Distal Tibial Shaft Fractures Research Articles

Preoperative CT Scans Prior to Distal Tibial Intramedullary Nailing Do not Change Treatment Decisions or Surgical Outcomes.

Distal tibia shaft fractures have a high association with posterior malleolar fractures (PMFs); hence, a preoperative ankle CT scan is commonly obtained. The purpose of this study was to determine whether a CT scan for distal third tibia shaft fractures is associated with differences in recognition of a posterior malleolus fracture (PMF), treatment of an identified PMF, outcomes, and postoperative complications. We retrospectively reviewed cases of adult patients with distal third tibia shaft fractures treated with an intramedullary nail between 2018 and 2020. Patients were divided into 2 groups based on whether they received a preoperative ankle CT scan. Outcomes included surgical time, the rate of missed PMFs or postoperative PMF displacement, the treatment of the PMFs, postoperative weight-bearing restrictions, Patient-Reported Outcomes Measurement Information System Global-10 (PROMIS Global-10) scores, and unplanned revision surgeries. 124 patients (age 45 ± 18 years; 39.5% female) with distal third tibia shaft fractures treated with intramedullary nailing and with minimum 6 months of follow-up were reviewed. 26 patients received preoperative CT scans, and 98 patients did not have CT scans. The rate of detected PMF was 69.2% (N = 18) in patients with CT and 55.1% (N = 54) in patients without CT (P = 0.19). No significant differences were observed in all outcomes between the 2 groups (P > 0.05). 3 PMFs not visible on radiographs were identified on CT, and they did not require fixation and did not displace. PMFs that were greater than one-third of the joint surface were more likely to have a preoperative CT (P < 0.01). Preoperative CT scans for distal third tibia shaft fractures may be useful in characterizing large PMFs; however, this knowledge does not translate into shorter surgical time, increased fixation rates, decreased unplanned revision surgery, or improved patient-reported outcomes. Discovery of PMFs did not always lead to fixation, and PMFs without fixation did not become further displaced.

Flexible nailing: Pushing the indications for diametaphyseal lower-extremity fractures.

Elastic stable intramedullary nailing (ESIN) has been shown to be an effective form of surgical management for lower-extremity diametaphyseal fractures in pediatric patients, but studies are limited because ESIN treatment for these fractures is relatively uncommon. We sought to determine whether ESIN can be used effectively in the most distal or proximal short-segment forms of these fractures. We queried the electronic medical record system at Johns Hopkins Hospital using Current Procedural Terminology codes for femur and tibia fractures treated with ESIN in patients under 18 years old between January 2015 and October 2022. Preoperative and postoperative radiographs were subsequently reviewed to identify patients with a proximal or distal third femoral or tibial shaft fracture treated with ESIN and to define criteria for short-segment diametaphyseal fractures. We used Beaty radiological criteria to evaluate radiographic outcomes and Flynn titanium elastic nails (TENs) outcome scale to assess clinical recovery after radiographic evidence of union. There were 43 children who met the inclusion criteria. Among them, 10 patients had short-segment diametaphyseal fractures. There were 22 (51.2%) who sustained femur fractures and 21 (48.8%) who sustained tibia fractures. Using Beaty radiologic criteria, ESIN was associated with more satisfactory outcomes in patients with distal or proximal third shaft fractures (32/33) than in patients with short-segment diametaphyseal fractures (7/10) (P = .03). Using the TENs outcome scale, 21 (63.4%) patients with distal or proximal third shaft fractures had excellent results, 11 (33.3%) had satisfactory results, and 1 (3%) had a poor result. Among patients with short-segment diametaphyseal fractures, 4 (40%) had excellent results, 5 (50%) had satisfactory results, and 1 (10%) had a poor result. There were no differences in TENs outcomes between the groups (P = .24). Patients with short-segment lower-extremity diametaphyseal fractures treated with ESIN had worse radiographic outcomes but did no worse clinically than patients with distal or proximal third shaft fractures. Consequently, ESIN should be considered a safe and effective surgical management option for pediatric patients with even the most distal or proximal forms of these fractures.

The Biomechanical Effects of Intramedullary Fixation to the Level of the Physeal Scar on Distal Tibia Fracture Stability.

The purpose of this study was to evaluate whether intramedullary nail contact with physeal scar improves construct mechanics when treating distal tibial shaft fractures. Axially unstable extra-articular distal tibia fractures were created in 30 fresh frozen cadaveric specimens (15 pairs, mean age 79 years). Specimens underwent intramedullary nailing to the level of the physeal scar locked with one or two interlocks or short of the physeal scar locked with two interlocks (reference group). Specimens were subjected to 800N of axial load for 25,000 cycles. Primary outcomes were stiffness before and after cyclic loading. Secondary outcomes were load to failure, load at 3 mm displacement, plastic deformation, and total deformation. The physeal scar with one interlock cohort demonstrated 3.8% greater stiffness before cycling ( P = 0.75) and 1.7% greater stiffness after cycling ( P = 0.86) compared with the reference group. The physeal scar with two interlocks group exhibited 0.3% greater stiffness before cycling ( P = 0.98) and 8.4% greater stiffness after cycling ( P = 0.41) in relation to the reference group. No differences were identified regarding load to failure or load at 3 mm displacement. In specimens with two interlocks, those in contact with the physeal scar demonstrated significantly less plastic ( P = 0.02) and total ( P = 0.04) deformation. Constructs ending at the physeal scar demonstrated stiffness and load to failure similar to those without physeal scar contact. Less plastic and total deformation was noted in two-interlock constructs with physeal scar contact, suggesting a possible protective effect provided by the physeal scar. These data argue that physeal scar contact may offer a small mechanical benefit in nailing distal tibia fractures, but clinical relevance remains unknown.

Intramedullary Nailing versus Minimally Invasive Plate Osteosynthesis for Distal Tibia Shaft Fractures: Retrospective Comparison of Functional and Cosmetic Outcomes

Intramedullary Nailing versus Minimally Invasive Plate Osteosynthesis for Distal Tibia Shaft Fractures: Retrospective Comparison of Functional and Cosmetic Outcomes

Distal Tibial Fractures – Surgical Outcome Following Minimally Invasive Percutaneous Plate Osteosynthesis

Objectives With preservation of the vascularity of the bone, preservation of the soft tissue envelope and containment of the fracture haematoma, minimally invasive procedures provide fixation in a biologically sound manner. With these in view, this study was conducted to evaluate the technique of surgical management in distal tibial fractures treated by internal fixation with locking compression plate (LCP) and screws through the minimally invasive percutaneous plate osteosynthesis (MIPPO) technique. Material and Methods In this cohort study, 21 patients with distal tibial fractures who were admitted to the hospital between November 2014 and August 2016 were tracked for at least 10 weeks and up to 39 weeks. Adults who were fit enough for surgery, both male and female, participated in the study. MIPPO procedures were followed for every case. In this investigation, a total of 21 cases were examined. Results 86% of cases with proper bone union were able to bear their full weight at or before the 18-week mark. Complete weight bearing was permitted for the final three patients (14%) at or before 39 weeks. Ninety per cent of patients had fracture union rates that were satisfactory to excellent at 23 weeks. Also, delayed unions were noted in three individuals; two cases experienced ankle stiffness, one as a result of prolonged immobilization and the other as a result of an intra-articular fracture. There were no infections or wound breakdowns during this trial. Conclusion The MIPPO technique with LCP plates is a good choice when intramedullary nailing is inadequate for metaphyseal and distal tibia shaft fractures. Also, early fracture union is easily accomplished using the MIPPO technique and careful application of these plates.

Pediatric distal third tibial shaft fractures: a comparison of surgical fixation methods and incidence of concomitant physeal fractures.

The purposeof this study was to compare outcomes of operatively treated pediatric distal third tibial shaft fractures fixed with elastic nailing or plate fixation and to evaluate the incidence of concurrent distal tibia physeal fractures. Retrospective review identified skeletally immature patients that underwent operative fixation of distal third tibia fractures at a level 1 children's hospital from 2010 to 2020. Patient and fracture characteristics were recorded. Analysis of treatment outcomes was performed and rates of concurrent distal tibia physeal fractures were evaluated. Of the 214 surgically treated tibial shaft fractures, 43 were distal third fractures. A concurrent distal tibia physeal fracture was present in 32.6% of patients. These were significantly associated with spiral distal third tibial shaft fractures. The presence of concurrent physeal fractures did not affect patient treatment outcomes. Comparing elastic nailing versus open reduction and plating revealed no difference with time to fracture union, time of postoperative immobilization, or time to full weight-bearing. While elastic nailing was associated with increased coronal angulation, translation, and shortening of fractures on initial postoperative imaging, there was no difference in rates of malunion at final follow-up. In our series, there were no differences in treatment outcomes based on fixation method. Our operatively treated distal third tibial shaft fractures had a higher rate of associated distal tibial physeal fractures than previously published in the pediatric orthopedic literature. We recommend careful evaluation of the ankle for concurrent physeal injuries in patients with distal third tibial shaft fractures indicated for operative treatment. Level of evidence: level III therapeutic study - retrospective comparative study.

Comparision of Distal Uniplanar Locking with Biplanar Distal Locking in Intramedullary Interlocking Nailing of Fractures Distal Shaft of Tibia

Objective: To study the effects of distal uniplanar locking and distal bi planar locking on union times in uncomplicated fractures distal shaft of tibia managed with an intramedullary interlocking nail.&#x0D; Study Design: Comparative prospective study.&#x0D; Place and Duration of Study: Department of Orthopedics and Trauma Combined Military Hospital Rawalpindi from Jan to Nov 2020.&#x0D; Methodology: Fifty-three patients having fractures distal shaft of tibia managed with intramedullary interlocking nail were studied. Twenty-nine patients were managed using two interlocking screws distally (uniplanar) in coronal plane (group-1). Twenty-four patients were managed with three bi planar screws comprising two coronal and one sagittal distal interlocking screw (group-2). Patients were followed every 4 weeks, and bone union time was assessed. Isolated closed fractures treated with closed reduction were included.&#x0D; Results: Patients treated with distal bi planar locking (group-2) had significantly reduced union time in weeks (11.25 ± 1.42) compared to uniplanar distal interlocking (group-1) (15.79 ± 1.80) (p&lt;.001).&#x0D; Conclusion: Union time for distal tibia shaft fractures is significantly reduced when treated with distal biplanar locking; it can be attributed to increased stability of the construct.

Feasibility of Machine Learning and Logistic Regression Algorithms to Predict Outcome in Orthopaedic Trauma Surgery.

Statistical models using machine learning (ML) have the potential for more accurate estimates of the probability of binary events than logistic regression. The present study used existing data sets from large musculoskeletal trauma trials to address the following study questions: (1) Do ML models produce better probability estimates than logistic regression models? (2) Are ML models influenced by different variables than logistic regression models? We created ML and logistic regression models that estimated the probability of a specific fracture (posterior malleolar involvement in distal spiral tibial shaft and ankle fractures, scaphoid fracture, and distal radial fracture) or adverse event (subsequent surgery [after distal biceps repair or tibial shaft fracture], surgical site infection, and postoperative delirium) using 9 data sets from published musculoskeletal trauma studies. Each data set was split into training (80%) and test (20%) subsets. Fivefold cross-validation of the training set was used to develop the ML models. The best-performing model was then assessed in the independent testing data. Performance was assessed by (1) discrimination (c-statistic), (2) calibration (slope and intercept), and (3) overall performance (Brier score). The mean c-statistic was 0.01 higher for the logistic regression models compared with the best ML models for each data set (range, -0.01 to 0.06). There were fewer variables strongly associated with variation in the ML models, and many were dissimilar from those in the logistic regression models. The observation that ML models produce probability estimates comparable with logistic regression models for binary events in musculoskeletal trauma suggests that their benefit may be limited in this context.

Determining your implant: Templating a nail for the distal tibia fracture

The goal of this article is to aid the orthopedic surgeon in determining whether an intra-medullary (IM) device for fixation of a distal tibia fracture is feasible. Using Computed Tomography (CT) scans of the fracture, this review demonstrates a simple way to determine whether two or even three distal interlocking screws are achievable in stable bone. Additionally, this paper offers a summary chart of commonly used tibial nails which can be used for planning purposes. Finally, a clinical summary of very distal tibial shaft fractures treated with IM fixation is provided.

Diagnosing Fractures of the Distal Tibial Articular Surface in Tibia Shaft Fractures: Is Computed Tomography Always Necessary?

To identify the incidence of distal articular fractures in a series of distal third tibia shaft fractures and to report the utility of both computed tomography (CT) scans and Radiographic Investigation of the Distal Extension of Fractures into the Articular Surface of the Tibia (RIDEFAST) ratios for identification of articular involvement. Retrospective cohort. Level 1 trauma center. Four hundred seventeen patients with distal third tibia shaft fractures were included in the study. Intramedullary nail or plate fixation. Type of articular fracture, time of diagnosis, and RIDEFAST ratios. One hundred one of the 417 distal third fractures (24%) had a fracture of the distal tibia articular surface. Of these 101 fractures, 41 (41%) represented an extension of the primary fracture line and 60 (59%) were separate malleolar fractures. Of the 101 articular fractures, 95 (94%) were identified preoperatively and 6 (6%) were identified intraoperatively. Of the 95 fractures identified preoperatively, 87 (92%) were identified on plain radiographs and 8 (8%) by CT scan. Thirty-five preoperative CT scans were performed on distal third tibia shaft fractures in search of an intra-articular fracture. In 27 patients (77%), no articular fracture was present, representing an overall yield of 23% among CT scans performed to rule out an articular fracture in distal third tibia shaft fractures. RIDEFAST ratios for all 101 distal tibia shaft fractures with articular involvement and 100 fractures with no articular involvement were not significantly different (P > 0.05) using both coronal and sagittal plane measurements. CT scans performed on distal third tibia shaft fractures in search of articular fractures had a low yield (23%). Widespread use of CT scan to diagnose fractures of the distal tibia articular surface in the setting of distal tibia shaft fractures does not seem warranted. No statistically significant differences in RIDEFAST ratios were found between fractures with and without articular involvement, indicating that more work is necessary before RIDEFAST can be used to reliably rule out articular involvement in this setting. Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Pediatric Distal Third Tibial Shaft Fractures: Are Short Leg Casts a Reasonable Option?

Pediatric Distal Third Tibial Shaft Fractures: Are Short Leg Casts a Reasonable Option?

Letter to the Editor With Respect to: Comparison of Short-leg and Long-leg Casts for the Treatment of Distal Third Tibial Shaft Fractures in Children, Barnett, Scott A. MD; Fontenot, Bailli BS; Leonardi, Claudia PhD; Gonzales, Joseph A. MD; Gargiulo, Dominic DO; Heffernan, Michael J. MD. March 2021 - Volume 41 - Issue 3 - pp. e259-e265.

Tribe, Howard C. BSc (Hons), PgCert (T&O), MEd, PhD, MBBS, MRCS; Lindisfarne, Edward FRCS (T&O)Author Information

Comparison of Long vs. Short Leg Casts for Distal Third Tibial Shaft Fractures in Children

Comparison of Long vs. Short Leg Casts for Distal Third Tibial Shaft Fractures in Children

Efficacy of suprapatellar approach for IMIL nailing of proximal and distal tibia shaft fractures

Background: The fractures of tibial shaft are very common. The fractures at the proximal and distal metaphysio-diaphysis treated with Intramedullary Interlocking nails pose challenge during reduction and nail insertion. The use of Suprapatellar approach for the IMIL nail entry is an efficient and time saving. Materials and Methods: A series of 20 cases of proximal and distal tibia shaft fractures were treated with IMIL nail using the suprapatellar approach. Out of 20 patients 14 were males and 6 were females. The patients were then followed up on regular intervals of 2 weeks, 6 weeks, 3 months, 6 months and 12 months. Results: All the fractures united well without any major complications. 4 patients had anterior knee pain and 2 patients developed superficial wound infection which was treated with antibiotics. Conclusion: The suprapatellar approach for proximal and distal shaft (Metaphysio-diaphysis) fractures is an advancement in treating such fractures. It is efficient and time saving and allows easy manipulation while reducing the fracture during the procedure without any major complications.

Intramedullary nail versus plate in osteosynthesis of distal tibial shaft fractures in adults

Objective To compare the efficacy between intramedullary nail and plate in the internal fixation for distal tibial shaft fractures in adults. Methods A retrospective analysis was conducted of the 49 patients with distal tibial shaft fracture who had been treated by internal fixation with intramedullary nail or plate at Department of Orthopaedics, The First People＇s Hospital of Neijiang from September 2014 to September 2018. They were 26 males and 23 females, aged from 19 to 71 years (average, 42.3 years). According to the AO/ASIF classification, there were 34 cases of type 43A1 and 15 cases of type 43A2. There were 7 open and 42 closed fractures. Of them, 23 received intramedullary nailing and 26 steel plating. The 2 groups were compared in terms of intraoperative blood loss, operation time, hospitalization time, fracture healing time, The American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, infection and fracture malunion. Results The 2 groups were comparable because there were no significant differences in the preoperative general data between them(P>0.05). The intraoperative blood loss in the intramedullary nail group (160.3 mL ± 15.2 mL) was significantly greater than that in the plate group (110.5 mL ± 13.4 mL) (P 0.05). There were no significant differences between the 2 groups either in the rates of malunion, infection or internal fixation failure (P>0.05). Five cases in the intramedullary nail group reported painful discomfort in the front of the knee joint while 7 cases in the plate group postoperative discomfort due to plate protrusion. Conclusions Both intramedullary nail and plate are effective treatments of adult distal tibial fracture. However, in order to minimize the risk of infection, intraoperative maneuvers should be as careful and gentle as possible, repeated violence be avoided and soft tissues be carefully protected. Key words: Tibia fracture; Fracture fixation, internal; Bone nail; Bone plate

Third Place Award: Characterization and incidence of occult posterior malleolar fractures

Background: Occult fractures of the posterior malleolus are often missed by primary care providers and radiologists. Delayed treatment of posterior malleolar fractures can be problematic because of the potential for malunion, arthritis, or instability. The incidence and characterization of missed posterior malleolar fractures has not been reported in the literature. Methods: A retrospective review was performed of all ankle fractures with CT scans from 2005 to 2015 at a single institution. Inclusion criteria included age older than 18 yr and posterior malleolar fracture as seen on CT scan. Exclusion criteria included distal tibial shaft fractures and pilon fractures. Forty-six patients were identified with the above criteria. Data collected included whether a fracture was missed on initial radiographs by a board-certified radiologist, and the size and angle of the posterior malleolar fragment. Results: Of the 46 patients with posterior malleolar fractures, nine (19.5%) were missed on the radiology report. Seven of 46 (15.2%) were not described on all plain films prior to the CT scan. Two of seven (28.6%) radiographically occult fractures underwent open reduction and internal fixation of the posterior malleolar fragment. The average angle of occult posterior malleolar fractures relative to the transmalleolar axis was quite variable, with an average of 17 degrees (SD 11 degrees, range −20 degrees to 50 degrees). Conclusions: With a 15% incidence of occult posterior malleolar fractures, a CT scan or multiple orthogonal views can be helpful to avoid missed fractures. Given the wide variability of fracture angle, a single external rotation view is unlikely to prevent all missed fractures on initial radiographic interpretations. Level of Evidence: Level III, retrospective cohort study.

NAIL OR PLATE IN THE MANAGEMENT OF DISTAL TIBIAL EXTRA-ARTICULAR FRACTURE, WHAT IS BETTER? EVALUATION OF FUNCTIONAL OUTCOME

The optimal treatment of fractures of the distal tibia without major disruption of the ankle joint has not been well defined. In this prospective study we reviewed our results of distal tibia shaft fractures treated with minimally invasive percutaneous plate osteosynthesis and IL nailing and compared the outcome Keywords: distal tibia, extra articular fracture, functional outcome

The Role of Biplanar Distal Locking in Intramedullary Nailing of Tibial Shaft Fractures.

To compare the union times of the uncomplicated tibial shaft fractures, which were distally locked by two coronal and one sagittal screws and by only two coronal screws. 45 patients with tibial shaft treated with intramedullary nailing included in this study. 23 of 45 fractures were treated with uniplanar two distal interlocking (Group 1) and 22 fractures were treated with biplanar three distal interlocking (Group 2). Patients with closed fractures treated by closed nailing and having a full set of radiographs on PACS system was included. Fracture unions were evaluated by two authors. Union time was significantly shorter in biplanar distal interlocking group (Group 2) compared to uniplanar distal interlocking group (Group 1) (P=0.02). Mean union time in groups 1 and 2 were 14.63±4.5 and 10.77±3.0 weeks, respectively .When only distal third tibial shaft fractures were evaluated, Group 2 [11.2±3.1 weeks (n:17)] had significantly lower union time compared to Group 1 [15.07±4.8 weeks (n:14)] (P=0.01). Inter-observer reliability for fracture union times was high with rho= 0.89 with SE of 0.51 (P<0.001). Biplanar distal interlocking procedure had a significantly shorter union time. Biplanar distal interlocking procedure allows a faster fracture union probably because of a more stable fixation construct.

Distal tibial triplane fracture with ipsilateral tibial shaft fracture: A case series

Background & purposeDistal tibial Triplane fracture with ipsilateral tibial shaft fracture is a rare but important problem. This rarely reported combination of injuries if not recognised may lead to deleterious consequences. Methods/PatientsThe local database of all emergency admissions was scrutinised to identify subjects before interrogation of the clinical notes and relevant radiographic imaging. FindingsThis paper reports a series of five children who were found to have triplane fracture of the distal tibia with concomitant ipsilateral fracture of the tibial shaft. ConclusionsWe suggest that a high index of suspicion for concomitant fractures should be maintained in the presence of either triplane fracture of the distal tibia or tibial shaft fractures in the peri-adolescent child. Minimum appropriate imaging should include orthogonal full length plain radiographs of the tibia as well as formal ankle radiographs.

Radiographic Investigation of the Distal Extension of Fractures Into the Articular Surface of the Tibia (The RIDEFAST Study).

To determine whether radiographic measurements are predictive of involvement of the distal tibia articular surface in tibial shaft fractures. Retrospective review. Academic Level-I trauma hospital. Two-hundred seventeen patients with tibial shaft fractures distal to the isthmus (OTA/AO: 42-A1-3; 42-B1-3; 42-C1-3; and 43-A1-3). Analysis of anteroposterior (AP) and lateral radiographs. The following parameters were measured: (1) angle between the predominant fracture line and the plane of the tibial plafond (α-angle), (2) length of the shaft fracture, (3) distance from the most inferior extent of the shaft fracture to the tibial plafond (DTP), (4) width of the tibial plafond, (5) width of the tibial isthmus, (6) ratio of fracture length to DTP (FTP), and (7) fibular fracture distance. Distal intra-articular involvement (DIA). A total of 217 patients were identified, 56 (26%) with DIA. The FTP ratio as measured on both the AP (odds ratio: 8.20, confidence interval, 4.26-17.22, P < 0.0001) and lateral radiographs (10.00, 4.78-23.23, <0.0001) was the most effective screening measurement for DIA. AP and lateral FTP ratios of 0.224 and 0.255, respectively, achieved a negative predictive value of 100%, eliminating the need for computed tomography in 16%-23% of injuries. Involvement of the distal articular surface in patients with distal tibial shaft fractures is significantly associated with fracture geometry and pattern. The FTP ratio may be used as an effective screening tool to rule out of intra-articular involvement. Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.