Review Question - QID 5645

This patient has an extraarticular distal tibia fracture and distal fibula fracture. Reamed intramedullary nailing and fibular plating is indicated in this case.

In the distal tibial metaphysis, there is no snug endosteal fit for an IM nail. Center-center nail placement in both proximal and distal fragments is necessary to maintain alignment. There is also increased stress on distal locking bolts to maintain fracture alignment. Assuming static medial-lateral distal locking screws, accurate coronal plane and rotational alignment is achieved by fibular plating as a first step. This also prevents late loss of alignment because of distal locking screw toggle. Reamed nailing allows a stiffer, larger nail to be placed, and allows redistribution of endosteal osteogenic material to the fracture site. Although there is endosteal vascular compromise, this does not affect fracture healing because of intact periosteal supply.

Bhandari et al. conducted a prospective, randomized, blinded comparison of 622 patients who had reamed nailing, and 604 who had unreamed nailing. For closed fractures, a significantly greater number in the unreamed group required bone grafting, implant exchange and dynamization. There was no difference in groups for open fracture nailing.

Egol et al. retrospectively reviewed distal metaphyseal tibia-fibula fractures treated with IM nailing with (25 cases) and without (47 cases) adjunctive plating. They found that plating was associated with maintenance of reduction (significant) as was the use of 2 medial-lateral distal locking bolts (not significant). They recommend fibular plating when IM nailing for distal tibia fractures.

Figures A and B show an extraarticular distal tibia fracture with distal fibula fracture.

Incorrect Answers
Answers 1 and 2: Locked tibia and fibular plating plating has more soft tissue dissection compared with fibular plating and tibia IM nailing. This increases the risk of wound complications.
Answer 3: Fibular plating reduces postoperative valgus malalignment and late loss of alignment.
Answer 4: In closed tibia fractures, unreamed nailing has a significantly greater need for bone-grafting, secondary dynamization, and exchange nailing compared with reamed nailing. In open tibia fractures, this difference is not significant.