortening, resulting in a small intraarticular step and a larger gap. The fracture plane is located between the frontal and sagittal.


Pure split fracture of the distal tibia with a rupture of the anterior syndesmotic ligament enlarge

It is combined with a proximal fibular fracture and with a rupture of the anterior syndesmotic ligament.

3 Approach top

Posteromedial approach to the distal tibia enlarge

Posteromedial approach

Since the proximal end of the illustrated tibial fracture is posteromedial, this is where an incision is required. A small posteromedial approach is performed.

After dividing the subcutaneous fat preserving the greater saphenous vein and nerve, the posteromedial tibial crest is exposed by a small longitudinal incision of the fascia of the deep flexor compartment.


Distal anterolateral approach to the distal tibia enlarge

Distal anterolateral approach

A separate small, distal anterolateral approach is helpful to apply a reduction forceps close to the joint and to insert separate lag screws.

Care has to be taken to the superficial peroneal nerve which crosses this approach in a slightly oblique direction.

4 Reduction top

Reduction of pure split fracture of the distal tibia enlarge

The fracture line is cleaned.

Reduction is achieved by fixation of a one-third tubular plate. The four-hole plate is placed at the level of the proximal end of the fracture, through the posteromedial approach. This plate aids reduction and acts in an antiglide mechanism.

A first screw is placed just proximal to the fracture and tightened, to reduce the fracture by pushing the fractured fragment distally.

The remaining distal gap is reduced with large pointed reduction forceps applied percutaneously. Temporary K-wires can be added if necessary.

The reduction of this large articular piece (red) must be completely anatomical.

Assessment of the reduction can be performed visually at the proximal end of the fracture and by using fluoroscopic control at the joint level. See also "assessment of reduction" under "authors' added material".

5 Insertion of lag screws top

Lag screw positioning to treat a pure split fracture of the distal tibia enlarge

When anatomic position of the fractured fragment is confirmed, lag screws are inserted above the articular surface and perpendicularly to the fracture plane.

In smaller fractured fragments, plate and screws may be inserted from the same side, through a slightly enlarged approach.


Lag screw positioning through the antiglide plate to treat a pure split fracture of the distal tibia enlarge

Additional stabilization

Fracture stabilization is finished with a lag screw through the antiglide plate to prevent a secondary displacement of the proximal end of the large fragment.

6 Assessment of ankle mortise stability top

Stability check of the ankle mortise (syndesmotic ligaments) enlarge

Stability of the ankle mortise (syndesmotic ligaments) has to be checked under fluoroscopic control using the pronation/external rotation test as shown in the illustration. Alternatively, depending on the location and size of the anterolateral approach, the hook test can be performed.


Suprasyndesmotic fibulotibial screw to stabilize the ankle mortise enlarge

If a syndesmotic disruption is present, there will be rotational instability of the distal fibula with widening, under stress, of the syndesmosis in the anterior part.

Since this is present in the illustrated case, a suprasyndesmotic fibulotibial positioning screw will be added.


Note: Intraoperative x-rays or image intensification are advised to confirm the position of the screw and the distal tibiofibular joint.

7 Fixation of the syndesmotic complex top

Radiographic example of buttress plating and lag screws to fix a pure split fracture of the distal tibia enlarge

After reduction of the fibula at the syndesmosis using either manual compression or percutaneously applied large reduction forceps, introduce the positioning screw through a separate stab incision obliquely from posterior to anterior at an angle of 25–30° and parallel to the tibial plafond. The ankle should be neutral or dorsiflexed during the insertion of this screw.

Place a 3.5 mm cortex screw just proximal to the tibiofibular joint. As this screw is not intended to act as a compressive lag screw, the thread must be tapped in both fibula and tibia.

In complete disruption of the syndesmosis with high instability, two screws are advisable.


Note: Intraoperative x-rays or image intensification are advised to confirm the position of the screw and the distal tibiofibular joint. See also "assessment of reduction" under "authors' added material".

v2.0 2018-11-12