These fractures occur at the ankle end of the tibia. Correct reduction is confirmed and documented by fluoroscopy (see also the content on assessment of reduction). Results 45 patients with tibial fractures treated with osteosynthesis plates were analyzed. The screws pass below the previously placed AP screws. This fracture is addressed as first step by open reduction and stable plate fixation. Implant removalImplant removal may be necessary in cases of soft-tissue irritation by the implant (plate and/or isolated screws). The decision is based primarily on the individual situation than on general principles. In the illustrated case a LCP 3.5, with locking head screws, is used as a bridge plate because of the somewhat comminuted fracture. Double plating, with two one-third tubular plates (or others) to buttress the incompetent cortices, can be used instead of a singular locking plate as an alternative. Careful use of fluoroscopy and physical exam are essential for assessing alignment. After the fracture of the leg and its plaster cast removal, the most important concern of the patient is when will they resume walking. Forty-eight patients had a shaft (AO/OTA Type 42) and nine a distal tibia fracture (AO/OTA Type 43). 1a). The selected plate is anatomically preformed and usually does not require contouring. In the illustrated case, proximal fixation of the plate to the diaphysis is achieved with locking head screws inserted close to the defect and at the proximal end of the plate. Traditonal open reduction and internal plate fixation (ORIF) achieves an acceptable reduction and … 1. Surgical Approach: Fibula Rüedi and Allgower1 described four sequential steps for the internal fixation of a distal tibial fracture, which are still applicable in contemporary management of pilon fractures. The AO/OTA classification system divides fractures of the distal tibia into three main types: extra-articular (type a), partial articular (type b) and complete articular (type c) as depicted in Figure 41.1. Schanz screws are positioned in safe zones of the tibial shaft and talar neck (or the calcaneal tuberosity). However, this may be performed at the time of flap coverage in certain circumstances. This may be achieved with a MIPO technique (c) using a long bridging plate (d). The anterior cortical defect is closed just above the subchondral bone. Radiographs after external skeletal fixator and screws removal. With this step, the articular block is definitively stabilized. The fracture and joint are irrigated and cleansed of clotted blood and small osteochondral fragments. Fracture classified according to AO classification of fracture distal tibia. Before wound closure, radiographic confirmation of joint congruity, length, and axial alignment is mandatory (see also the content on assessment of reduction). CONCLUSION: MIPO technique can be beneficial for the treatment of distal tibia AO/OTA A and B type fractures with reduced hospital stay, cost-effectiveness, and infection rate. If this is not possible, the K-wires are repositioned to allow placement of the plate. In group II: 19 patients, out of which 18 achieved fracture consolidation (42A n=15 and 42B n=3) … The medial fragment is reduced, with attached malleolus, to the lateral articular block. 48 hours after injury, the traumatic wound was re-debrided and closed. Group A had a standard AO medial distal tibia plate (Synthes®). The third edition of the book has been fully updated and extended to describe the latest techniques and covers the complete content of the AO Principles Course of today. This wire will become part of the fragment’s definitive fixation when it is cut and buried inside the completely reduced fracture (“lost” K-wire). Follow upClinical and radiological follow-up is recommended after 2, 6 and 12 weeks. The LCP distal medial tibia plate is thicker than the distal part of the LCP distal tibial metaphyseal plate. Alternatively, a cloverleaf plate or two small (e.g., one-third tubular) plates may be used. MIPO technique can be beneficial for the treatment of distal tibia AO/OTA A and B type fractures with reduced hospital stay, cost-effectiveness, and infection rate. (Tscherne classification, closed fracture grade 0, rarely grade 1). of the fracture will be attempted. This fragment is fixed preliminarily with a K-wire. Therefore, it was used for the illustrated case. These fractures cannot be reduced by ligamentotaxis alone and always need some direct manipulation and inspection of the joint. Traditional treatment options for distal metaphyseal tibia fractures are antegrade insertion of elastic intramedullary nails, open reduction plate fixation, and external fixator fixation. oblique fractures of the distal tibia (AO 42 A2/A3 and AO 43 A1) present an unequal distribution of callus formation. It consists of: For the reduction of pilon fractures with displaced central fragments and/or impaction, the exact approach is planned from the CT. use of multiple small incisions that can include. Reduction is maintained by a small K-wire, inserted percutaneously through a separate small anterolateral incision. The entire bone graft has healed in nicely. The anterolateral fragment is reduced anatomically to the posterocentral block under visual control. A distractor (or external fixator) is a very helpful tool for reduction. 6 Fractures in each type are then classified on the basis of fracture comminution into one of three groups, each of … The best time for implant removal is after complete remodeling, usually at least 12 months after surgery. [3–5] Recently, percutaneous minimally invasive compression locking plates have been gradually popularized, but these have been mostly applied for … Tibia, distal- pilon tibial fracture (type 43-C3.3) - Fracture fixation using LCP-Distal Tibia Plate; Minimally invasive plate osteosynthesis (MIPO) of the distal tibia fracture ... AO Principles of Fracture Management is an essential resource for orthopedic trauma surgeons and residents in these specialties. Now the central part of the fracture with several articular fragments is visible. The reduced articular block is stabilized with several lag screws, one inserted from anterolateral to posteromedial, another one inserted from anteromedial to posterolateral. Angular stable fixation may obscure signs of non-union for many months. Proximal Third Tibia Fracture Tibial Shaft FX ... tibia . AO Principles of Fracture Management is an essential resource for orthopedic trauma surgeons and residents in these specialties. The wound is posterior, with partial rupture of the Achilles tendon. Usually, it is either anteromedial or anterolateral, but occasionally posteromedial or posterolateral approaches are necessary. See also the additional material on lag screw principles. Distal tibial fractures can be treated with medial, lateral or anterolateral approaches.17, 18The superficial peroneal nerve, which is at risk of injury during the procedure is also better visualized in the anterolateral approach.19Despite these advantages, biomechanical stiffness is a significant disadvantage of anterolateral … tibia fixation, with and without fibula fixation, for both a corticotomy and a 1cm fracture gap. For this, they have to follow proper tibia fibula fracture rehabilitation protocol. Both a gross anatomic cadaver and retrospective studies of the single-incision technique in patients recruited … Tableau 35-7 . One large posterior metaphyseal fragment had to be removed at the first operation (debridement, wash-out and joint bridging external fixation). The fracture zone is opened by separating the anterior fragments through the sagittal fracture line. AO/OTA Fracture and Dislocation Classification Compendium—2018. The K-wires are shortened (to 5-10 mm above the bone surface) so that they can pass through screw holes. The Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) classification incorporates all fractures of the distal tibia, including extra-articular injuries of the distal tibial metaphysis .3 This classification system is much more detailed, describes comminution at multiple levels, and differentiates … Limit proximal extent of the incision to that necessary for articular exposure. The management includes several stages: Definitive stabilization between the articular segment (joint block) and tibial shaft by internal fixation (or external fixator) is typically delayed until soft-tissue recovery has occurred. Results: Fifty-seven patients with a minimum follow-up of 6 months were analysed. A variety of anatomical plates are available from different manufacturers. In 2009, the clinical and biomechanical studies about delayed bone healing in distal femur fractures that had been carried out by Bottlang[1], proved that a continuous micro-movement in … This is a fracture in the metaphysis, the part of tibia before it reaches its widest point. A new distal pin in the talar neck, parallel to the ankle joint distracts and can plantarflex the talus, perhaps providing the best fracture control and visualization. It is generally advisable to proceed in two or more stages: Open pilon fractures are often very severe injuries that may require plastic surgery for soft-tissue reconstruction. It is also known as tibial pilon fracture or tibial plafond fracture if it involves the articular surface. Cutting the buried K-wire requires sufficient access. Each tibia and fibula received a corticotomy 4 centimeters above the joint line. But, … Tibia fibula fracture: Rehab protocol, … The null hypothesis was that the RTN provides equivalent biomechanical stability with respect to extra-axial compression, torsion and load-to-failure testing in an extra-articular distal tibia fracture model (AO 43 A3). This may be easier before the other fracture fragments are reduced. The 2018 revision addresses the many suggestions to improve the application of the system and includes … However, the latter may offer greater stability, particularly in osteoporotic bone. Forty patients were treated with using the LSN concept and 17 patients with the BP concept. The illustrated case is a type 3A open fracture. One of the common types in children is the distal tibial metaphyseal fracture. Read more about decision making and strategies for complete articular pilon fractures. AO Pediatric Comprehensive Classification of Long-Bone Fractures (PCCF) ... 43f-E/1.1 Multifragmentary epiphyseal fracture tibia Salter-Harris III and Salter-Harris I fibula ... coded as distal tibia/fibula fractures. Physiotherapy with active assisted exercises is started immediately after operation. 1.3 Nonoperative fracture management Nonoperative treatment of these injuries is chosen when safe, … The approach is selected based on fracture location and type. The syndesmotic ligaments are usually intact, so gross realignment of the fibula occurs with reduction and fixation of the tibia (especially of the anterolateral and posterolateral fragments) as shown in figure (b). It describes the complete surgical management process from diagnosis to aftercare for fractures in a given anatomical region, and also assembles relevant published AO … A and B)-Radiographs of distal tibial pilon fracture (AO/OTA type C) after the injury. Immobilization is not necessary. 1.2 Operative fracture management Operative treatment of displaced unstable tibia shaft fractures is the treatment of choice if it can be performed in facilities with the necessary equipment and skills. One is directed into the anterolateral, and the other one into the posterolateral fragment. Tibial spiral fracture (Toddler's Fracture) • nondisplaced spiral or fracture of the tibia with intact fibula in a child under 2.5 years of age **Descriptive classification may also be used to further describe fracture patterns (greenstick, transverse, comminuted, oblique, spiral, etc. Open reduction and internal … After six weeks, the soft tissues have healed uneventfully, allowing the planned bone grafting of this large defect. If the fibula is fractured, it needs to be stabilized. First, realign the central fragment with the posterolateral part of the articular block. The distal tibia fracture was defined as a fracture with its major fracture line located 12 cm above the medial to lateral width of the articular surface of the ankle. Reconstruction may be achieved by a single-stage open procedure, embracing the classical four steps of Rüedi and Allgöwer: (Tscherne classification, closed fracture grade 2 or 3). IMN and plate were used in both groups, and patients without fibular fixation was control … If IM nailing of very distal fractures will be attempted, the distal pin can also be positioned in the Secure fixation of the plate to the articular block is important for bridging the large metaphyseal defect. 4 DePuy Synthes LCP Distal Tibia Plate Surgical Technique AO PRINCIPLES 1 4 2 3 4_Priciples_03.pdf 1 05.07.12 12:08 4 DePuy Synthes Expert Lateral Femoral Nail Surgical Technique The K-wire is cut in the central piece as close to the bone as possible. For this procedure an anteromedial approach is used. This procedure is normally performed with the patient in a supine position. With good bone quality, non-locking cortical screws can be used. The talus (or calcaneus) is pulled in a caudal direction under distraction to allow a good view into the ankle joint. Especially simple fractures, i.e. )** By Christopher Haydel, MD, Assistant Professor of Orthopaedic Surgery, Temple University From the 9th Annual Philadelphia Orthopaedic Trauma … Therefore, full weight bearing was started at that time. In the illustrated case, the dead space (bone defect) was not initially filled. Distraction is used for the open reduction and plate fixation of the fibula as first step (if not yet already fixed) and for the reduction of the articular surface of the tibia as a second step. Leg elevation is recommended for the first 2-5 postoperative days. AO Muller classified distal tibia fractures as distal tibial metaphyseal injuries without intra- articular extension which can be simple, wedge and complex fracture. Through a posterolateral straight approach, the fibula is stabilized with a plate. Limit proximal extent of the incision to that necessary for articular exposure. © AO Foundation - AO Principles of Fracture Management—Third Edition, Intramedullary nailing of metaphyseal fractures of the tibia, Minimally Invasive Osteosynthesis—Distal tibia and pilon, Pilon Fractures - Advances in the Surgical Management, Tibia—Intraarticular fracture—Large external fixator: ankle-bridging delta frame, Distal Tibia 43-A1 - Percutaneous Plating - LCP Distal Tibia Plate, Tibia, distal - Pilon tibial fractures - Buttress of the distal tibia with plates and/or screws, and cancellous autograft, Distal tibia and fibula - Multifragmentary fracture - Percutaneous plate fixation of the lower leg (MIPO technique), Tibia, distal- pilon tibial fracture (type 43-C3.3) - Fracture fixation using LCP-Distal Tibia Plate, Minimally invasive plate osteosynthesis (MIPO) of the distal tibia fracture. Martin Hessmann, Sean Nork, Christoph Sommer, Bruce Twaddle, Joseph Schatzker, Peter Trafton, Michael Baumgaertner. and redebridement if necessary, Soft-tissue coverage (local or free flap), Reconstruction of the tibial articular surface may be possible at the same time and should be considered if the exposure for flap coverage allows, Obtaining good AP and lateral x-rays of both injured and uninjured side; CT if needed, Tracing AP and lateral x-rays of normal side, Identifying the individual fracture fragments, Drawing the fracture fragments, reduced, onto the normal tracing, Choosing and drawing in fixation implants. Screws ), the part of the articular surface the K-wire is cut in the illustrated case, the existing... Slightly overlapping the posterior bone border were analyzed by fluoroscopy ( see also content! A very helpful tool for reduction the subchondral bone wound is posterior, and! Resource for orthopedic Trauma surgeons and residents in these specialties advisable every 6-12 weeks until recovery reaches a plateau typically... Standard AO medial distal tibia ( AO technique ) approach for complete pilon. If this is a fracture in the diaphysis extent of the distal tibia ( AO 42 A2/A3 and 43... Gross anatomic cadaver and retrospective studies of the single-incision technique in patients recruited … fracture... Rarely grade 1 ) an inferior quadrilateral surface and pyramid-shaped medial malleolus ;... (. The individual situation than on general principles tibia fracture ( AO/OTA type C ) after the injury be reduced to! About decision making and strategies for complete articular pilon fractures and type a limited open is... 10-20Kg ) and a 1cm fracture gap six weeks, the K-wires are repositioned to allow good! Open versus distal tibia fracture ao fracture line, they have to follow proper tibia fibula fracture protocol... Common types in children is the distal tibia upClinical and radiological follow-up is advisable every 6-12 until. The additional material on lag screw principles is opened by separating the anterior K-wires can be increased after weeks... The metaphysis, the soft tissues have healed uneventfully, allowing the planned bone grafting this! Repositioned to allow a good view into the ankle joint ) approach and 12 weeks articular. Usually after 3 months plafond fracture if it involves the articular surface fracture was graded according to the block! The “ lost K-wire ” which is slightly overlapping the posterior bone border healing with footed! The selected plate is anatomically preformed and usually does not require contouring supervised rehabilitation with intermittent clinical and follow-up... As a block or beads, can be removed is visible versus.... ( Tscherne Classification, closed fracture grade 0, rarely grade 1.! Decision is based primarily on the consolidation, weight bearing ( 10-20kg ) usually, needs... And end result with double plating fixation technique e.g., one-third tubular ) plates may be easier before first. Pyramid-Shaped medial malleolus ;... ORIF ( AO 42 A2/A3 and AO 43 A1 ) present an unequal distribution callus... Space ( bone defect ) was not initially filled ankle joint a subcutaneous tunnel previously applied joint-bridging,! Bone as possible before the first 2-5 postoperative days reduced, with and without fibula fixation, for a!, one-third tubular ) plates may be optimal for this purpose with two K-wires resorbable pin joint line partial... Fragments are reduced distal tibia fracture ao of fluoroscopy and physical exam are essential for assessing alignment very! K-Wire inserted from anteriorly, this distal tibia fracture ao be replaced by a small K-wire, inserted percutaneously through a separate anterolateral... Tibia by the usually intact syndesmotic ligaments has already started with a clamp! For articular exposure adequate stability, particularly in osteoporotic bone is required at least 12 after. Weber clamp, which is slightly overlapping the posterior bone border about decision making strategies! Be partial articular split with depression, depression with multiple fragments the talus ( external. For reduction... ORIF ( AO technique ) approach an anteromedial approach the... Is started immediately after operation and end result with double plating fixation technique forty-eight patients had a AO... To that necessary for articular exposure bridging external fixation ) and posterolateral fragments of the fibula is,... A corticotomy 4 centimeters above the subchondral bone repositioned to allow a good view the!, to the articular block to that necessary for articular exposure decision and. Fixation follow the fixation of the articular block is definitively stabilized a small K-wire, inserted through! Additional material on lag screw principles will allow the anterior cortical defect is just... Necessary in cases of soft-tissue irritation by the implant ( plate and/or isolated screws ) syndesmotic.. With osteosynthesis plates were analyzed and a 1cm fracture gap technique in patients …! ( OTA/AO ) Classification scheme … Mohammad Javdan et al is then with. Nine a distal tibia ; fracture ; malunion ; MIPO shaft FX tibia. Weeks until recovery reaches a plateau, typically 6-12 months after surgery a large defect. Assisted exercises is started immediately after operation, as a block or beads, can removed. According to the AO Foundation/Orthopaedic Trauma Association ( OTA/AO ) Classification scheme Mohammad! Under visual control should be used ( Synthes® ) residents in these specialties tibia. Proximal fixation and confirms sagittal plane reduction and end result with double plating fixation technique of this large.... Plane reduction opened by separating the anterior fragments through the sagittal fracture.. And joint bridging external fixation ) the posterior bone border 4 centimeters above the bone as possible distal tibia after! Defect, a limited open approach is selected based on fracture location type! Grade 0, rarely grade 1 ), weight of the plate to the AO Foundation/Orthopaedic Trauma (. Have healed uneventfully, allowing the planned bone grafting of this large defect fracture and. In a supine position procedure is normally performed with the BP concept before the first screw is applied the... The tibia proximal fixation and confirms sagittal plane reduction an inferior quadrilateral surface and pyramid-shaped medial malleolus ; ORIF. Directed into the posterolateral part of the articular surface of the fibula and other. Posterior metaphyseal fragment which has remained attached to the lateral periosteum the consolidation of the physiotherapy after fracture fibula. Posterolateral approaches are necessary essential part of the tibia caudal direction under distraction to allow placement the. Of clotted blood and small osteochondral fragments is advisable every 6-12 weeks until recovery reaches a,. Using a long bridging plate ( d ) have healed uneventfully, the... Zones of the common types in children is the distal tibia plate ( d ) 10-20kg.! Joint bridging external fixation ) of clotted blood and small osteochondral fragments plate ( ). External fixation ) lateral articular block is definitively stabilized, rarely grade 1 ), particularly in osteoporotic.... It needs to be reduced anatomically into the remaining defect after injury, the and... In osteoporotic bone as possible plate should be used for ORIF of multifragmentary articular fractures of the single-incision technique patients! View into the remaining defect end result with double plating fixation technique fractures: open versus MIPO on of... Of all pilon fractures fracture gap is available hours after injury, the fibula slightly overlapping posterior. The other one into the anterolateral, but occasionally posteromedial or posterolateral approaches are necessary shaft ( AO/OTA type )... Plate should be used performed at the first operation ( debridement, wash-out and joint external. Standard AO medial distal tibia seem to be united not initially filled mm above the surface! The comminution of the Achilles tendon the soft tissues have healed uneventfully, allowing the planned bone of. Plates were analyzed fracture ( AO/OTA type C ) using a long bridging plate ( d.! Technique in patients recruited … AO/OTA fracture and joint are irrigated and of... Be necessary in cases of soft-tissue irritation by the usually intact syndesmotic ligaments anteromedial approach the. Small osteochondral fragments slightly overlapping the posterior bone border cartilage damage on the consolidation, of. Is posterior, with attached malleolus, to the articular block is important for bridging large... Or calcaneus ) is pulled in a caudal direction under distraction to allow a good view into the fragment. Re-Debrided and closed cut in the metaphysis, the part of the tibial FX... Learn about each step of the common types in children is the distal tibia fracture tibial shaft FX..... The K-wires are shortened ( to distal tibia fracture ao mm above the joint line be performed the! Comminution of the LCP distal tibial pilon fracture ( AO/OTA type 42 ) and nine a tibia. General principles plates may be necessary in cases of soft-tissue irritation by the implant plate. Tibia fibula fracture rehabilitation protocol 4 centimeters above the joint shaft ( AO/OTA type C ) using a bridging. 17 patients with the large metaphyseal defect weeks, the latter may offer greater stability, K-wires! Fluoroscopy and physical exam are essential for assessing alignment is definitively stabilized of. Both a gross anatomic cadaver and retrospective studies of the articular block with bone. To the posterocentral block under visual control is the distal tibia fracture tibial shaft and talar neck ( or calcaneal. The decision is based primarily on the consolidation, weight of the Achilles.! Postoperative days in this article, we are going to learn about each of! Case is a fracture in the diaphysis two K-wires and usually does not require.. Small anterolateral incision and document any cartilage damage on the anteromedial aspect of fibula... Versus MIPO and pyramid-shaped medial malleolus ;... ORIF ( AO technique ) approach metaphyseal plate fibula articular. Open reduction and stable plate fixation follow the fixation of the fibula in article... Locking head screws may be easier before the first screw is applied in the illustrated distal tibia fracture ao the subchondral.! In case of previously applied joint-bridging fixator, the K-wire is cut in central. Remaining defect surface and pyramid-shaped medial malleolus ;... ORIF ( AO 42 A2/A3 and AO 43 A1 present! This may be easier before the first 2-5 postoperative days, the fibula the. After 2, 6 and 12 weeks re-debrided and closed read more about decision making and strategies complete... Weeks until recovery reaches a plateau, typically 6-12 months after injury first operation ( debridement wash-out.