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fracture of distal tibia

I do not think so......
Was it necessary to subject this
elderly man to surgery to achieve the assumed good
result?

I share with you a 66 years old case of Extra-articular displaced fracture of  distal tibia. X rays provided indicate
that the distal tibia fracture was successfully treated non operatively. The fracture healed with nearly anatomic length and alignment.

He was doing partial weight bearing after 6 weeks. Now after 10 weeks,  he is walking with the aid of walker (full weight bearing) with a high below knee cast. 

Because the 66-year-old man is
already impaired on account of his
old age and associated severe osteoarthritis, after surgery he would have pain and would not be able to walk shortly after the surgery. Ambulation, with the aid of a walker is possible with non operative treatment.

X ray AP and lateral views showing good union after 10 weeks of fracture distal 
tibia
X ray of the same patient 5 weeks after fracture 


Review of literature 
 Introduction 
Extra-articular fracture of distal tibia is difficult to manage due to poor blood supply of distal tibia and limited soft tissue coverage of the fracture.

Types
Fractures of distal tibia has both extra-articular and intra-articular patterns. Fractures occur with varying severity. Associated soft tissue injury is a common concern in all of these injuries. Associated injuries are commonly present.

AO classification 
Extra-articular 
-Simple
-wedge
-multifragmentary
Partial articular  
-Split
-Split depression
-depression 
Complete articular 
-Simple
-Simple articular multifragmentary metaphyseal
-Multifragmentary

Simple Extra-articular fracture
These distal tibial fractures can be further classified by AO as:
  • Spiral (classified by AO as 43A1.1)
  • Oblique (43A1.2)
  • Transverse (43A1.3)

Clinical assessment 
Extra-articular fracture of distal tibia may affect the soft tissues as well as the sensory and motor function of the foot structures. A compartment syndrome is a serious complication that should be excluded.
 
The compartment syndrome 
It is suspected if: 
- persistent deep ache in the leg. 
- Pain that is greater than expected for the severity of the injury. 
- Numbness.
- Swelling, tightness and bruising
- Bullae.
- However, fracture blisters are common in the absence of compartment syndrome

Difference between crush injury and 
Compartment syndrome
Crush injury
It is a systemic manifestations of muscle cell damage (muscle disintegration)
 that result from prolonged continuous pressure or crushing on large muscles like those of the leg.
Compartment syndrome 
It is defined as any condition in which a increased pressure within an anatomical compartment results in decreased blood supply that becomes insufficient to tissue within that space.

X rays
Standard AP and lateral x-rays are taken to the knee, leg and the ankle. 
The fibula must be classified as intact, or fractured into two or multiple fragments.

CT-scan
 may be helpful to detect the extent of involvement of the articular surface.  

Complications
Extra-articular distal tibia fractures have a high complication rate both pre-operatively and post-operatively.  
soft tissue damage
crush injury 
Compartment syndrome
Neuro-vascular 
 infection
malalignment
Non union 
pseudarthrosis
ankle arthrosis
Peroneal nerve injury

Treatment

The operative treatment for the extra-articular distal tibia fractures is controversial.
- Intramedullary nail
 Indicated if fracture is proximal enough to be treated with it.   
- Minimally invasive plate osteosynthesis (MIPO)
Indicated in distal tibial metaphyseal fracture that is too distal for intramedullary nail.
- External fixator 
Indicated in severe soft tissue damage or open fractures type III.

 . The aim of our study was to compare the results we have had with intramedullary nail (IMN) and minimally invasive plate osteosynthesis (MIPO) in distal metaphyseal (extra-articular) tibia fractures. 



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