Intra-articular fractures of the distal tibia: Current concepts of management

Abstract

Results of the treatment of intra-articular fractures of the distal tibia have improved significantly during the last two decades.Recognition of the role of soft tissues has led to the development of a staged treatment strategy. At the first stage, joint-bridging external fixation and fibular fixation are performed. This leads to partial reduction of the distal tibial fracture and allows time for the healing of soft tissues and detailed surgical planning.Definitive open reduction and internal fixation of the tibial fracture is performed at a second stage, when the condition of the soft tissues is safe. The preferred surgical approach(es) is chosen based on the fracture morphology as determined from standard radiographic views and computed tomography.Meticulous atraumatic soft-tissue handling and the use of modern fixation techniques for the metaphyseal component such as minimally invasive plate osteosynthesis further facilitate healing. Cite this article: EFORT Open Rev 2017;2:352-361. DOI: 10.1302/2058-5241.2.150047.

Keywords: closed treatment; complications; diagnosis; distal tibia; intra-articular fractures; outcomes; surgical treatment.

Fig. 1

The role of foot position in the type of distal tibial fracture.

Fig. 2

a) Common articular fracture fragments; b) Common articular fracture lines; c) Common articular impression zones. Panels (b) and (c) reproduced with permission from Cole PA, Mehrle RK, Bhandari M, Zlowodzki M. The pilon map: fracture lines and comminution zones in OTA/AO type 43C3 pilon fractures. J Orthop Trauma 2013;27:e152-156.

Fig. 3

AO/OTA classification of distal tibial fractures. Adapted with kind permission from AO Foundation, Switzerland. 43-A extra-articular fracture. 43-A1 simple; 43-A2 wedge; 43-A3 complex. 43-B partial articular fracture. 43-B1 pure split; 43-B2 split depression; 43-B3 multifragmentary depression. 43-C complete articular fracture. 43-C1 articular simple, metaphyseal simple; 43-C2 articular simple, metaphyseal multifragmentary; 43-C3 articular multifragmentary.

Fig. 4

Temporary external fixation frame with transcalcaneal pin.

Fig. 5

Schematic drawing of surgical approaches to distal tibia: a) medial approach; b) anteromedial approach; c) anterior approach; d) anterolateral approach (for tibia and fibula); f) lateral approach (for fibula only); g) posterolateral approach; h) posteromedial approach.

Fig. 6

Medial (orange), lateral (blue) and posterior (green) columns of the distal tibia. Reproduced with permission from Assal M, Ray A, Stern R. Strategies and surgical approaches in open reduction internal fixation of pilon fractures. J Orthop Trauma 2015;29:69-79.

Fig. 7

a, b) Patient S, a 67-year-old woman who fell down from the stairs. c, d) Comminuted distal tibial and fibular fractures, treated initially with external fixation and fibular fixation. Definitive fixation on day 14 - posteromedial and anterolateral approaches for joint reconstruction, percutaneous plate positioning. e, f) Follow-up two years after the surgery.

Fig. 8

Patient D, 46-years-old. a, b) Skiing injury. c, d) Initial fibular fixation and external fixation on the medial side. e, f) Definitive fixation on day 12 - small anterolateral approach for reduction and fixation of anterolateral fragment and minimally invasive plate osteosynthesis of the tibia with pre-contoured medial plate.