Distal tibia fractures

DISTAL TIBIA FRACTURES

DR. SABYASACHI BARDHAN

DEFINITION

Distal tibia fractures are primarily located within a square based on the width of the distal tibial metaphysis.

ANATOMY

Internal rotation of distal tibia

SOFT TISSUE

Paucity of soft tissue coverageon the anterior aspect

EPIDEMIOLOGY

Avg. age 35-40

Rare in children

Males 3 x more common

3-9% of all tibia fractures

Associated injuries 25-50%

MECHANISM

Axially directed force Intra articular fractures More soft tissue injury High energy/ open

injuries

Rotational force Spiral fractures Variable amount of soft tissue injuries/ open fractures

RUDI ALLGOWER CLASSIFICATION

Type 1

Type 2

Type3

AO CLASSIFICATION: 43

A:

Extraarticular

B:

Partial articular

C:

Complete articular

CLINICAL PRESENTATION

Pain

Swelling

Deformity

……………

Blisters

Open wound

Associated injuries

IMAGING

X Ray CT Scan

PRIMARY MANAGEMENT

Bulky padding POP splint/ BB

splint Temporary Exfix Strict elevation Pain relief

Debridement & Lavage

Temporary Ex fix Antibiotics Relook after 48 hrs Plastic surgery opinion Elevation

Closed fractures

Open fractures

NON OPERATIVE

Plaster of paris cast/ Synthetic cast Undisplaced/Minimally displaced Rudi Allgower type 1/type 2 AO C3 Poor GC

Loss of reduction Stiffness

PRE-OP CONSIDERATIONS

Delay for reduction in swelling, wrinkle signs

5-10 days (usually within 3 weeks) Elevation and splint Calcaneal traction/ Ex fix Management of blisters

PRINCIPLES

Anatomical reduction

Stable internal fixation

Minimal soft tissue damage

Early pain-free mobilization

SURGICAL OPTIONS

Open reduction and internal fixation

Percutaneous fixation

MIPO

IM Nail

External fixator

ORIF

Should be done with restraint!! Done after Soft tissue normalizes Low profile plates Locking plates Fibula first One stage or 2 stage Anteromedial or Posterolateral approach

Anteromedial Approach

Fracture involves the medially aspect

Plate on subcutaneous surface

Anterolateral approach

•For fractures involving posterolateral corners

•Plate under extensor muscles

PERCUTANEOUS SCREW FIXATION

For mildly displaced fractures A, B1,B2, C1

Indirect reduction by external fixator or distractor is very useful

MIPO

Type A, B and sometimes Type C1, C2 Indirect reduction by ligamentotaxis Plate on medial surface

IM Nail

IM Nail supplemented with screws

EXTERNAL FIXATOR

Type A3, B3,C3 Poor soft tissue condition

COMPLICATIONS

Malunion

Ankle stiffness

Arthritis

Skin necrosis

Wound dehisence

CONCLUSION

Very challenging fractures Unpredictable results Soft tissue considerations are of

paramount importance Fix fibula first Articular congruity

THANK YOU