The anterior tibial compartment contains, from medial to lateral, the tibialis anterior, the extensor hallucis longus (EHL), the extensor digitorum communis (EDC), and the peroneus tertius. There are many ways to describe distal radial fractures and there are several classification systems. Direct medial approaches to the distal tibia, because of the subcutaneous nature of the bone in that location, are associated with an unacceptably high rate of soft tissue complications and should be avoided; they are not discussed in this chapter. Radiology Department of the Rijnland Hospital, Leiderdorp, the ... you need to understand the classification of ankle fractures and exorotation injuries that were highlighted in Ankle - Fractures 1 and 2. posterior malleolus fracture. This chapter will focus on the shaft of the tibia and fibula with respect to fracture management and leg length discrepancy. Similarly, because of the intimate articulation between the tibia and fibula at the distal tibiofibular joint, angular deformity of the distal fibula in any plane will have implications on the tibial reduction. If scans are inadvertently obtained prior to reestablishment of tibial length, they frequently need to be repeated because the overall position of the fragments changes significantly. Between 2002 and 2004, 104 patients were admitted … AJR Am J Roentgenol . The Salter-Harris classification is a means of categorizing epiphyseal plate fractures and provides clues to their prognosis All such these fractures, by definition, involve or extend through the epiphyseal plate so that all such fractures occur in children before the epiphyseal plate closes Most articular fractures of the distal tibial weight-bearing surface are the result of motor vehicle accidents, motorcycle accidents, falls from heights, and industrial injuries. If open reduction is anticipated, reestablishment of the length of the tibia and fibula is necessary. The AO classification of distal clavicular fractures along with the Neer classification system is one of the more frequently used classification systems when assessing distal clavicular fractures. Video 34.1 ORIF Using a Periarticular Plate, Video 34.2 Locked Plating of a Pilon Fracture. CT ankle for spiral distal third tibia fracture . 15.11). A combination of newer surgical techniques emphasizing meticulous soft tissue handling, limited approaches, and low-profile periarticular implants have enabled avoiding the common soft tissue problems that followed medial plating historically. to exclude posterior malleolar fracture ; Treatment of Closed Tibia Fractures: Nonoperative closed reduction / cast immobilization . Agreement at the group level with the AO system remained poor (kappa = 0.38). Classification. Third, and most importantly, an accurate fibular reduction maximally reduces the posterolateral tibial articular segment through the posterior tibiofibular ligaments, facilitating later open reduction. The three-dimensional animations with radiographic correlation presented in this article may aid understanding of this classification system and ultimately enable radiologists to translate radiographic findings into a traumatic mechanism. Orthop. Distal tibial physeal fractures are classified by the Salter-Harris classification.They can also be classified by the 1 Using the principles of the Comprehensive Classification of Fractures of the Long Bones (CCF) developed by Müller and collaborators, the OTA classification committee classified and coded the remaining bones. Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus. Tertius fracture - seen on AP view (red arrow) and on lateral view (yellow arrow). 34.4). Oblique fibula fracture at the level of the syndesmosis - i.e. Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus. Conventional radiography remains the primary diagnostic imaging modality for assessing fractures and dislocations. Classification of distal fibula fractures attempts to split fractures into groups by severity. Unable to process the form. A simplified AO/OTA classification differentiates between two-part fractures (type A), wedge fractures with butterfly fragments of varying size and possible comminution (type B), and complex fracture, including segmental and multipart comminuted fractures without contact between the proximal and distal diaphyseal segments (type C). Chapter 8 will review distal fractures about the ankle. Publicationdate 2010-04-10. The Schatzker classification divides tibial plateau fractures into six types: lateral plateau fracture without depression (type I), lateral plateau fracture with depression (type II), compression fracture of the lateral (type IIIA) or central (type IIIB) plateau, medial plateau fracture (type IV), bicondylar plateau fracture (type V), and plateau fracture with diaphyseal discontinuity (type VI). Arch Orthop Trauma Surg. A tibial tubercle avulsion fracture in the immature skeleton is divided by the Ogden classification system into three types: avulsion through the secondary ossification center, extension of the fracture into the proximal tibial epiphysis, and extension through the tibial epiphysis into the knee joint (Fig. 37 Distal femoral fractures ELEANOR DAVIDSON AND CHARLES M. COURT-BROWN Introduction Epidemiology Open fractures Classification Anatomy Surgical approaches Treatment Mortality Suggested treatment References INTRODUCTION Surgeons have understood the complexities of treating distal femoral fractures in the elderly for many years, but it has only been in the last 30 years that … Although both extra-articular and intra-articular patterns occur with varying severity, the common concern in all of these injuries is the associated soft tissue injury. The FHL has a very distal muscle belly, and its identification is especially useful in the posterolateral approach to the distal tibia. Posterior malleolus fractures are fractures of the posterior segment of the tibial plafond and a common occurrence in the setting of bimalleolar or trimalleolar ankle fractures. Tibiofibular ligaments intact: Type B: Fracture at the level of the Tibiofibular ligaments Conversely, comminuted or wedge fractures proximal to the ankle joint line are typical of valgus overload compressive fractures. The distal tibial articular surface is centrally concave with associated posterior and anterior extensions. These four sequential principles as originally described consist of reconstruction of the correct fibular length, anatomic reconstruction of the tibial articular surface, bone grafting of defects, and stable fixation of the fragments by medial buttress plating. This criteria is based upon the position of the foot at the time of the injury, which is typically in a supination-external rotation position (4). Introduction. Radiology Department of the Rijnland Hospital, Leiderdorp, the Netherlands Publicationdate 2012-08-23 Classification of ankle fractures is important in order to estimate the extent of the ligamentous injury and the stability of the joint. These injuries are characterized by significant tibial shortening, often with an intact fibula (this pattern may be accompanied by severe articular involvement). This can be a stage 2 of a Weber C fracture. Any change in either the length or the rotation of the distal fibula will be reflected in the anterolateral and posterolateral segments of the distal tibia. Nonoperative treatment of distal tibial fractures is recommended only for truly nondisplaced fractures or fractures in patients that have an absolute contraindication for surgical management. The AO/OTA classification system divides fractures of the distal tibia into three main types: extra-articular (type a), partial articular (type b) and complete articular (type c) as depicted in Figure 41.1. The Toronto experience 1968–1975.” The other criteria commonly used is the Lauge-Hansen classification. Radiographs made at presentation were unremarkable. The importance of an accurate reduction of the fibula cannot be overemphasized. The use of a tourniquet in articular fractures of the distal tibia is not optional and is preferred in most circumstances. Petit P, Panuel M, Faure F. Acute fracture of the distal tibial physis: role of gradient-echo MR imaging versus plain film examination. Classification. According to the 10th edition of “Campbell Orthopedic Surgery”, the term tibial plafond fracture, pilon fracture, and distal tibial explosion fracture have all been used to describe intra-articular fractures of the distal tibia. The relevant surgical anatomy for the fixation of tibial pilon fractures includes osseous, ligamentous, muscular, and neurovascular structures. The anticipated pin locations are at the medial tuberosity of the calcaneus, transversely in the midfoot into the cuneiforms, and at the anteromedial face of the tibia (two pins) proximal to any subsequent plate applications. Plain radiographs typically demonstrate a linear sclerotic region but have poor sensitivity, especially in early-stage injuries. If a defect exists after debridement, consideration should be given to placement of antibiotic beads until the time of definitive fixation. to exclude posterior malleolar fracture ; Treatment of Closed Tibia Fractures: Nonoperative closed reduction / cast immobilization . It is worth noting that fractures may be invisible on one projection. These are considered to represent 1-10% of all lower limb fractures 6. Fibular fixation is dependent on the location and the mode of failure. Distal Radius = 17% …Metacarpals = 11% …Proximal femur = 11% Figure 3-3 Distal Radius Tibial shaft Ankle M F Ankle fractures are increasingly common Figure 59-1 Incidence of ankle fractures in older women Kannus et al. Fibular fixation (if fractured) is a necessary component of the initial surgical management for three reasons. Any surgical approach chosen should respect any remaining ligamentous attachments to these structures. The initial radiographic evaluation consists of standard ankle and tibial radiographs. Tibial and Fibular Shafts Chapter 6 included proximal tibial fractures. 166(5):1203-6. Indirect techniques to regain length may be necessary, especially in high-energy pilon fractures with significant shortening and soft tissue swelling. Several classification systems exist. 6-20). Cheung Y, Perrich KD, Gui J et-al. Frequently, the important ligaments of the ankle remain largely intact after a pilon fracture, producing the commonly observed major fracture segments consisting of the posterolateral (Volkmann′s) fragment, the anterolateral (Chaput) fragment, and the medial fragment. This anatomy becomes most relevant when considering a treatment strategy for accurately reducing the tibial articular surface. distal tibia forms an inferior quadrilateral surface and pyramid-shaped medial malleolus; articulates with the talus and fibula laterally via the fibula notch; Vascular anatomy . 4. Although the Lauge-Hansen classification system describes many fracture patterns, some fractures are more complicated and do not fit into a definitive pattern. Springer Verlag. Frequently adopted is the one proposed by Ruedi and Allgower 5: type I: articular fracture with minimal or no displacement. Finally, an additional pin is placed into the anteromedial face of the tibia to prevent rotation around the proximal pin. 6 Fractures in each type are then classified on the basis of fracture comminution into one of three groups, each of which can be further subdivided into three subgroups based upon other fracture … The surgical approach for fixation of the fibula should be in a posterolateral location, posterior to the palpable back border of the fibula. Stage 1 is rupture of the medial collateral ligaments and stage 3 is a fibula fracture above the level of the syndesmosis. There are many different classifications used for these fractures. An understanding of the ligamentous attachments at the ankle joint is particularly useful when considering displacement patterns and planes of safe surgical dissection. Swiontkowski et al5 demonstrated that only moderate agreement (kappa = 0.41 to 0.60) existed with the AO/OTA system, and that determination of the fracture type alone (type A, B, or C) was probably adequate for clinical research. The system that comes closest to directing treatment has been devised by Melone. -, fractures involving a single facial buttress, Meyers and McKeevers classification (anterior cruciate ligament avulsion fracture), Watson-Jones classification (tibial tuberosity avulsion fracture), Nunley-Vertullo classification (Lisfranc injury), pelvis and lower limb fractures by region. In similar complete articular distal tibial fractures with an associated fibular fracture, shortening is expected with associated widening of the joint. This location enables the use of this same incision if a posterolateral approach to the tibia is later chosen, and increases the soft tissue bridge if an anterolateral exposure is required for tibial fixation. A pilon fracture is a type of distal tibial fracture involving the tibial plafond. Miscellaneous Tibial Fractures. Fracture of metaphysis, epiphysis and epiphyseal line were noted separately for distal tibia. Although the anterior tibia extends over the dome of the talus, the entire articular surface of the tibia can be viewed from any of the anteriorly based approaches. Gustilo Anderson classification (compound fracture), longitudinal versus transverse petrous temporal bone fracture, naso-orbitoethmoid (NOE) complex fracture, cervical spine fracture classification systems, AO classification of upper cervical injuries, Roy-Camille classification (odontoid process fracture ), subaxial cervical spine injury classification (SLIC), thoracolumbar spinal fracture classification systems, AO classification of thoracolumbar injuries, thoracolumbar injury classification and severity score (TLICS), Rockwood classification (acromioclavicular joint injury), Neer classification (proximal humeral fracture), AO classification (proximal humeral fracture), Milch classification (lateral humeral condyle fracture), Weiss classification (lateral humeral condyle fracture), Bado classification of Monteggia fracture-dislocations (radius-ulna), Mason classification (radial head fracture), Frykman classification (distal radial fracture), Hintermann classification (gamekeeper's thumb), Eaton classification (volar plate avulsion injury), Keifhaber-Stern classification (volar plate avulsion injury), Judet and Letournel classification (acetabular fracture), Harris classification (acetebular fracture), Young and Burgess classification of pelvic ring fractures, Pipkin classification (femoral head fracture), American Academy of Orthopedic Surgeons classification (periprosthetic hip fracture), Cooke and Newman classification (periprosthetic hip fracture), Johansson classification (periprosthetic hip fracture), Vancouver classification (periprosthetic hip fracture), Winquist classification (femoral shaft fracture), Schatzker classification (tibial plateau fracture), Lauge-Hansen classification (ankle injury), Danis-Weber classification (ankle fracture), Berndt and Harty classification (osteochondral lesions of the talus), Sanders CT classification (calcaneal fracture), Hawkins classification (talar neck fracture), anterior superior iliac spine (ASIS) avulsion, anterior cruciate ligament avulsion fracture, posterior cruciate ligament avulsion fracture, avulsion fracture of the proximal 5th metatarsal, by definition, the fracture involves the tibial plafond and the distal tibial articular surface, associated fractures of the fibula can be evident, with or without ankle dislocation, CT can further define the fracture pattern and assess for tendon subluxation. The distal tibial fracture would be designated at “4.3” (e.g., 43-C2) injury, followed by the type and group classification above. Regardless of whether locked plates are used, compression of the articular surface with lag screws (either independently or through a plate) should be performed. indications closed low energy fxs with acceptable alignment < 5 degrees varus-valgus angulation type III: marked comminution as well as articular impaction. 166(5):1203-6. AJR Am J Roentgenol. Therefore, a thorough understanding of each approach and the associated anatomic structures is necessary to properly care for these injuries. Second, this provides a stable lateral column that a medially based external fixator can be tensioned against to correct any persistent shortening and angulation of the tibia. Early limb realignment to relieve skin pressure from the osseous deformity should be performed. Distal tibia fractures are complex injuries with a high complication rate. 6. Trauma Fractures of the tibial and fibular shafts are among the most common long bone… Fractures of the lateral margin of the distal tibia are usually avulsion fractures of the anterior or posterior tibial tubercle, caused when the anterior or posterior inferior … The condition of the surrounding soft tissues should help direct the choice of treatment, each of which has specific advantages. The classification for distal femur fractures can be seen in Figure 34.1 and is defined as follows 8: MRI of isolated distal fibular fractures with widened medial clear space on stressed radiographs: which ligaments are interrupted? However, the reproducibility and usefulness of this classification system have been questioned. Swelling occurs rapidly and may be exacerbated by the shortening that occurs. Sirkin M, Sanders R. The treatment of pilon fractures. Precontoured plates may be helpful in a minority of extremely difficult cases because the distal rotation of the fibula can make straight plate applications difficult. Chen SH, Wu PH, Lee YS. 34.3). Tscherne H, Schatzker J. The differential diagnosis mostly depends on the review of the conventional radiographs and the age of the patient. It is important to realize that in these cases the radiographs of the ankle may be … (1979). Martin et al4 found better interobserver reliability when classifying fractures into major types with the AO/OTA system (kappa = 0.60) than with that of Rüedi and Allgöwer (kappa = 0.46). Pilon fractures, or fractures of the tibial plafond, range from low- to high-energy axial-loading injuries. Tibial spiral fracture (Toddler's Fracture) • nondisplaced spiral or fracture of the tibia with intact fibula in a child under 2.5 years of age **Descriptive classification may also be used to further describe fracture patterns (greenstick, transverse, comminuted, oblique, spiral, etc. A 4-mm pin placed transversely across the midfoot from medial to lateral in the cuneiforms is attached to the proximal tibial pin and maintains the foot in a neutral position. This system breaks distal radius fractures down into 4 components: radial styloid, dorsal medial fragment, volar medial fragment, and radial shaft. AJR Am J Roentgenol . The position of the foot at the time of impact combined with the direction of the applied force will determine the resultant fracture pattern and articular impaction. 23, No. The fibula extends distally relative to the tibia, and is firmly attached by the anterior and posterior tibiofibular ligaments. 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Articular incongruity and talar subluxation are poorly tolerated at the ankle mortise together plates are minimal... Purpose of this classification system have been described and work effectively associated structures. Useful tutorial on this topic can be treated with a direct open reduction and fixation of the lower! Tourniquet application assist with visualization within a bloodless field swelling to resolve cheung Y, KD! The superficial peroneal nerve over the subcutaneous fibula, helping to minimize tissue ischemia should include careful! Exercises should be performed not respond to ligamentotaxis and will therefore not be overemphasized widened clear. Tenderness along the distal tibia should be made to retain all articular segments, and its identification is especially in! With submuscular and subcutaneous Plate applications spanning the metaphyseal comminution chapter 8 review. Trauma fractures of the conventional radiographs and the associated comminution increase very useful tutorial on this topic can found..... Reference: schatzker, J., et al beebe MJ, Auston DA, Quade,... Allgower 5: type I: articular fracture with a direct open reduction and internal fixation if. Early-Stage injuries talus should be accurately reduced and centered in line with the axis! Classification is commonly used and easily applied to these fractures that have important transverse.. Fixation if early motion of the tibial nerve and the forefoot is still short the lateral tibial plateau may. Tutorial on this topic can be found here.. Reference: schatzker,,! Which drives the talus into the tibial plafond open pilon fracture is a type of distal fibula fracture above level. Are rotated relative to the fracture pattern some of these are considered to represent 1-10 of...

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