Distal tibia fractures

Basic idea about distal tibia fractures

1. DISTAL TIBIA FRACTURES DR. SABYASACHI BARDHAN

2. DEFINITION Distal tibia fractures are primarily located within a square based on the width of the distal tibial metaphysis .

3. A NATOMY Internal rotation of distal tibia

4. SOFT TISSUE Paucity of soft tissue coverageon the anterior aspect

5. EPIDEMIOLOGY Avg. age 35-40 Rare in children Males 3 x more common 3-9% of all tibia fractures Associated injuries 25-50%

6. MECHANISM Axially directed force Intra articular fractures More soft tissue injury High energy/ open injuries Rotational force Spiral fractures Variable amount of soft tissue injuries/ open fractures

7. RUDI ALLGOWER CLASSIFICATION Type 1 Type 2 Type3

8. AO CLASSIFICATION: 43 A: Extraarticular B: Partial articular C: Complete articular

9. CLINICAL PRESENTATION Pain Swelling Deformity …………… Blisters Open wound Associated injuries

10. IMAGING X Ray CT Scan

11. PRIMARY MANAGEMENT Bulky padding POP splint/ BB splint Temporary Exfix Strict elevation Pain relief Debridement & Lavage Temporary Ex fix Antibiotics Relook after 48 hrs Plastic surgery opinion Elevation Closed fractures Open fractures

12. NON OPERATIVE Plaster of paris cast/ Synthetic cast Undisplaced /Minimally displaced Rudi Allgower type 1/type 2 AO C3 Poor GC Loss of reduction Stiffness

13. PRE-OP CONSIDERATIONS Delay for reduction in swelling, wrinkle signs 5-10 days (usually within 3 weeks) Elevation and splint Calcaneal traction/ Ex fix Management of blisters

14. PRINCIPLES Anatomical reduction Stable internal fixation Minimal soft tissue damage Early pain-free mobilization

15. SURGICAL OPTIONS Open reduction and internal fixation Percutaneous fixation MIPO IM Nail External fixator

16. ORIF Should be done with restraint!! Done after Soft tissue normalizes Low profile plates Locking plates Fibula first One stage or 2 stage Anteromedial or Posterolateral approach

17. Anteromedial Approach Fracture involves the medially aspect Plate on subcutaneous surface

18. Anterolateral approach For fractures involving posterolateral corners Plate under extensor muscles

19. PERCUTANEOUS SCREW FIXATION For mildly displaced fractures A, B1,B2, C1 Indirect reduction by external fixator or distractor is very useful

20. MIPO Type A, B and sometimes Type C1, C2 Indirect reduction by ligamentotaxis Plate on medial surface

21. IM Nail IM Nail supplemented with screws

22. EXTERNAL FIXATOR Type A3, B3,C3 Poor soft tissue condition

23. COMPLICATIONS Malunion Ankle stiffness Arthritis Skin necrosis Wound dehisence

24. CONCLUSION Very challenging fractures Unpredictable results Soft tissue considerations are of paramount importance Fix fibula first Articular congruity

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