OTA 1999 Posters

Small Plate Fixation of Distal Tibial Metaphyseal Fractures

David C. Goodspeed, MD; Timothy G. Weber, MD; D. Kevin Scheid, MD, Orthopaedics Indianapolis, Indianapolis, IN

Purpose: The purpose of this study was to determine the outcome and complications of a series of patients with distal tibial metaphyseal fractures that were treated with a single 3.5-MM compression plate.

Methods: A retrospective study of 25 patients with distal tibial metaphyseal fractures treated by the senior authors was analyzed. Inclusion criteria were tibia fractures at the level of the metaphysis or metadiaphyseal junction, with or without a single minimally displaced extension into the ankle joint (AO types 42A1-3.3, 42B1-3.3, 43A, 43C1-C2). Exclusion criteria included any comminution at the articular surface or an ipsilateral proximal tibia fracture. Within this group of patients, all fractures treated by a single 3.5-mm compression plate on the tibia with or without fibular fixation were identified. This resulted in a study group of 25 fractures in 25 patients. This approximated a consecutive series as this is the preferred treatment method of these fracture patterns by the senior authors. All but 4 of the plates were placed on the medial (subcutaneous) border of the tibia to minimize stripping of the anterior musculature.

Follow-up included chart review and serial x-rays until bony union on all 25 patients. In addition, a final subjective evaluation by questionnaire was performed on 21 (84%) of the patients. The length of this subjective follow- up averaged 23.5 months (range, 6-85 months). For radiographic analysis, malunion was defined as >5 degrees of malalignment of the joint surface in any plane.

Results: The average age of the patients was 39 years (range, 15-66 years). There were 6 open and 19 closed fractures. There were no nonunions or delayed unions. Time to full weight bearing without assistive devices averaged 3.75 months (range, 2.5-5.0 months). Two patients required additional procedures prior to union: one percutaneous screw tightening at 6 weeks and one syndesmotic screw placement for mortise widening at 4 weeks. In no case was conversion to a different form of fixation required. There was one (4%) malunion of 8 degrees valgus.

There were no soft tissue or bony infections, nor were there any wound complications requiring additional antibiotics, skin grafts or soft tissue flaps. There were two complications. One patient developed a postoperative deep vein thrombosis in the operative leg requiring anticoagulation. Another patient developed reflex sympathetic dystrophy that resolved with treatment and hardware removal. At time of final follow-up, only 3 (12%) patients have undergone hardware removal.

Subjective follow-up was available on 21 patients. Of these, 17 (81%) reported no or mild pain at the fracture site or ankle. Those with greater levels of pain had it only with specific activities. Fourteen (67%) had at least some decrease in level of maximum activity. However, 19 (90%) reported unlimited ambulatory ability. The other two patients could walk at least one mile. In addition, of the 17 patients employed outside of the home before the injury, 16 (94%) returned to their previous level of work without restriction. The other patient returned with lesser duties. No patient was on narcotic medication as a result of these injuries at final follow-up.

Discussion and Conclusion: Distal tibial metaphyseal fractures are challenging fractures to treat. Intramedullary nailing is possible, but control of the distal fragment can be difficult. In addition, a high incidence of knee pain has been reported. Fixation with large fragment plates has resulted in significant rates of wound complications or bothersome hardware. This study reports on the outcomes of 25 patients with distal tibial metaphyseal fractures treated with small plate fixation. The inclusion/exclusion criteria were selected to include fractures that might be candidates for intramedullary nailing. The majority of patients in this study had a satisfactory outcome with a low rate of complications and hardware removal. These data compare favorably with those reported for intramedullary nailing of similar fractures.¹ We believe that small plate fixation on the medial side of the tibia with or without fibular fixation should be considered as a viable treatment option for distal tibial metaphyseal fractures.

1. Robinson CM, McLauchlan GJ, McLean IP, Court-Brown CM. Distal Metaphyseal Fractures of the Tibia with Minimal Involvement of the Ankle: Classification and Treatment by Locked Intramedullary Nailing. J Bone Joint Surg., 77-B: 781-787, 1995.