Distal Tibial Metaphyseal Fractures Research Articles

Micromotion in the fracture healing of closed distal metaphyseal tibial fractures: A multicentre prospective study

The dynamic locking screw (DLS) in association with minimally invasive plate osteosynthesis (MIPO) in a bridging construct for simple metadiaphyseal long bone fractures enables modulation of the rigidity of the system and facilitates the development of early and triplanar bone callus.Twenty patients affected by distal tibial fracture were treated with MIPO bridging technique and DLS at the proximal side of the fracture. Time of consolidation, quality of the reduction, complications and American Orthopaedic Foot and Ankle Society (AOFAS) score were monitored and the results compared with those from a control group treated with only standard screws on both fracture sides. Student t-test for independent samples was used for the comparison of means between the two groups. Chi-square test was used for the comparison of proportions. A multiple logistic regression model was constructed to assess the possible confounding effects. Performance was considered significant for p<0.05. The mean healing time was 17.6±2.8 weeks in the group treated with standard screws and 13.5±1.8 weeks in the group treated with DLS (t=5.5, p<0.0001). The DLS was associated with early healing and triplanar bone callus.

Distal tibial metaphyseal fractures: does blocking screw extend the indication of intramedullary nailing?

Aim. To evaluate the clinical use of blocking screws as a supplement to stability in distal tibial metaphyseal fractures treated with statically locked intramedullary nail. Main Outcome Measurement. Alignment and reduction preoperatively, postoperatively, and at healing were the main outcome measured with an emphasis on maintenance of initial reduction on followup. Patients and Methods. This was a prospective study of 20 consecutive cases of distal tibial metaphyseal fractures treated with statically locked intramedullary nailing with supplementary blocking screw between August 2006 and September 2007 with a maximum followup of 3 years. Medullary canal diameter was measured at the levels of fracture and isthmus. Results. The mean diameter of tibia at the level of isthmus was 11.9 mm and at the fracture site was 22.9 mm. Mean length of distal fracture segment was 4.6 cm. Mean varus/valgus alignment was 10.3 degrees preoperatively and 1.7 degrees immediatly postoperatively and was maintained till union. Using Karlstrom-Olerud score the outcome was excellent to good in 90%. Conclusion. We conclude that the use of blocking screw as a supplement will aid in achieving and maintaining the reduction of distal tibial metaphyseal fractures when treated with intramedullary nailing thereby extending the indication of intramedullary nailing.

Outcome of displaced distal tibial metaphyseal fractures in children between 6 and 15 years of age treated by elastic stable intramedullary nails

From June 1995 to August 2012, 18 children were treated surgically using elastic stable intramedullary nails for displaced closed fractures of the distal metaphysis of the tibia. The patients were followed radiographically and clinically on a regular basis until union was clinically and radiographically achieved. Thirteen boys and five girls with a mean age at trauma of 11 ± 2.9 years (range 6-15) were included in the study. Radiographically, all fractures healed without evidence of delayed union, re-fracture, hardware migration. All patients were pain free at last follow-up and all regained full, normal activities including sports. IV.

Management of Tibial Metaphyseal Fractures by Hybrid External Fixator

Introduction: The Hybrid External Fixator combines the advantages of the monolateral pin fixators and the circular Ilizarov wire fixators. Principle of early motion has been touted as the functional savior of major intra articular injuries in application of hybrid external fixation. Materials & Methodology: 48 patients were considered for the study with tibial fractures admitted in Mamata General Hospital from May 2011 to May 2013. Results: The union and functional outcome of hybrid external fixator in simple and complex proximal and distal metaphyseal fractures of tibia in adults was evaluated at our centre. The fractures of the proximal tibia united with an average of 13.3 weeks (12 - 16 weeks). The fractures of the distal tibia united with an average of 14.42 weeks (13 - 22 weeks) with minimal complications. Conclusion: Our study shows high satisfaction rate after fixation, provides adequate stability and allows early motion of the joint. It is also effective in extra articular fractures occurring within 5 cm of the joint as the IM nails often do not provide enough stability and plating requires extensive soft tissue dissection.

Minimizing the complications of intramedullary nailing for distal third tibial shaft and metaphyseal fractures

BackgroundThe complications of intramedullary nailing of distal third tibial shaft and metaphyseal fractures have a direct impact on ankle and hind foot function. MethodsWe retrospectively evaluated 28 patients. Unreamed nail was negotiated across the well reduced fracture till subchondral bone and fixed with 2 to 3 distal locking screws in different planes. ResultsFracture union rate was 85%. Three out of 28 patients had malalignment. Mean ankle, hindfoot functional score was 85. ConclusionComplications can be minimized by impacting the unreamed nail till the subchondral bone while maintaining the fracture well reduced and by using multiple distal locking screws in different planes.

The Retrograde Tibial Nail: Presentation and biomechanical evaluation of a new concept in the treatment of distal tibia fractures

Displaced distal tibia fractures require stable fixation while minimizing secondary damage to the soft tissues by the surgical approach and implants. Antegrade intramedullary nailing has become an alternative to plate osteosynthesis for the treatment of distal metaphyseal fractures over the past two decades. While retrograde intramedullary nailing is a standard procedure in other long bone fractures, only few attempts have been made on retrograde nailing of tibial fractures. The main reasons are difficulties of finding an ideal entry portal and the lack of an ideal implant for retrograde insertion.The Retrograde Tibial Nail (RTN) is a prototype intramedullary implant developed by our group. The implant offers double proximal and triple distal interlocking with an end cap leading to an angle-stable screw-nail construct of the most distal interlocking screw. Its design meets the requirements of a minimally invasive surgical approach, with a stable fracture fixation by multiple locking options. The 8mm diameter curved nail, with a length of 120mm, is introduced through an entry portal at the medial malleolus. We see possible indications for the RTN in far distal tibial shaft fractures, distal extraarticular metaphyseal tibial fractures and in distal tibia fractures with simple extension into the ankle joint when the nail is combined lag screw fixation.A biomechanical comparison of the current RTN prototype against antegrade nailing (Expert Tibial Nail, Synthes®, ETN) was performed. Both implants were fixed with double proximal and triple distal interlocking. Seven biomechanical composite tibiae were treated with either osteosynthesis techniques. A 10mm defect osteotomy 40mm proximal to the joint line served as an AO 43-A3 type distal tibial fracture model. The stiffness of the implant-bone constructs was measured under low and high extra-axial compression (350 and 600N) and under torsional load (8Nm). Results show a comparable stability during axial loading for the two implant types with slightly higher stability in the RTN group. Rotational stability was superior for the RTN. Statistical analysis proved a significant difference (p<0.05) between the ETN and RTN for rotational stability. This study suggests that retrograde tibia nailing with the RTN is a promising new concept for the treatment of distal tibia fractures.

Treatment of distal tibia metaphyseal fractures; plating versus intramedullary nailing: A systematic review of recent evidence

Treatment of distal tibia metaphyseal fractures is challenging. The purpose of this study was to systematically review the recent literature regarding management of extra-articular distal tibia fractures with a view to compare the outcome of intramedullary nailing with plate fixation. Advanced literature search was performed using Medline (Ovid), Embase (Ovid) and Cochrane databases. Data were extracted regarding number of participants, fracture fixation devices, percentage of open fractures, malunions, nonunions, wound infections and metal removal etc. After inclusion, exclusion criteria, two RCTs and four retrospective comparative studies were deemed suitable for this review. The overall results showed relatively higher rate of infection in plating group as compared to intramedullary nailing. However malalignment was more common with intramedullary nailing. Both techniques can provide adequate treatments in appropriately selected patients. None of the studies had sufficient power to show clinically significant difference. Further studies are required to compare new locking plates with intramedullary nails.

Intramedullary Nail Fixation of Fibular Fractures Associated With Tibial Shaft and Pilon Fractures

Treatment of distal tibial fractures is technically challenging. The purpose of this study was to evaluate the use of distally locked retrograde Ender nail fixation of axially stable fibular fractures associated with these distal tibia fractures. During a 4-year span, we treated 23 fibular fractures, associated with either distal tibial metaphyseal or articular fractures, with a retrograde 3.5-mm Ender nail. The surgical protocol along with radiographic and clinical outcomes is presented. Using this technique, we have achieved excellent fibular union with minimal complications.

PF3 A comparison of minimally invasive plate and intramedullary nailing fixation in the treatment of distal tibial metaphyseal fractures

PF3 A comparison of minimally invasive plate and intramedullary nailing fixation in the treatment of distal tibial metaphyseal fractures

Treatment of distal tibial fractures with the Ilizarov external fixator - a prospective observational study in 39 consecutive patients

BackgroundThe management of displaced distal tibial fractures is still controversial. The different internal fixation techniques are often burdened by relatively high complication rates. Minimally invasive techniques with ring fixators have been introduced as an alternative allowing immediate reduction and stabilization, avoiding a staged protocol. The aim of this prospective study was to analyze the clinical and radiographic outcome the Ilizarov technique in patients with distal metaphyseal tibial fractures, with or without intra-articular involvement.MethodsThirty-nine consecutive patients with isolated fractures treated with the Ilizarov technique were followed prospectively for one year. Depending on the type of fracture, 4 or 5 rings were used, in some cases with additional foot extension. Unrestricted weight-bearing was allowed in all cases. Pre- and post-operatively conventional radiographs, post-operative pain assessment and complications were evaluated. The function was evaluated clinically and with self-appraisal protocols: EQ-5D, NHP and FAOS.ResultsNo patient developed compartment syndrome or deep venous thrombosis. Pin infections were frequent, but they were mostly superficial and were treated with antibiotics and/or the removal of isolated pins. Two patients required debridement. One of them had a deep infection and developed a residual deformity which was corrected and healed after re-operation. Another patient had a severe residual deformity. The fixator was removed after a median period of 16 weeks (range 11–30). The radiological results were poor in 5 patients but the overall self-appraisal showed satisfactory results in 36 patients.ConclusionsThe Ilizarov method allowed early definitive treatment with a low complication rate and a good clinical outcome.

Minimal-invasive Plattenosteosynthese am distalen Tibiaschaft

Minimally invasive plate osteosynthesis of distal metaphyseal and/or diaphyseal tibial fractures. Extraarticular tibial fractures or distal tibial fractures with simple intraarticular components (AO 42 A-C + AO 43 A, C1, C2) of the distal tibia shaft. Closed or open soft tissue conditions, most suitable for closed soft tissue damage Oestern-Tscherne grade I-II. High degree open fractures, where the plate would not be covered by soft tissue. Comminuted Pilon fractures. Closed reduction manually, over the plate or the external fixator/large distractor. Short incision on the medial malleolus. Epiperosteal insertion of the plate anteromedial. Improve reduction stepwise and insertion of screws on each main fragment. Relative stability is achieved by using bridging techniques. Fibula fixation in special cases. Mobilization after 1-3days with toe-touch weight bearing. Full weight bearing after 8-10weeks. Implant removal optional after 1-2years in cases of soft tissue irritation. Uneventful healing with good function was observed in 85% of patients within 4months. Delayed unions were observed in 5-10% of cases and nonunions or malalignment were observed in 5% of patients. All patients were satisfied with function at the 2-year follow-up.

Percutaneous locking plates for fractures of the distal tibia

Distal tibial metaphyseal fractures pose many complexities. This study assessed the outcomes of distal tibial fractures treated with medial locking plates. Eighteen patients were selected based on the fracture pattern and classified using the AO classification and stabilized with an AO medial tibial locking plate. Time to fracture union, complications, and outcomes were assessed with the American Orthopedic Foot and Ankle Society Ankle score at 12 months. Sixteen of the 18 patients achieved fracture union, with 1 patient lost to follow-up. Twelve fractures united within 24 weeks, with an average union time of 23.1 weeks. Three delayed unions, two at 28 weeks and one at 56 weeks. The average time to union was 32 weeks in the smokers and 15.3 weeks in the nonsmokers. Five of the 18 patients (27%) developed complications. One superficial wound infection, and one chronic wound infection, resulting in nonunion at 56 weeks, requiring revision. Two patients required plate removal, one after sustaining an open fracture at the proximal end of the plate 6 months after surgery (postfracture union)and the other for painful hardware. One patient had implant failure of three proximal diaphyseal locking screws at the screwhead/neck junction, but successful fracture union. The average American Orthopedic Foot and Ankle Society ankle score was 88.8 overall, and 92.1 in fractures that united within 24 weeks. Distal tibial locking plates have high fracture union rates, minimum soft tissue complications, and good functional outcomes. The literature shows similar fracture union and complication rates in locking and nonlocking plates.

Biomechanical comparison of distal locking screws for distal tibia fracture intramedullary nailing

Background: Newer generation intramedullary (IM) tibial nails provide several distal interlocking screw options. The objectives were to determine: 1) if the new oblique interlocking option provides superior stability, 2) which screw orientation/ configuration is the most biomechanically stable, and 3) if three distal interlocking screws provide better stability. Methods: A preliminary experiment was performed in torsion, compression, and bending tests with four different screw configurations: (I) one medial-to-lateral and one oblique, (II) two me-dial-to-lateral, (III) one medial-to-lateral and one anterior-to-posterior, and (IV) one medial-to-lateral, one anterior-to-posterior and one oblique in simu-lated distal metaphyseal fracture tibiae. Twenty- four Synthes EXPERT tibial IM nails were used for six specimens of each screw configuration. Parts I and II, tibial IM nails were locked with 5.0 mm in-terlocking screws into simulated distal tibiae (PVC and composite analogue tibia). Part III, the two most stable configurations were tested using five pairs of simulated cadaveric distal tibiae metaphy-seal fractures. Results: Significant differences were attributable to distal screw orientation for intrame- dullary nailing of distal tibia fractures. Configura-tions II and IV were found to be more stable than the other two configurations. No significant differ-ence was detected in construct stability in all modes of testing between Configurations II and IV. Dis-cussion: Configuration I did not provide superior stability for the distal tibia fracture fixation. Con-figurations II and IV provided equivalent stability. When choosing IM fixation for treatment of distal tibia metaphyseal fractures two medial-to-lateral screws provide the necessary stability for satisfac-tory fixation. Clinical Relevance: This study indi-cated an option for operative treatment of distal metaphyseal tibia fracture fixation where preserva-tion of soft tissue and rigid stabilization are needed.

A Comparison of the Compressive Strength of Various Distal Locking Screw Options in the Treatment of Tibia Fractures with Intramedullary Nails

Treatment of distal metaphyseal tibia fractures is often challenging. Newer tibial intramedullary (IM) nails are designed with a wider variety of distal locking options to offer greater stability in treating these fractures. In this study we attempted to determine the most biomechanically stable number and configuration of distal locking screws when treating distal metaphyseal tibia fractures with IM nails. A transverse osteotomy was created 4 cm from the tibial plafond in identical composite saw bones models (Type 43A fracture) as well as in human cadaveric bones. Each specimen was nailed using a tibial nail (Stryker T2). Distal locking was performed in one of the three configurations: (a) Group I: two screws in the medial lateral (ML) direction; (b) Group II: one ML screw and one screw in the anterior posterior (AP) direction; (c) Group 111: two ML screws and one AP screw. The specimens were then mounted onto a uniaxial material testing machine (Instron) and tested in compression. Our results showed that there was no statistical difference in the load-carrying capacity of Group 1 and Group II. This suggests that the treating surgeon can choose either of these two configurations depending on the wound or other considerations without sacrificing the compressive load-carrying capacity of the IM nail fixation. The load-carrying capacity of the Group III samples with these locking screws was higher than those of Group I & II, although this difference was not statistically significant. This work is being continued to compare the load-carrying capacity of the bone samples with the cortical thickness of bone. We also plan to examine the relationship between the load-carrying capacity of these surgical constructs with the bone mineral density of the metaphysis of these tibial specimens.

Surgical management of distal tibial metaphyseal fractures with a locking plate

Surgical management of distal tibial metaphyseal fractures with a locking plate

Extra-Articular Distal Tibia Fractures: A Mechanical Evaluation of 4 Different Treatment Methods

This cadaveric biomechanical study compared the mechanical properties of standard plating (SP), locked plating (LP), intramedullary nailing (IMN), and angular stable intramedullary nailing (ASN) for the treatment of axially unstable distal tibia metaphyseal fractures (OTA type 43.A3) with an intact fibula. A distal tibia metaphyseal fracture was created in 30 fresh frozen cadaveric specimens by performing an osteotomy 30 mm above the plafond. The fibula was left intact. Specimens were divided into 4 groups. Specimens underwent fracture fixation with a standard distal tibia plate, a medial locked plate, an intramedullary nail, or an angular stable intramedullary nail. Specimens were loaded vertically along the tibial axis to 700 N, followed by cyclical loading at 700 N for 10,000 cycles, and then to failure. The IMN group demonstrated greater stiffness and load to failure than the LP group, which was greater than the SP group. The ASN group was not different in terms of stiffness and load to failure from the LP group for the number of specimens tested. The IM group required the greatest energy to failure, and all groups were significantly greater than the SP group. Under axial loading conditions with an intact fibula, both IMN and LP provide stable fixation. There was no advantage to the use of an ASN over a standard IMN. IMN resulted in the highest stiffness, load to failure, and failure energy for OTA type 43.A3 fractures with as little as 3 cm of distal bone stock.

Percutaneous Contoured Locking Plate Fixation of the Pilon Fracture: Surgical Technique

Preservation of the soft tissue is of particular importance in the care of pilon fractures. Improper soft tissue management has been attributed to high rates of nonunion, nerve injury, and failures (1–12). Traditional open reduction internal fixation (ORIF) of pilon fractures allows for direct visualization of the fracture(s) but is criticized for the large exposure and periosteal stripping. As a result, this approach has been blamed for high nonunion rates as well as failure of the soft tissue to accommodate implants (1, 5, 8, 13). External fixation has also been used but has not demonstrated much advantage to internal fixation and requires significant postoperative care. Also, external fixation has a higher incidence of malunion (6, 14) and has inherent risks for pin-tract infections (14, 15). In an attempt to limit the iatrogenic soft tissue injury (5, 6, 7), some surgeons have used a limited ORIF concentrating on restoration of the articular surface combined with ring or hybrid external fixation. The “2-stage” technique combines the benefits of both external and internal fixation, and is thought to limit soft tissue related complications by allowing soft tissue recovery time before the introduction of internal fixation. Initial temporary external fixation combined with limited exposures for internal fixation (2-stage technique) at a later date allows for less disruption of the soft tissue envelope, leading to a decrease in complications associated with traditional open approaches. This may be achieved through relatively “small incisions” extending from the pole of the malleolus to the metaphyseal fracture(s), although these incisions can still be quite long, especially when significant articular reconstruction and/or bone grafting is required. Other descriptions include “limited approach” or “minimally invasive”; and this differs from a true percutaneous approach. With the advent of locking plate technology, surgeons have successfully managed a variety of fractures though smaller incisions to introduce the plate(s)—the percutaneous approach. Unlike traditional plating methods, locking plates do not rely on frictional forces between the plate/bone interface to achieve compression and stability. This allows for less damage to the periosteal blood supply, which may theoretically decrease the incidence of delayed or nonunion, soft tissue complications, and possibly secondary loss of fixation (16, 17). A recent study by Salton et al (18) demonstrated no major complications and only 4 minor soft tissue complications in a series of 19 patients treated with a limited incision and percutaneous medial plate fixation. More recently available contoured locking plates with multiple options for metaphyseal screw placement through the “percutaneous” incision allow for the surgeon to achieve stability through this access point. With percutaneous locking plates, the incision may be even smaller than used with the traditional 2-stage technique.

Successful treatment of bilateral open calcaneal fractures with concomitant lower extremity injuries: A case report

Open calcaneal fractures are high morbidity injuries and the risk of complications depends on the concomitant injuries, on the size and the position of the traumatic wound. A 53-year-old male patient with bilateral open calcaneal fractures and associated concomitant lower extremity injuries such as subtalar dislocation, talonavicular dislocation and open distal tibial metaphyseal fracture was immediately operated by percutaneous Kirschner wire fixation combined with external fixators. He was able to walk with full weight bearing without any assistance at the end of the first postoperative year. Early aggressive debridement and irrigation followed by fixation with percutaneous Kirschner wires and external fixator can supply bony alignment in open comminuted calcaneal fractures associated with concomitant lower extremity injuries and should be considered for the healthy and active patients before primary arthrodesis.

Comment on Mohammed et al.: Intramedullary tibial nailing in distal third tibial fractures: distal locking screws and fracture non-union

The treatment of distal third tibial fractures being challenging, we read with great interest the article by Mohammed et al. “Intramedullary tibial nailing in distal third tibial fractures: distal locking screws and fracture non-union” [1]. Modern tibial nail designs have interlocking holes that enable distal placement of screws in close proximity to the tip of the nail. Three distal interlocking holes at 5, 15 and 25 mm, respectively, from the nail tip are common in current tibial nails. Also success of at least two interlocking screws in the distal fragment after removal of the distal tip of the traditional nail has been reported [2]. Screw failure and malalignment have been common problems reported in the literature following the use of a single interlocking screw in distal tibial fractures [3, 4]. Distal locking screws have less cortical purchase in metaphyseal bone; as control of the intramedullary nail position in the distal tibial canal depends on these screws, there is increased stress on the screws to maintain fracture alignment [4]. Consequently late complications, in particular loss of reduction, are attributed to implant failure at the distal locking sites of the intramedullary nail [4]. The study [1] however reported that 52% of the cases had only one distal locking bolt, which is against accepted principles. Also Mohammed et al. reported that 5 of 12 cases with a single distal screw treated for non-union had unreamed nailing. The unreamed interlocking nail screw system cannot be equated with reamed interlocking nails. Mosheiff et al. [5] reported that 22 of 52 patients with distal tibial metaphyseal fractures treated with unreamed nailing required secondary procedures (e.g. dynamisation, autogenous bone grafting, fibulectomy) to progress to union. Thus the use of unreamed nails may have been an important variable in the non-union cases. Designed as temporary implants, the unreamed nails can only bear a certain number of load cycles, significantly less than the locking screws of reamed nails. As a consequence, screw failure occurs frequently in unreamed nailing, especially on weight-bearing [6]. In spite of 46% of the cases in the study by Mohammed et al. having unreamed nailing, they had only one (0.9%) incidence of screw breakage. It would be helpful if the authors could detail the postoperative protocol and the method of supplementary protection used, if any, during mobilisation and ambulation in the two subsets of patients as these also influence the screw breakage and healing process.

The Effect of Concurrent Fibular Fracture on the Fixation of Distal Tibia Fractures: A Laboratory Comparison of Intramedullary Nails With Locked Plates

To compare the fixation stability of intramedullary nails to that of locked plates for the treatment of distal metaphyseal tibia and fibula fractures. A simulated, distal metaphyseal tibia fracture was created in 8 pairs of cadaveric tibia-fibula specimens. One of each pair was treated using an intramedullary nail (Trigen IM Nail System; SN Richards, Memphis, TN) and the other with a locked plate (Peri-Loc Periarticular Locked Plating System; SN Richards). Each specimen was vertically loaded to 250 N in central, anterior, posterior, medial, and lateral locations; loaded to 250 N in cantilever bending in anterior to posterior and posterior to anterior directions; and loaded to 250 N mm in torsion. Load-displacement curves were generated to determine the construct stiffness for each loading scenario, with comparisons made between the 2 treatment groups. Each specimen was then cyclically loaded with 750 N vertical loads applied for 10, 100, 1000, and 10,000 cycles. Measurements of fracture displacements were made and compared between treatment groups. A fibular osteotomy was then created in each specimen at the same level as the tibia fracture to simulate a same-level tibia-fibular fracture. Torsional stiffness assessment and cyclic vertical loading for 10, 100, 1000, and 10,000 cycles were repeated and fracture displacement measurements were again obtained. The locked plate construct was stiffer than the intramedullary nail construct for central, anterior, and posterior loading scenarios (P < 0.005, P < 0.03, and P < 0.02, respectively). The intramedullary nail construct was stiffer than the locked plate construct for both anterior to posterior and posterior to anterior cantilever bending (P < 0.03 and P < 0.02, respectively). No statistically significant difference in stiffness was noted between treatment groups for medial and lateral vertical loading or for torsional loading (P = 0.09, P = 0.32, and P = 0.84, respectively). There was no significant difference between treatment groups with respect to fracture displacement after cyclic vertical loading. After creation of the fibular osteotomy fracture, construct displacements after 1000 and 10,000 cycles significantly increased and torsional stiffness significantly decreased for both treatment groups. The locked plate constructs had significantly less displacement after cyclic loading of 1000 and 10,000 than the locked nail constructs (P < 0.001 and P < 0.0001, respectively). Locked plate constructs were stiffer in torsion after osteotomy than the intramedullary nail constructs (P < 0.05). This study demonstrated that, in the treatment of distal metaphyseal tibia fractures, locked plates provided more stable fixation than intramedullary nails in vertical loading but were less effective in cantilever bending. An intact fibula in the presence of a distal tibia fracture improved the fracture fixation stability for both treatment methods. In fracture patterns in which the fibula cannot be effectively stabilized, locked plates offer improved mechanical stability when compared with locked intramedullary nails.