Journal of Orthopaedic Surgery �����������������
2009;17(3):317-20
Intramedullary nailing and plate osteosynthesis
for fractures of the distal metaphyseal tibia and
fibula
Ajay Krishan, Chetan Peshin, Dara Singh
Department of Orthopaedics, GMC Jammu, India
ABSTRACT
Purpose. To assess the results of concurrent
intramedullary nailing plus plate osteosynthesis for
fractures of the distal tibia and fibula.
Methods. 15 men and 10 women (mean age, 35 years)
with concurrent fractures of the distal tibia and fibula
underwent intramedullary nailing (for the tibia) and
plate osteosynthesis (for the fibula). 17 fractures were
type A1, 6 type A2, and 2 type A3. Compound type
IIIB or more extensive fractures were excluded.
Results. The mean follow-up duration was 2 years.
The mean time to bone union was 20 weeks. Six
patients underwent dynamisation and 4 bone grafting.
Two patients had malalignment (angulation of >5º in
any plane), but none was rotational. No patient had
shortening, hardware breakdown, or deep-seated
infection. Two patients had superficial cellulitis at the
site of the distal locking screws.
Conclusion. Concurrent intramedullary nailing and
plate osteosynthesis for fractures of the distal tibia
and fibula is effective in preventing malalignment.
Plate osteosynthesis for the fibula provides additional
stability even when a single distal locking bolt is used
to fix the intramedullary nail to the tibia.
Key words: bone malalignment; fibula; fracture fixation,
internal; fracture fixation, intramedullary; tibia
INTRODUCTION
Plate osteosynthesis for fractures of the distal tibia
is often associated with delayed healing, infection,
and hardware problems.1,2 Locked intramedullary
nailing is the treatment of choice for closed fractures
of the tibial shaft.3,4 For proper alignment, the nail
should be centrally placed in both the proximal and
distal fragments,1,5 but does not fit properly into the
distal fragment of the lower third of the tibia. This
places additional stress on the distal locking bolts
and may lead to breakage and malalignment. We
Address correspondence and reprint requests to: Dr Chetan Peshin, Department of Orthopaedics, GMC Jammu, India. E-mail:
chetanpeshin@gmail.com
Journal of Orthopaedic Surgery
318 A Krishan et al.
Figure 1 Radiographs showing fixation using an interlocking
intramedullary nail for fractures of the distal tibia plus a
dynamic compression plate for fractures of the distal fibula.
assessed the results of intramedullary nailing and
plate osteosynthesis for fractures of the distal tibia
and fibula.
MATERIALS AND METHODS
Between June 2005 and October 2007, 15 men
and 10 women (mean age, 35 years) underwent
intramedullary nailing for fractures of the distal third
of the tibia plus plate osteosynthesis (using a one
third tubular plate or dynamic compression plate)
for fractures of the distal third of the fibula (Figs. 1
and 2). Patients with fractures near the junction of
the distal one third, compound type IIIB or more
extensive fractures,6 or fractures more than 2 weeks
old were excluded. All compound fractures were
debrided. 17 fractures were type A1, 6 type A2, and 2
type A3, according to AO classification.7 Road traffic
accident was the main cause of injury. In 4 patients
with a compound type-IIIA fracture, specialised nails
were used as the distance between the distal locking
bolt and the nail tip was just 1 cm. In the early period
when such nails were unavailable, the distal end of the
nail was trimmed using a hack-saw. Due to technical
reasons, 12 patients had their intramedullary nails
fixed with only one distal locking bolt.
Postoperatively, patients were kept non–weightbearing for 12 weeks. Active and passive movements
were encouraged. At week 12, the progress of healing
Figure 2 Radiographs showing intramedullary nailing
using only one distal locking bolt and plate osteosynthesis for
segmental fractures of the distal tibia and fibula.
was assessed using radiographs and weight bearing
was initiated. Malalignment (angulation of >5º in any
plane)8 was assessed by comparison with the normal
leg. Patients were followed up at weeks 3, 6, 12, and
24, and then every 3 months during the first year and
6 monthly thereafter.
RESULTS
The mean follow-up duration was 2 years. The
mean time to union was 20 weeks. All patients were
available for the final follow-up (Table). Six and 4
patients underwent dynamisation and bone grafting,
respectively. Two patients had angular malalignment,
but none had rotational malalignment. No patient
had shortening, hardware breakdown, or deep-seated
infection. Two patients had superficial cellulitis near
the screw insertion sites and were treated with oral
antibiotics, debridement, and dressing. There was no
correlation between the number of locking bolts used
and malalignment.
DISCUSSION
The characteristics and treatments offered to
patients with fractures of the distal tibia and fibula
Vol. 17 No. 3, December 2009
Intramedullary nailing and plate osteosynthesis for fractures of the distal tibia and fibula 319
Table
Characteristics and treatment outcomes of the patients
Patient Sex/age
no.
(years)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
M/23
M/28
M/19
F/34
M/50
M/52
F/40
M/26
F/45
F/28
M/30
M/35
F/33
M/37
F/38
M/40
M/49
F/56
F/51
F/33
M/16
M/19
M/32
M/35
F/36
Fracture type
Time to
Final angulation
bone union
AO classification Gustillo classification
Anteroposterior Mediolateral
(weeks)
A1
A2
A1
A2
A1
A3
A1
A1
A1
A1
A1
A1
A2
A1
A1
A2
A1
A1
A1
A1
A2
A1
A1
A2
A3
II
IIIA
I
I
II
IIIA
II
I
IIIA
I
IIIA
differ from those having more proximal fractures.
Intramedullary nailing enables closed stabilisation
while preserving vascularity of the fracture site and
integrity of the soft-tissue envelope. It is the treatment
of choice for fractures of the tibial shaft but not the
distal metaphyseal tibia. The intramedullary canal
at this level prevents intimate contact between the
nail and endosteum.9 There are concerns regarding
fixation stability and malunion, especially when
less than 2 locking bolts are used to secure the distal
fragment.10,11 A fibular plate can therefore be used to
enhance stability.
In 63 patients treated with intramedullary nailing,
all but 5 had satisfactory outcomes.5 Poor outcome
was attributed to technical errors; no displacement
was noted during nail insertion or locking, even in
patients with distal tibial fractures and undisplaced
intra-articular involvement.5
In a series of 73 distal leg fractures, 93% were
closed, 83% were type A1, 17% had some comminution,
and 4 had partial articular involvement.12 Interlocked
Grosse-Kempf nails (entailing dynamic locking for
simple fractures and static locking for comminuted
fractures) were used for tibial fractures and associated
fibular fractures were plated before nailing. In
fractures at the level of the distal screw, the tip of the
15
14
12
17
19
23
21
17
21
20
17
21
15
21
18
17
19
21
20
20
17
16
18
20
26
5º
6º
4º
3º
5º
5º
11º
3º
4º
3º
8º
7º
8º
7º
No. of distal
locking bolts
used
1
2
1
2
1
3
2
1
1
2
2
2
1
2
1
2
2
1
2
1
2
1
1
2
1
nail was sawed off to allow more distal seating of
the nail. 96% of these fractures healed without major
complications. There was no shortening of >1 cm or
angulation of >5°. The 3 non-unions were managed
with dynamisation, bone grafting, or the Ilizarov
technique.12
In a biomechanical study, the strength of a
shortened intramedullary nail (terminal 1 cm
removed) for fractures within 4 cm of tibiotalar
joint was not significantly different from that of a
standard intramedullary nail for fractures 5 cm from
joint.13 Neither construct was strong enough to resist
a moderate compression bending load, and weight
bearing was restricted until the bone had healed.
For fractures of the distal tibia and fibula, the
proportion of patients with reduction loss was
significantly greater after intramedullary nailing
alone than after intramedullary nailing and plate
and screw fixation.14 Thus, fibular plating was
recommended whenever intramedullary nailing was
used in unstable distal tibiofibular fractures.
In our study, the incidence of malalignment was
negligible, as weight bearing was restricted until
radiographic union. Results were satisfactory even
when a single locking bolt was used. Only 2 cases had
gross malalignment (angulation of >5º in any plane).
320 A Krishan et al.
Journal of Orthopaedic Surgery
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