[The articular fracture of the lower limb]

O Weber, M C Müller, H Goost, C Burger, K Kabir, D Wirtz
Zeitschrift Für Orthopädie und Unfallchirurgie 2009, 147 (3): 298-305

AIMS: The combination of a distal tibia fracture with an additional upper ankle joint injury is a challenge. Apart from various implants the intraoperative problem is the handling of these two injuries with appropriate reduction and retention. The existing and further developing soft tissue damage has to be taken into consideration. The aim of this study is to evaluate the surgical management of this type of fracture.

PATIENTS AND METHODS: Between 2000 and 2007 we treated 22 patients with tibia fractures and coexisting upper ankle fractures. All patients could be traced for follow-up examinations. We deduced the impact energy of the trauma and the soft tissue damage. The tibial and ankle fracture sites were categorised. The time elapsed until full weight bearing was measured. The ankle joint function was inspected.

RESULTS: A high energy trauma existed in 10 and a low energy trauma in 12 patients. In the high energy group we found in 5 cases A3, in 2 cases B1 and 1 B2 and 1 B3 and 1 C2 fracture of the tibia. In 5 cases a bimalleolar ankle injury existed, once a medial ankle fracture und in 3 cases an isolated distal fibula fracture. One patient had an open ankle joint luxation. In some cases an additional fibula shaft fracture was seen. "Fracture communication" between the tibia fracture and the ankle injury was not seen at all. An intramedullary nail stabilisation was used in 9 cases, while in 1 patient due to the soft tissue damage an external fixator was applied. In the low-energy group there were 4 B1, 4 B2 and 4 C1 fractures of the tibia. We found 6 injuries of the posterior plafond and 6 cases with a central fracture line of the pilon. A fracture communication between ankle and tibial shaft was detected in all cases. In 7 patients we used a minimally invasive locking plate and in 5 cases a nailing technique for stabilisation of the tibia fracture. Overall, we saw 1 distraction fault, 1 valgus misfitting of the fracture, 1 pin infection and 2 soft tissue necrosis as postoperative complications. The time interval until osseous union was 3.5 months. Monoarticular fractures of the upper ankle joint had better results according to the Weber score.

CONCLUSION: One can divide the distal articular tibial shaft fracture into two groups. In the high energy entity the ankle joint injury happens first, and afterwards the tibial shaft fracture occurs. Therefore, both fracture sites are usually not communicating, which means they are in fact two types of fracture. On the other hand, in the low energy group, both fractures are communicating. Here, the tibial shaft fracture is equal to the inner ankle fracture in a classic bimalleolar fracture. Therefore we have only one fracture site.

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