Session I - Tibia Fractures

Distal-Fourth Tibial Fractures Treated with Locked Intramedullary Nailing: Does Fibular Fracture Influence Malalignment?

A. Paige Whittle, MD, John Crates, MD, George W. Wood, II, MD, Scott M. F. Duncan, MD

Campbell Clinic-University of Tennessee, Memphis, Tennessee, USA

Purpose: This retrospective study was undertaken to determine whether the location of the fibular fracture or fibular stabilization affected the alignment of the tibia at the time of fracture union.

Materials and Methods: Between 1992 and 1995, 64 patients with fractures of the distal fourth of the tibia were treated with statically-locked intramedullary nails. Fifty-five patients with an average age of 37 years were followed to fracture union. Most fractures were caused by high-energy trauma. Twenty-seven fractures were open: 14 type I, 5 type II, 4 type IIIA, and 4 type IIIB. Forty-one patients had associated fibular fractures: 28 same level (within 2 cm of tibial fracture) and 13 different level. Five of 28 same-level fibular fracture were treated with ORIF (3 plates, 2 Rush rods). Forty-one nails were locked with two distal screws and nine were locked with one distal screw. Malalignment was defined as 5° of coronal angulation, 10° of sagittal angulation, or 1 cm of shortening.

Results: All fractures united. Thirty-five (70%) of fractures maintained anatomical alignment and 15 (30%) were malaligned. Valgus angulation occurred in 14 fractures and valgus and posterior angulation in one fracture. None of the fractures with intact fibulas, and none of the five fractures treated with internal fixation of the fibula were associated with malalignment. Fourteen of 23 (61%) unfixed same-level fibular fractures and one of 13 (8%) different-level fibular fractures were associated with malalignment. Four of 9 (44%) fractures locked with only one distal screw were malaligned. Of the remaining five well-aligned fractures, three fibular fractures had been stabilized and one fibular fracture was at a different level.

Discussion: The indications for intramedullary nailing of the tibia have been expanded to include fractures in the metaphyseal region of the tibia, both proximally and distally, which has led to an increased incidence of malalignment. The role of an associated fibular fracture and the level of such fracture has not been defined.

Conclusions: Malalignment of distal-fourth tibial fractures treated with locked intramedullary nails is associated with unstabilized fibular fractures that occur at the same level. If intramedullary nailing of the distal-fourth tibial fractures is performed, we recommend stabilization of all same-level fibular fractures.