OTA 1999 Posters

Intramedullary Nailing of Distal-Third Tibia Fractures

William T. Obremskey, MD, MPH; James Crowther, MD; Robin E. Driver, Wake Medical Center, Raleigh, NC

Introduction: In North America, distal tibia fractures (OTA 42A,42B,C 43A) are routinely treated with an intramedullary (IM) nail. Distal third fractures of the tibia are commonly treated with plating in many European centers. Clinical experience indicates that obtaining and maintaining alignment of this fracture is often difficult with this fracture. The purpose of this retrospective review was to review the time to union, alignment, return to function, and complications of IM nailing of distal-third tibia fractures in a level II trauma center.

Methods: The charts and radiographs of all tibia fractures treated at a level II trauma center were reviewed from 1992-1996. The closed fractures that were distal-third tibial fractures in skeletally mature patients and treated with an intramedullary nail were reviewed. Demographic data were obtained and radiographs were evaluated for time to union and degree of angulation at union (varus, valgus, apex anterior, apex posterior). Patients were contacted to determine ability to return to work and activities, as well as amount of persistent pain. Complications and the elective removal of implants were also evaluated.

Results: 38 patients with distal third tibial fractures meet the criteria for evaluation. Patients' average age was 40 years (SD±15.9)(Range 15-74). 85% of injuries occurred due to low energy falls or sports injuries. Thirty of thirty-eight patients had adequate follow-up and radiographs; 9/30 (30%) healed with 6° of varus, valgus, apex anterior, or apex posterior. No fracture lost alignment during fracture healing. Time to weight bearing as tolerated was 11.6±5.7 weeks (range 3-30 weeks, 95% CI ±2.7 weeks) and time to radiographic union was 14.7±15.3 weeks (range 1.75-53 weeks, 95% CI 5.8 weeks). Average follow-up was 17.7±9.8 months (range 7-52 months, 95% CI ±4.0). Five of thirty patients (16.7%) had at least pain with activity or frequent pain on latest follow-up; 4/30 patients (13.3%) developed a deep infection and one required a below-knee amputation. Only 1/30 patients (3.3%) required an elective removal of the intramedullary nail.

Discussion: Distal-third fractures of the tibia are commonly treated with intramedullary nailing in North America. These injuries had a relatively high rate of malalignment with 30% healing with 6° angulation and a 13.3% infection rate. One might consider delayed operative treatment of this injury until soft tissue injury improved and perform plating of the distal tibia to improve alignment.

Conclusions: It is difficult to obtain anatomic alignment with distal-third fractures of the tibia. An intramedullary nail effectively stabilizes distal third fractures of the tibia to allow union but has a risk of malalignment and infection.