A Review of Current Management of Distal Tibia Extraarticular Fractures

Sujan Raj Paudel^1*, Ankit Shrivastava² & Ram Kewal Shah³

¹Orthopaedic Surgeon, Scheer Memorial Adventist Hospital, Banepa, Nepal
²Orthopaedic surgeon, Janakpur Trauma Hospital, Janakpur, Nepal
³Head of Department, Department of Orthopaedics, Janaki Medical College, Janakpurdham, Nepal

*Correspondence to: Dr. Sujan Raj Paudel, Orthopaedic Surgeon, Scheer Memorial Adventist Hospital, Banepa, Nepal.

Copyright © 2019 Dr. Sujan Raj Paudel, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Introduction
The treatment of distal tibia fractures is challenging because of the limited soft tissue, the subcutaneous location of the bone, and poor vascularity. The biological and mechanical environments must be compatible with the processes of cell and tissue proliferation and differentiation [1,2]. Though multiple factors are involved in nonunion mechanical cause alone accounts for 59% [3]. The mechanical factor is determined by local stress and strain within the fracture which is described by gap size or interfragmentary movement [4]. Spontaneous healing can be observed in wild animals even with great mobility while in turn minimal instability of closely reduced fractures may result in delayed or non-union [5].

Various methods of treatment including plaster, traction, splints, external fixation and internal fixation methods like intramedullary nails or plates have been used to treat distal tibia fractures. The optimal treatment of unstable distal tibia without articular involvement remains controversial [6,7] (Fig. 1).

With new treatment approaches, most distal tibia fractures eventually unite. But nonunion has significant morbidity [8]. It not only affects the limb but has profound impact on person’s mental health and quality of life [9]. Soft tissue maladaptation and contracture resulting from nonunion at times compromise successful restoration of limb length or adjacent articular mobility [10]. Patients with a nonunion are 97 times more likely to need a reoperation [11]. The impact of tibial fracture nonunion on physical health was comparable with the reported impact of end-stage hip arthrosis and worse than that of congestive heart failure [9]. These patients also have significant lost productivity resulting in indirect costs [12].

The main target of this review is to identify the factors responsible for the complication (delayed union or nonunion) of distal tibial fracture in our set up. We have seen increased use of distal locking plates in these fractures and at the same time we observe many cases of disturbed healing of fractures due to inappropriate use of fixation device. This review paper clearly brings out the salient points for discussion and understanding.

Methods
A thorough literature search was made in pubmed using key words: extraarticular tibia fractures, distal tibia fractures, nonunion of distal tibia. Out of 466 articles, case reports, case series and articles published before 2010 were excluded. Original research articles and review articles published between 2010 January to 2018 December were considered for review. Authors independently reviewed all 241 article abstracts. After abstract were studied, 51 articles were considered for full text review. This review paper is based on author’s understanding of relevant literature related to extraarticular fractures of distal tibia.

Conservative Treatment
Conservative treatment of undisplaced distal tibia fractures with cast has showed acceptable functional outcome in various studies. (Fig. 2) Pandey et al reported a series of cast treatment of nonarticular distal tibia fractures where all fractures united within 6 months. Fracture displacement in plaster cast and malunion was observed in few cases, but functional outcome was within acceptable limit [13].

Sarmiento et al reported that the angular deformity and shortening in distal tibia fractures managed with functional brace was comparable with those reported by other investigators using intramedullary nails and functional outcome was excellent [14,15]. Later in 2008, Sarmiento recommended against functional bracing to fractures that initially have greater than 12mm shortening and angular deformity greater than 8º [16].

External Fixation
Traditionally external fixation has been reserved for trauma with severe skin injury, as a temporary solution in a two-staged protocol [17] (Fig. 3). Definitive primary external fixation of distal tibia fractures may result in insufficient reduction, malunion, and pin tract infection.6 Circular external fixator might be preferred due to its easy application, fewer complications, early mobilisation and shorter treatment time. Illizarov circular external fixator provides immediate weight bearing as tolerated, irrespective of radiological or clinical healing with no infection, deformity or non-union [18].

Extracutaneous Locking Compression Plate
External fixation using a precontoured distal femoral locking plate is easy to perform, less invasive, and the low profile plate can be concealed under stockings [19]. Distal tibial fracture is an ideal indication for extracutaneous locking plate. The external plating is characterized by fewer soft tissue impingement, improved cosmesis, and convenient for removal. For optimum stability, the plate-bone distance should be less than 30mm [20].

Intramedullary Nailing
Intramedullary nailing is the most popular method of treating extraarticular distal tibia fractures. It allows atraumatic closed stabilization, preserves vascularity of fracture site and integrity of soft tissue envelope and has fewer wound problems (Fig. 4). Because of the hourglass shape of the medullary canal, it is wider at fracture site than at the isthmus. It prevents intimate contact between the nail and endosteum. This results in the play of the nail along the interlocking screws. Torsional and angular stability of fixation is questionable and there is risk of malunion or nonunion [21-23].

Intramedullary nailing produces higher rates of malunion in the distal fractures [24]. Distal tibial malalignment may be more poorly tolerated than proximal malalignment. The incidence of delayed union or nonunion and implant failure is higher with unreamed nailing, which is attributed to smaller sized nails [25-27].

Various techniques have been recommended to improve stability of nailing the metaphyseal fractures including blocking screws (poller screw), temporary unicortical plating, percutaneous reduction clamps, and fibular plating [28]. Use of blocking (poller) screws in combination with an intramedullary nail can improve and maintain reduction and fixation of distal tibia fractures at the metaphysio-diaphyseal junction [29]. Adjunctive fibular stabilization in unstable distal tibia fibula fractures helps to prevent malalignment of tibia nailing [30].

Newer Intramedullary Nails
Expert tibial nail (ETN) has multidirectional locking options. So fibula plating is not necessary with ETN. This helps to avoid soft tissue problems and delayed healing attributed to fibula fixation [31,32]. Retrograde tibial nail has produced comparative results in biomechanical comparison with expert tibial nail but is still in experimental stage [33].

Locking Plate Osteosynthesis
Locking plate osteosynthesis can be used either as a bridge plate, resulting in relative stability or as a neutralisation plate, in combination with lag screw providing absolute stability [34,35]. Extraarticular distal tibia fractures fixed with minimally invasive percutaneous plate osteosynthesis (MIPPO) technique using locking plate have advantages of shorter operation time, less wound complications and less malunion than with intramedullary nailng. Locking plates have shown union in all cases and very low complications even in the intraarticular fractures of distal tibia [36,37] (Fig-5).

MIPPO respects the soft tissue envelope along with maintaining the biological environment needed for proper osseous healing [38,39]. Additional use of interfragmentary screws helps to achieve better reduction and faster fracture healing in simple distal tibia fractures, with fewer complications [34,40]. However, for complex and comminuted fractures, relative stability with bridge plating by MIPPO is the preferred method for correcting bone alignment and protecting soft tissue, leading to functional recovery [40-42]. Malleolar skin irritation is common problem because of prominent hardware.

Though the fracture union rates are similar in locked and nonlocked plating, higher incidence of malalignment and reoperation are seen with nonlocked plating [43,44].

Intramedullary Nailing or Locking Plate?
However, for metaphyseal fractures or those at the metaphyseal-diaphyseal junction, choice of fixation device and technique is controversial. Prevalence of valgus malunion was higher in the IMN group and recurvatum was more prevalent in the MIPO group [45]. Many authors have found no or minor differences in outcome with nailing or plating techniques [46-51]. Complications in both the groups appeared to be related to high-energy mechanisms and open fractures [52].

Intramedullary Nail combined with Plate
There are certain scenarios like very distal fracture preventing the required fixation stability and/or a large bony defect that extends into the metaphysis causing the nail to take a significant more amount of load that might lead to failure; in these specific scenarios an intramedullary nail plate combination can be extremely helpful in achieving one’s desired goals in restoring appropriate length, alignment, and rotation [53].

Newer Methods
Various new methods applicable to distal tibial fractures have been studied, including dynamic locking screws [54], retgrograde tibial nail [55], etc. But their rate of nonunion is yet to be tested in large population. Once nonunion has been established, low intensity pulsed ultrasound, dynamization [56], reamed exchange nailing [57,58], expandable intramedullary nail with autologous bone graft [59], and posterolateral plating with or without bone grafting [60-62] have shown good outcomes in appropriately selected patients, which is beyond the scope of this review. Whatever treatment planned for nonuninon, should be done after identification and appropriate management of all modifiable risk factors (e.g. smoking, use of NSAIDs) [57].

Discussion
It is widely accepted principle for fixation of extraarticular fractures that flexible fixation with moderate axial movement provides an effective stimulus for periosteal callus formation and thereby accelerates healing [5]. Whilst axial compression is regarded as stimulatory, the role of interfragmentary shear is controversial [63]. In a series of cast treatment by Pandey et al, all fractures untied within 6 months. E. Hasenboehler et al, found prolonged duration required for healing in simple fractures with MIPPO [38]. In another study conducted by Dinko Vidovic, there was delayed union in two patients (9.5%), both of whom had simple fracture patterns (43 A1) treated with MIPPO [64]. The nail and plate together resulted in better result whereas the plate and nail singly had no differences with the outcome.

Tissue differentiation at fracture site depends on strain, which in turn depends on the distance between the moving fracture surfaces [65]. In multifragmentary comminuted fragments, the movement is distributed between many fragments, so the movement is enough to stimulate callus formation and secondary bone healing.5 In simple fractures, there are only two moving surfaces. It effects on the formation of cartilage or bone tissue. Cartilage is formed with less stability and with more stability bone tissue is formed. So it should be fixed with absolute stability of surgical technique, otherwise it would create delayed union or nonunion [66] (Fig. 6).

In clinical practice, the majority of nonunions are due to mechanical problems with instability, resulting in too much strain at the fracture site. The bone maintains its biological potential to heal, but fails to function due to the mechanical conditions. The majority of nonunions will heal if the correct mechanical environment is produced by surgery, without the need for biological adjuncts such as autologous bone graft [67]. It is important however, to preserve soft tissue envelope.

Conclusion
The treatment of distal tibia fractures is controversial. We prefer absolute stability in two part fractures to eliminate interfragmentary shear force; and relative stability in multifragmentary comminuted fractures. Choice of fixation device depends on availability of implant and expertise of surgeon.

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