Tibial Metaphyseal Fractures Research Articles

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.

Cozen’s phenomenon: a remindera

A four-year-old child attended Accident and Emergency following a fall from a slide with a displaced and angulated proximal tibial metaphyseal fracture. Treatment included closed manipulation under anaesthesia and an above knee cast for seven weeks. Serial radiographs over the following few months were satisfactory demonstrating good alignment and evidence of healing. However, at four-months review new-onset genu valgum with mechanical axis deviation was noted. No evidence of spontaneous resolution was noted over the following 12 months and hence a corrective hemi-epiphysiodesis was performed. At 12-months post-operatively, there was marked clinical and radiographical improvement in alignment. Classically Cozen's phenomenon is described as the late-onset post-traumatic valgus deformity associated with proximal tibial metaphyseal fractures in children. We want to reemphasise the early recognition of children at risk of this unique complication. In addition, we wish to highlight the progression of the late-onset valgus and its subsequent management.

Reply to the comment on Kritsaneephaiboon et al.: Minimally invasive plate osteosynthesis of distal tibial fracture using a posterolateral approach: a cadaveric study and preliminary report

Dear Dr. Yun-feng Yang and colleagues, Thank you very much for your interest in our article [1]. We would like to answer your concerns point by point as below. According to the AO (Arbeitsgemeinschaft fur Osteosynthesefragen) principle of fracture treatment, the principles of fracture reduction should be the same even when using the minimally invasive plate osteosynthesis (MIPO) technique for the direct reduction of articular fracture and indirect reduction of diaphyseal or metaphyseal fracture [2]. For pilon fractures, the displaced articular fragments should be reduced by a direct technique. However, indirect reduction with the MIPO technique should be performed for comminuted metaphyseal or diaphyseal extension. Our preliminary case had an open fracture of the left distal tibia (AO 43-C2), which means this patient had a simple articular fracture with a multifragmentary metaphyseal fracture of left distal tibia. Initially we could reduce the articular fracture directly through the anterior soft tissue defect and then fix this fracture with one lag screw. Subsequently, we temporarily stabilised the axial alignment of the fracture with a spanned external fixator across the left ankle. Because the anterior soft tissue is compromised, we used the MIPO technique with the contralateral anterolateral distal tibial locking plate through a posterolateral approach for definitive fixation of the multifragmentary metaphyseal fracture in this case. You cannot use the posterolateral approach of the ankle for the exposure or reduction of the articular surface of the distal tibia because the posterior overhang of the distal tibial plafond limits visualisation of the anterior articular surface [3]. Therefore it is better to use the anterolateral or anteromedial approach in the case of pilon fracture with anterior fracture comminution. For the placement of medial screw through the contralateral anterolateral distal tibial locking plate at the distal fragment, we made a one centimetre extension of the skin incision with more retraction of flexor hallucis longus (FHL) medially. There was no requirement to make an additional posteromedial incision. We can use the distal incision of our MIPO technique using the posterolateral approach for the reduction and fixation of both distal tibia and fibula within a single incision [3, 4]. The posterolateral aspect of distal tibia can be exposed between the plane of the peroneus longus and the FHL. In addition, the posterior fibula can be addressed by releasing the peroneal tendon and muscle subperiosteally from the fibula [5]. Finally, we can conclude that the MIPO technique using the posterolateral approach is considered as an alternative option for distal tibial fracture with or without fibular fracture, particularly when the anterior soft tissue is compromised. Contrarily, this MIPO technique is not suitable for pilon fracture with anterior fracture comminution. Sincerely yours, Apipop Kritsaneephaiboon, M.D.

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.

Reply to comment on Kritsaneephaiboon et al. “Minimally invasive plate osteosynthesis of distal tibial fracture using a posterolateral approach: a cadaveric study and preliminary report”

Dear Dr. Yun-feng Yang and colleagues, Thank you very much for your interest in our article [1]. We would like to answer your concerns point by point as below. According to the AO (Arbeitsgemeinschaft fur Osteosynthesefragen) principle of fracture treatment, the principles of fracture reduction should be the same even when using the minimally invasive plate osteosynthesis (MIPO) technique for the direct reduction of articular fracture and indirect reduction of diaphyseal or metaphyseal fracture [2]. For pilon fractures, the displaced articular fragments should be reduced by a direct technique. However, indirect reduction with the MIPO technique should be performed for comminuted metaphyseal or diaphyseal extension. Our preliminary case had an open fracture of the left distal tibia (AO 43-C2), which means this patient had a simple articular fracture with a multifragmentary metaphyseal fracture of left distal tibia. Initially we could reduce the articular fracture directly through the anterior soft tissue defect and then fix this fracture with one lag screw. Subsequently, we temporarily stabilised the axial alignment of the fracture with a spanned external fixator across the left ankle. Because the anterior soft tissue is compromised, we used the MIPO technique with the contralateral anterolateral distal tibial locking plate through a posterolateral approach for definitive fixation of the multifragmentary metaphyseal fracture in this case. You cannot use the posterolateral approach of the ankle for the exposure or reduction of the articular surface of the distal tibia because the posterior overhang of the distal tibial plafond limits visualisation of the anterior articular surface [3]. Therefore it is better to use the anterolateral or anteromedial approach in the case of pilon fracture with anterior fracture comminution. For the placement of medial screw through the contralateral anterolateral distal tibial locking plate at the distal fragment, we made a one centimetre extension of the skin incision with more retraction of flexor hallucis longus (FHL) medially. There was no requirement to make an additional posteromedial incision. We can use the distal incision of our MIPO technique using the posterolateral approach for the reduction and fixation of both distal tibia and fibula within a single incision [3, 4]. The posterolateral aspect of distal tibia can be exposed between the plane of the peroneus longus and the FHL. In addition, the posterior fibula can be addressed by releasing the peroneal tendon and muscle subperiosteally from the fibula [5]. Finally, we can conclude that the MIPO technique using the posterolateral approach is considered as an alternative option for distal tibial fracture with or without fibular fracture, particularly when the anterior soft tissue is compromised. Contrarily, this MIPO technique is not suitable for pilon fracture with anterior fracture comminution. Sincerely yours, Apipop Kritsaneephaiboon, M.D.

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.

Compartment syndrome like picture in metaphyseal comminuted fracture of tibia treated by locking plate due to tight closure

A 22-year-old male came to casualty on 5 th May 2012 after a fall from motorcycle. He complained of excruciating pain and swelling over right knee. There was an open wound of 7 × 2 cm over supra-patellar region and diffuse swelling over knee joint with severe tenderness over proximal aspect of right tibia. X-ray showed intra-articular fracture of proximal tibia extending to diaphysis classified as type 6 by Schatzker classification for proximal tibia, with fibula shaft transverse fracture. The skin over the fracture was contused. Debridement with primary wound closure was done in emergency. Skeletal traction was applied through a lower tibial Steinman pin. Patient was operated after 15 days when wound healed and swelling subsided. Locking plate was applied on medial aspect using Minimally invasive percutaneous plate osteosysthesis (MIPPO) technique. Post-operatively over 4 hours patient developed severe pain and swelling in operated leg which mimicked compartment syndrome. Suture removal was done immediately in the ward from the distal aspect, which relieved the symptoms but lead to exposure of the plate. A rotational flap was done to cover the plate in coordination with a plastic surgeon on the next day.

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.

Les fractures métaphysaires du tibia proximal de l’enfant, par accident de trampoline, ne progressent pas nécessairement en valgus : une série de sept cas et une brève revue de littérature

Fracture of the proximal tibial metaphysis in children is a rare injury but notorious for carrying the risk of subsequent valgus deformity of the tibia. Trampoline-caused fracture of the proximal tibial metaphysis in children may not progress into valgus. We followed up six children who collectively sustained seven fractures of the proximal tibial metaphysis while trampolining with other heavier and/or older children. Initial and follow-up x-rays were reviewed by an orthopaedic surgeon and two radiologists. None of the patients developed valgus deformity with follow-up. Trampoline is associated with a specific type of injury to the proximal tibia when children are trampolining with other heavier children even without falling off the trampoline. This fracture is linear and complete, often non-displaced. Unlike “other” proximal tibial metaphyseal fractures, trampoline-associated proximal tibial metaphysical fracture in children is not associated with a risk of subsequent valgus deformity. Level 4. Type of study: case series.

Trampoline fracture of the proximal tibial metaphysis in children may not progress into valgus: A report of seven cases and a brief review

Fracture of the proximal tibial metaphysis in children is a rare injury but notorious for carrying the risk of subsequent valgus deformity of the tibia. Trampoline-caused fracture of the proximal tibial metaphysis in children may not progress into valgus. We followed up six children who collectively sustained seven fractures of the proximal tibial metaphysis while trampolining with other heavier and/or older children. Initial and follow-up x-rays were reviewed by an orthopaedic surgeons and two radiologists. None of the patients developed valgus deformity with follow-up. Trampoline is associated with a specific type of injury to the proximal tibia when children are trampolining with other heavier children even without falling off the trampoline. This fracture is linear and complete, often non-displaced. Unlike "other" proximal tibial metaphyseal fractures, trampoline-associated proximal tibial metaphysical fracture in children is not associated with a risk of subsequent valgus deformity. Level 4. case series.

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.

Study of Results of Minimal Invasive Plate Fixation in Metaphyseal Fracture of Tibia in Adult

Modern way of living has lead to increased incidence of comminuted fractures of bones. This is due to the ever increasing vehicular traffic and industrial activity Management of these fractures by itself is challenging. In this we have studied 40 patients with complex metaphysical tibia fracture and treated by minimal invasive procedure. We have studied the operative time, technique and various post operative outcomes (mobilization time, callus time etc.).At the end of study we have concluded that minimal invasive procedure is treatment of choice for close tibia metaphyseal fracture due to its early post operative mobilization and early callus formation.

Tibial tubercle advancement osteotomy with bone allograft for patellofemoral arthritis: a retrospective cohort study of 50 knees

Forty consecutive patients (21 females and 19 males) in a single centre underwent 50 tibial tubercle advancement osteotomy procedures for patellofemoral arthritis between January 1993 and April 2007. Twenty knees with patellar maltracking also underwent medialisation of the tibial tubercle (6-12 mm) in addition to the standard 10-15 mm elevation. Femoral head bone allograft blocks were utilised in all cases, and all patients achieved bony union without further surgery. Forty-five knees had previously undergone arthroscopy, 18 with arthroscopic lateral releases. Ninety-four percentage of knees had sustained improvement in visual analogue pain scores (mean improvement of 37.4, P < 0.05) at a mean follow-up of 81 months (range 26-195 months), with 96% of patients still satisfied; and 92% of knees had sustained improvement in Shelbourne and Trumper anterior knee function scores (mean improvement of 39.8, P < 0.05). Overall clinical outcomes were rated excellent/good in 77%, fair in 35% and poor in 8% of knees. Two knees required arthroplasty surgery over the follow-up period (at 18 months and 8 years), and their anterior knee pain and function scores were not included in the analyses. Six knees (12%) suffered major complications: 1 temporary common peroneal neuropraxia; 2 intraoperative tibial metaphyseal fractures; and 3 tibial tuberosity fractures (at 8 days, 3 weeks and 3 months). Four knees (8%) suffered superficial wound infections, 31 knees had some numbness around the midline scar, 7 knees had scar pain lasting up to 12 months, and 22 knees (44%) experienced some discomfort relating to the metalwork, which was removed in all these cases. Tibial tubercle advancement osteotomy can be an effective treatment for anterior knee pain and for patients with arthroscopic evidence of patellar chondral damage. It can provide excellent/good long-term functional results in the majority of patients, with very high satisfaction levels and sustained improvement in pain symptoms. The use of femoral head bone allograft is both effective in obtaining bony union and by definition avoids the donor-site morbidity. Knees with patellar malalignment may also undergo individualised medialisation of the tibial tubercle such that the patella lies in the centre of the femoral trochlea, and may benefit from lateral trochleaplasty surgery in the presence of trochlear dysplasia. However, the major operative complication rate is high at 12%, and fracture of the tibial tubercle is associated with a poorer outcome. One can expect 10% of operated knees to have had some clinical deterioration in the patellofemoral joint by a mean follow-up of 93 months.

A triangular support screw improves stability for lateral locking plates in proximal tibial fractures with metaphyseal comminution: a biomechanical analysis

This study evaluates a proximally angulated cortical screw forming a triangular construct in lateral locking plates of comminuted intraarticular tibial plateau fractures. Sixteen composite tibiae were used for the fracture model and a complete articular fracture of the proximal tibia (AO 41.C2) was performed. A compression force was applied to the medial tibial plateau with an alternating, stepwise loading: 250 N-10 N-300 N-10 N-350 N-10 N-400 N. The relative motion between the different fragments of each sample was measured using a contactless, 3-dimensional digital image correlation system. Between the medial and lateral condyle, elastic as well as plastic shear was significantly lower using the triangular support screw (p < 0.05). In the metaphyseal region, elastic deformation remained identical, independent of the screw positioning. However, plastic deformation (varus collapse) was significantly reduced by 30-40% using a triangular support screw at higher compression forces (>300 N; p < 0.05). Based on the results of this study, the use of a triangular support screw in metaphyseal comminuted tibial plateau fractures might enhance fracture stability. However, further studies are necessary to prove these biomechanical results in composite bone.

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