Abstract
BackgroundTreatment of distal tibial intra-articular fractures is challenging due to the difficulties in achieving anatomical reduction of the articular surface and the instability which may occur due to ligamentous and soft tissue injury. The purpose of this study is to present an algorithm in the application of external fixation in the management of intra-articular fractures of the distal tibia either from axial compression or from torsional forces.Materials and methodsThirty two patients with intra-articular fractures of the distal tibia have been studied. Based on the mechanism of injury they were divided into two groups. Group I includes 17 fractures due to axial compression and group II 15 fractures due to torsional force. An Ilizarov external fixation was used in 15 patients (11 of group I and 4 of group II). In 17 cases (6 of group I and 11 of group II) a unilateral hinged external fixator was used. In 7 out of 17 fractures of group I an additional fixation of the fibula was performed.ResultsAll fractures were healed. The mean time of removal of the external fixator was 11 weeks for group I and 10 weeks for group II. In group I, 5 patients had radiological osteoarthritic lesions (grade III and IV) but only 2 were symptomatic. Delayed union occurred in 3 patients of group I with fixed fibula. Other complications included one patient of group II with subluxation of the ankle joint after removal of the hinged external fixator, in 2 patients reduction found to be insufficient during the postoperative follow up and were revised and 6 patients had a residual pain. The range of ankle joint motion was larger in group II.ConclusionIntra-articular fractures of the distal tibia due to axial compression are usually complicated with cartilaginous problems and are requiring anatomical reduction of the articular surface. Fractures due to torsional forces are complicated with ankle instability and reduction should be augmented with ligament repair, in order to restore normal movement of talus against the mortise. Both Ilizarov and hinged external fixators are unable to restore ligamentous stability. External fixation is recommended only for fractures of the ankle joint caused by axial compression because it is biomechanically superior and has a lower complication rate.
Highlights
Treatment of intra-articular fractures of the distal tibia is challenging due to the difficulties they present in achieving anatomical reduction of the articular surface of the ankle joint and the instability that may occur due to ligamentous and soft tissue injury
Intra-articular fractures of the distal tibia due to axial compression are usually complicated with cartilaginous problems and are requiring anatomical reduction of the articular surface
External fixation is recommended only for fractures of the ankle joint caused by axial compression because it is biomechanically superior and has a lower complication rate
Summary
Treatment of intra-articular fractures of the distal tibia is challenging due to the difficulties they present in achieving anatomical reduction of the articular surface of the ankle joint and the instability that may occur due to ligamentous and soft tissue injury. The original classification of Pilon fractures by Ruedi and Allgower and the principles of treatment which they suggested, namely initial fibula fixation for length restoration, anatomical reduction of the articular surface, use of bone grafts in the metaphysis and internal fixation [3] was followed by high rate of complications, especially infection when the injury of soft tissues was severe [4,5] This led many authors in treating these fractures in two steps, first by applying a temporary external fixation, followed by open reduction and internal fixation when the condition of soft tissues was improved [6]. The purpose of this study is to present an algorithm in the application of external fixation in the management of intra-articular fractures of the distal tibia either from axial compression or from torsional forces
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