Distal Tibial Fractures

Distal Tibial Fractures

 

Definition

 

Metaphyseal

Extra-articular

 

Distal Tibial Fracture

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Intra-articular Extension

 

Posterior Malleolar Fractures

- occult in 70%

- especially with spiral distal tibial fractures

 

Distal Tibia Intra-articularDistal Tibia Intra-articularDistal tibia CTDistal tibia CT

 

Distal tibia Distal tibia 2Distal tibia 3Distal tibia 4

 

Wang et al. J Orthop Surg Res 2021

- systematic review

- incidence 70% occult fractures

https://pubmed.ncbi.nlm.nih.gov/34074309/

 

Nonoperative Management

 

Tibial Shaft Fracture Non Operative Treatment BeforeTibial Shaft Fracture Non Operative Treatment After

 

 

Operative Management

 

Options

 

1. Temporary external fixator

2. IM Nail

3. Plate

 

Temporary External fixation

 

Indications

- significant swelling

- significant displacement / non controlled in cast

- significant wounds, need for soft tissue coverage

 

Technique

- two pins proximal tibia

- trans-calcaneal pin

 

AO Trauma Ankle Bridging Delta Frame

https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/distal-tibia/partial-articular-split-depression-fracture/temporary-joint-bridging-triangular-external-fixation#principles-of-joint-bridging-triangular-external-fixation

 

Distal Tibial Fracture DisplacedDistal Tibial Fracture External FixationDistal Tibial Fracture ORIF

 

Nail v Plate

 

Liu et al. Orthop Surg 2019

- meta-analysis of 10 RCTs, 911 patients

- no difference in nonunion, delayed union, or time to union

- reduced incidence of malunion with MIPO plate

- reduced wound problems with nail

https://pubmed.ncbi.nlm.nih.gov/31823496/

 

Intra-medullary Nail

 

Distal Tibial FractureDistal Tibial Nail APDistal Tibial Nail Lateral

 

Indications

- wounds / soft tissues not suitable to plate

- relatively stable

- sufficient distal bone

 

Design

 

Distal tibial nails

- multiple distal screws

- usually 2 medial-lateral and 1 AP

- most distal screw within 5 mm of end of nail

 

Smith & Nephew Tibal Meta Nail

https://www.smith-nephew.com/global/surgicaltechniques/trauma/trigen_meta_instrument_01361v10114_us.pdf

 

Vumedi nail video

https://www.vumedi.com/video/distal-tibia-nailing-when-how/

 

Technique

 

Consider semi-extended suprapatella nail

- easier to reduce fracture

- easier to get AP and lateral fluoroscopy

 

Most important is to centre guide wire over talus

- in lateral and AP

- use finger reduction tools and pass across fracture site to exact centre in AP and lateral

- bone reduction forceps

- blocking screws

- universal external fixation

- plate fibula

 

Fibular fixation

 

Peng et al. J Foot Ankle Surg 2021

- tibial IMN +/- fibular fixation

- meta-analysis of 4 trials, 283 patients

- tibial malalignment of 67% (126 / 189) in non fibular fixation group

- tibial malalignment of 20% (19/94) in the fibular fixation group

https://pubmed.ncbi.nlm.nih.gov/33218862/

 

Distal tibia fibularFibular fixation Distal tibia

 

Posterior malleolar fixation

 

Typically stabilize intra-articular fracture first

 

Posterior malleolusPosterior malleolus 2Posterior Malleolus 3

 

B.  Distal Tibial ORIF with plate

 

Indications

- too distal to nail

- very comminuted / unstable

- intra-articular extension

 

Distal tibial plate 1Distal tibial plate 2

 

Technique

 

1. Consider fixing the fibula

- will aid reduction / avoid malunion

- help control very unstable fractures

 

2. Anatomically contoured plates

- options of medial plate v anterolateral plate

- medial plate for varus deformity

- anterolateral plate for valgus deformity

 

Distal tibia plateDistal tibia plate 2Distal tibia plate 3Distal tibial plate 4

 

Distal tibia plate 5Distal tibia plate 6

 

Complications

 

Barcak et al. J Orthop Trauma

- single surgeon, extra-articular fractures

- 43 IMN and 43 MIPO plate

- both groups similar

- nonunion rate 7 - 8%

- malalignment 3%

- wound complication 3%

- 26% of IMN required distal locking screws removed

https://pubmed.ncbi.nlm.nih.gov/27101167/

 

Nonunion

 

Distal Tibial ORIF Nonunion

 

Plate and bone graft

 

Lin et al. Injury 2017

- 9 patients with distal tibia nonunion

- posteolateral approach to avoid poor anterior skin

- plate and iliac crest bone graft

https://pubmed.ncbi.nlm.nih.gov/28342545/

 

External fixator

 

Schoenleber et al. Foot Ank Int 2015

- 8 patients treated with ilizarov / taylor spatial frame

- hypertrophic nonunions

- callous distraction - allowed correction of deformity and shortening

- all achieve union at 6 months

https://pubmed.ncbi.nlm.nih.gov/25358806/

 

Malunion

 

Distal Tibial Malunion

 

Infection

 

Persistent infected nonunion post distal tibial nail

- nail removed

- irrigation +++

- ilizarov frame with immediate weight bearing

- union obtained, infection eradicated

 

Distal tibial infected non union with Ilizarov APDistal tibial infected non union with Ilizarov Lateral