Distal Tibial Fractures

Distal Tibial Fractures







Distal Tibial Fracture


















Intra-articular Extension


Posterior Malleolar Fractures

- occult in 70%

- especially with spiral distal tibial fractures


Distal Tibia Intra-articularDistal Tibia Intra-articularDistal tibia CTDistal tibia CT


Distal tibia Distal tibia 2Distal tibia 3Distal tibia 4


Wang et al. J Orthop Surg Res 2021

- systematic review

- incidence 70% occult fractures



Nonoperative Management


Tibial Shaft Fracture Non Operative Treatment BeforeTibial Shaft Fracture Non Operative Treatment After



Operative Management




1. Temporary external fixator

2. IM Nail

3. Plate


Temporary External fixation



- significant swelling

- significant displacement / non controlled in cast

- significant wounds, need for soft tissue coverage



- two pins proximal tibia

- trans-calcaneal pin


AO Trauma Ankle Bridging Delta Frame



Distal Tibial Fracture DisplacedDistal Tibial Fracture External FixationDistal Tibial Fracture ORIF


Nail v Plate


Liu et al. Orthop Surg 2019

- meta-analysis of 10 RCTs, 911 patients

- no difference in nonunion, delayed union, or time to union

- reduced incidence of malunion with MIPO plate

- reduced wound problems with nail



Intra-medullary Nail


Distal Tibial FractureDistal Tibial Nail APDistal Tibial Nail Lateral



- wounds / soft tissues not suitable to plate

- relatively stable

- sufficient distal bone




Distal tibial nails

- multiple distal screws

- usually 2 medial-lateral and 1 AP

- most distal screw within 5 mm of end of nail


Smith & Nephew Tibal Meta Nail



Vumedi nail video





Consider semi-extended suprapatella nail

- easier to reduce fracture

- easier to get AP and lateral fluoroscopy


Most important is to centre guide wire over talus

- in lateral and AP

- use finger reduction tools and pass across fracture site to exact centre in AP and lateral

- bone reduction forceps

- blocking screws

- universal external fixation

- plate fibula


Fibular fixation


Peng et al. J Foot Ankle Surg 2021

- tibial IMN +/- fibular fixation

- meta-analysis of 4 trials, 283 patients

- tibial malalignment of 67% (126 / 189) in non fibular fixation group

- tibial malalignment of 20% (19/94) in the fibular fixation group



Distal tibia fibularFibular fixation Distal tibia


Posterior malleolar fixation


Typically stabilize intra-articular fracture first


Posterior malleolusPosterior malleolus 2Posterior Malleolus 3


B.  Distal Tibial ORIF with plate



- too distal to nail

- very comminuted / unstable

- intra-articular extension


Distal tibial plate 1Distal tibial plate 2




1. Consider fixing the fibula

- will aid reduction / avoid malunion

- help control very unstable fractures


2. Anatomically contoured plates

- options of medial plate v anterolateral plate

- medial plate for varus deformity

- anterolateral plate for valgus deformity


Distal tibia plateDistal tibia plate 2Distal tibia plate 3Distal tibial plate 4


Distal tibia plate 5Distal tibia plate 6




Barcak et al. J Orthop Trauma

- single surgeon, extra-articular fractures

- 43 IMN and 43 MIPO plate

- both groups similar

- nonunion rate 7 - 8%

- malalignment 3%

- wound complication 3%

- 26% of IMN required distal locking screws removed





Distal Tibial ORIF Nonunion


Plate and bone graft


Lin et al. Injury 2017

- 9 patients with distal tibia nonunion

- posteolateral approach to avoid poor anterior skin

- plate and iliac crest bone graft



External fixator


Schoenleber et al. Foot Ank Int 2015

- 8 patients treated with ilizarov / taylor spatial frame

- hypertrophic nonunions

- callous distraction - allowed correction of deformity and shortening

- all achieve union at 6 months





Distal Tibial Malunion




Persistent infected nonunion post distal tibial nail

- nail removed

- irrigation +++

- ilizarov frame with immediate weight bearing

- union obtained, infection eradicated


Distal tibial infected non union with Ilizarov APDistal tibial infected non union with Ilizarov Lateral