The Journal of TRAUMA Injury, Infection, and Critical Care

Two-ring Hybrid External Fixation of Distal Tibial Fractures:

A Review of 47 Cases
Jukka Ristiniemi, MD, Tapio Flinkkila, MD, PhD, Pekka Hyvonen, MD, PhD, Martti Lakovaara, MD,
Harri Pakarinen, MD, Fausto Biancari, MD, PhD, and Pekka Jalovaara, MD, PhD
Background: The healing of a metaphyseal fracture line is a major problem
in cases of distal tibial fracture treated
with external fixation.
Methods: Forty-seven distal tibial
fractures treated with two-ring Ilizarov
hybrid external fixation (16 AO/OTA type
A and 31 type C, 10 open) were followed
up. Fracture reduction and union time
was evaluated and IOWA and RAND 36Item Health Survey scores were used to
assess functional outcome.
Results: Thirty-five fractures united
uneventfully in a median time of 20 weeks,
but 12 fractures needed additional procedures because of delayed union. According to univariate analysis, the risk factors
for a longer time needed for fracture union

were translational displacement and current smoking, and the risk factors for reoperation because of delayed union translational
displacement fibular fracture fixation, and the
number of cigarettes smoked per day. In multivariate analysis, translational displacement was a risk factor for both longer
time to fracture union and reoperation
and fibular fracture fixation was a risk
factor for reoperation. If the translational
displacement was less than 3 mm, the reoperation rate was 6%, whereas if the displacement was more than 3 mm, it was
83%. Reoperation was performed on 50%
of the patients who underwent fibular fixation and on 15% of the patients who did
not undergo fibular fixation. There were
only marginal decreases in the range of

motion and arthritis scores in the AO/

OTA
fracture types other than type C3. There
were no significant differences in RAND
36 scores between the general Finnish
population aged 18 to 64 years and our
patients.
Conclusions: Hybrid external fixation
of distal tibial fractures is associated with
delayed union, which is closely related to the
degree of residual translational displacement after reduction. Fixation of an associated fibular fracture does not help to
achieve better contact in the tibial fracture
and increases the risk of delayed union.
Key Words: Tibial fractures, Pilon
fractures, External fixation, Fracture
union, Delayed union, Nonunion.
J Trauma. 2007;62:174 183.

istal tibial fractures are uncommon, accounting for only

1% of all lower extremity fractures.13 Open reduction
with internal fixation (ORIF) often results in serious
wound healing problems and deep infection in high-energy
fractures with soft-tissue injuries and severe comminution.4 7
External fixation is a commonly used treatment8,9 and has
been shown to result in acceptable functional outcome with
few serious complications.10
In the treatment of tibial shaft fractures, external fixators
have a reputation of being nonunion machines.11 Clinical
studies have shown that the quality of reduction, especially
avoiding fracture gap, is extremely important.12,13 This fact has
received little attention in the literature on distal tibial fractures.
The published series on hybrid14 16 or ankle bridging external
fixation8,9 shows a tendency for delayed union and need for
additional operations especially in metaphyseal fractures.
Several factors have been recognized as risk factors
for delayed healing of fracture: sex, malnutrition, anemia,
Submitted for publication May 2, 2005.
Accepted for publication February 8, 2006.
Copyright 2007 by Lippincott Williams & Wilkins, Inc.
From the Department of Orthopaedic and Trauma Surgery, University
Hospital of Oulu, Oulu, Finland.
Address for reprints: Jukka Ristiniemi, MD, Department of Orthopaedic and Trauma Surgery, Oulu University Hospital, P.O. Box 90029, OYS,
Oulu, Finland; email: jukka.ristiniemi@oulu.fi.
DOI: 10.1097/01.ta.0000215424.00039.3b

174

and diabetes mellitus (systemic factors); corticosteroids,

nonsteroidal anti-inflammatory drugs, chemotherapeutic
cytotoxins, and smoking (pharmacological factors); and
location of the fracture, high fracture energy, soft-tissue
disruption, infection, and nerve injury (local factors). In
addition, some aspects of fracture care, such as motion at
the fracture site, the fracture gap, periosteal stripping during open reduction, and repeated manipulation of the fracture in the early phase increase the risk of delayed union.17
There are no studies specifically addressing the impact of
the risk factors on the outcome of distal tibial fractures
treated with external fixation.
Our purpose was to review our experience in the treatment of distal tibial fractures with two-ring hybrid external
fixation and to evaluate the risk factors associated with delayed union.

PATIENTS AND METHODS

Within the period from October 1998 to November
2003, 2,091 tibial or malleolar fractures were treated in
Oulu University Hospital. In all, 106 fractures were in the
AO/OTA18 zone 43 (within 5 cm from the ankle joint).
Thirteen zone 43 fractures with minimal displacement
were treated conservatively with a cast. Twenty-six type B
fractures and nine type C fractures with minor soft-tissue
injury were treated with open reduction and internal fixation. Six
type C fractures with severe comminution of the distal tibia were
January 2007

External Fixation of Distal Tibial Fractures

Fig. 1. Gustilo-Anderson grade 3B open fracture with diaphyseal extension (A) was treated with hybrid external fixation (B). There was 4
mm of posterolateral translation in proximal fracture. The fracture was nailed for delayed union of the proximal fracture line after the distal
fractures had healed (C). The fracture united in good alignment but there was malorientation of the ankle joint 3 years after the injury (D).

treated with external fixation spanning the ankle joint. Fifty-two

fractures with moderate or severe soft-tissue injury were selected
for treatment with hybrid external fixation, and these patients
constituted our study group.
Five patients were excluded from the study. Three of
them could not be followed up, one patient had a highly
comminuted pilon fracture and early arthrodesis of the ankle
joint, and another patient with multiple organ complications
underwent lower-limb amputation because of severe deep
infection. Thus, the present study included a total of 47
patients (27 men and 20 women; mean age 49 years, range
1579 years). Twenty-four patients had a relatively lowenergy injury (fall from less than 2 m, such as stairs or
sporting injuries), whereas 23 had a high-energy injury (fall
from over 2 m in 11 cases, road traffic crash in 5 cases, and
Volume 62 Number 1

industrial accident in 7 cases). Eight patients had multiple

injuries. Data concerning the mechanism of injury, the AO/
OTA fracture classification, the grade of open fractures, operative notes, and postoperative recovery were prospectively
collected by specialists of orthopedic traumatology on a special form. Smoking, medication, body mass index, and concomitant illnesses were obtained from the patient records.

Classification of Fractures
The fractures were classified according to the AO/OTA
classification.18 All of them were in zone 43 (within 5 cm
from the ankle joint) and thus too distal for intramedullary
nailing. Six fractures had diaphyseal extension (Fig. 1), but
bifocal fractures, as described by Keating et al.,19 were not
included in this series. There were 16 extra-articular type A
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The Journal of TRAUMA Injury, Infection, and Critical Care

fractures (10 A1, 4 A2, 2 A3) and 31 type C fractures (10 C1,
11 C2, and 10 C3). We do not consider type B fractures
suitable for hybrid external fixation. The metaphyseal fracture
line was spiral in 13 cases, oblique in 5, transverse in 3, simple
wedge in 11, and comminuted in 15. Forty-six fractures had an
associated fibular fracture. Ten fractures were open (2 type II, 2
type IIIA, and 6 type IIIB) and classified according to the
Gustilo-Anderson classification.20 There were two minor
(wedge 50% but 100%, 2.5 cm) and three moderate
(wedge 50% but 100%, 2.5 cm) bone defects according
to the modified Winquist-Hansen classification,21 which were
recorded during the operation of the fracture.

Operative Technique
Thirty-three injured limbs were initially splinted and kept
elevated to reduce swelling. Fourteen fractures involving serious
soft-tissue injuries were temporarily stabilized with external fixation crossing the ankle joint (Hoffman II, Stryker, Geneva,
Switzerland). The definitive operation was performed within a
mean of 2 days (range, 0 15) on splinted fractures and within a
mean of 10 days (range, 527) on temporarily fixed fractures.
The definitive operation was done by three orthopedic surgeons
specializing in orthopedic traumatology.
In 26 cases, the joint line was reconstructed using miniinvasive techniques through incisions over the major fracture
lines or percutaneously with 3.5-mm screws. The associated
fibular fracture was fixed with lag screws and/or a plate in 13
cases and with a Rush pin in one case. The two-ring hybrid
external fixator (Ilizarov, Smith & Nephew, Memphis, TN)
was used as a neutralization device. Distal tibial fragments
were fixed with two to four 1.8-mm olive wires depending on
the size of the distal fragments, and one 5-mm half pin was
occasionally also used if the distal fragment was large
enough. Diaphyseal fixation was performed by applying two
or three 5-mm titanium half pins with 70 to 90 degrees
divergence with reference to each other; one pin was connected to a metal ring and the others to the ring with a Rancho
cube. The distal wires were connected to another full ring,
and four threaded rods connected the two rings to each other
after reduction of the metaphyseal-diaphyseal fracture. No
attempts were made to fix the distal and proximal fragments
to each other by lag screws. Open fractures were treated
according to a staged protocol with intravenous antibiotics,
immediate debridement, primary stabilization with temporary
bridging external fixation, repeated revisions, and early softtissue coverage when the wound was clean (mean 11, range
4 27 days). Primary bone grafting was done in one case and
early delayed bone grafting (mean 43, range 28 55 days) in
four cases because of a metaphyseal bone defect after an open
fracture. One fracture had to be bone grafted twice. One closed
AO/OTA C3 fracture with diaphyseal extension and impaction
was bone grafted 4 weeks after the injury. Physiotherapy was
started 3 to 5 days after the operation to maintain ankle and knee
movements, and it was continued until the healing of the fracture. Partial weight bearing was allowed until the wound was
176

healed, after which full weight bearing was gradually allowed as

tolerated. The patients were scheduled for frame removal as
soon as there was radiographic evidence of bridging callus or
disappearance of the fracture lines. The mean fixator time was
19 weeks (range 8 40).

Radiographic Measurements
Routine anteroposterior and lateral digital radiographs
were used to measure the radiographic parameters from postreduction and follow-up films. PCView 1.2 DICOM 3.0
(Jons-Finland Oy, Heinavesi, Finland) software was used for
this purpose. The measurements were made by the first author. Displacement of the diaphyseal-metaphyseal fracture
line was measured after reduction from the follow-up radiographs by the method described by Green and Gibbs.22 To
determine the translation on both anteroposterior and lateral
radiographs, lines were drawn from the exterior of the cortices of the proximal and distal fragments to the level of the
fracture (Fig. 2C). The degree of true translation was calculated according to the following formula:

Translation (mm) APtrans (mm)2 LATtrans (mm)2,

where APtrans is the translation measured from the anteroposterior radiograph and LATtrans is the translation measured from the lateral radiograph. All radiographs were read
by the first author.

Follow-up
The patients were followed up monthly at the outpatient
clinic until the fracture united. The fractures were considered
united when anteroposterior and lateral radiographs showed
bridging of three out of four cortices or the fracture lines had
disappeared and there was no pain in the fracture upon weight
bearing. Fracture union was defined as delayed when an
additional operation was required to promote fracture union.
Thirty-eight patients could be reviewed at the outpatient
clinic after a mean time of 3 years and 5 months (range 2 6
years). The range of motion of the ankle joint was measured
according to the method described by Lindsjo et al.23 Functional recovery was assessed using the IOWA ankle score24
and self-administered RAND 36-Item Health Survey.25 The
general Finnish population was used as controls for RAND
36-Item Health Survey scores. Standing anteroposterior and
lateral radiographs were taken from both legs, including both
knee and subtalar joints. Joint line orientation was assessed
by the method described by Paley et al.26 The fracture was
considered malunited if there was at least 10 degrees difference in either anterior distal tibial angle (ADTA) or lateral
distal tibial angle (LDTA) compared with the uninjured
tibia. Osteoarthritis was assessed according to the method of
Williams et al.27 by comparing the injured and uninjured
ankle joints. An ankle free of osteoarthritis is given 10 points,
and points are subtracted based on subchondral sclerosis (1
to 2), subchondral cysts (1 to 2), osteophytes (1 to 2),
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External Fixation of Distal Tibial Fractures

Fig. 2. AO/OTA A1 type spiral fracture (A) was treated with a two-ring hybrid fixator (B). Three months after the injury there was no clinical
or radiologic sign of fracture union. Radiography (B) showed 7 mm lateral and 3 mm posterior translation, which was the biggest
displacement in this series. According to the graphic presentation (C), there was 8 mm of true translation 27 degrees posterolaterally
measured from the mediolateral plane. Additional pins were inserted into both fragments (D), and translation was corrected along the plane
of deformity by sliding the two rings in reference to each other (E). The fracture united in 32 weeks and 4 years after the injury there was
good alignment and fracture union (F).

and joint space narrowing (1 to 4). The clinical tests were

performed by an independent research physiotherapist, and
the radiographs were analyzed by the first author.

Statistical Analysis
Statistical analysis was performed using SPSS statistical
software (SPSS v. 10.0.5, SPSS Inc., Chicago, IL). ContinuVolume 62 Number 1

ous variables are reported as median and 25th and 75th

percentiles. Fishers exact test with or without the Monte
Carlo method was used for univariate analysis of categorical
data. The Mann-Whitney test and the Kruskall-Wallis test
were used to assess the distribution of continuous variables in
the different subgroups. Spearmans test was used to evaluate
the correlation between continuous variables. The receiver
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The Journal of TRAUMA Injury, Infection, and Critical Care

Fig. 2. (Continued).

operating characteristics (ROC) curve was used to identify

the best cutoff value of the degree of translation predisposing
to delayed union requiring reoperation. Linear and logistic
regressions with the help of backward selection were used for
multivariable analysis. Only preoperative variables whose p
values at univariate analysis were 0.05 were considered for
inclusion in the regression model. A p 0.05 was considered
statistically significant.

RESULTS
The median time for fracture union was 20 weeks (25th
and 75th percentile 1730). Thirty-five fractures united without additional operations during a median period of 19 (16
22) weeks, while 12 patients required reoperation because of
delayed union in a median time of 21 (16 24) weeks from the
injury. Three type C fractures with diaphyseal extension
178

(Fig. 1) were nailed after the intra-articular fractures had

healed. Two fractures were treated with ORIF and bone
grafting. In one case, external fixation with interfragmentary
compression (Fig. 2) was used. Six fractures were bonegrafted, one fracture twice. Eventually, all fractures united.

Functional Results
Follow-up data were available for 38 patients. Clinical
ankle scores and RAND 36-Item Health Survey scores are
presented in Table 1. Overall, there were no significant differences between the general Finnish population aged 18 to
64 years and our series in RAND 36-Item Health Survey
scores. The patients with AO/OTA type C fractures, open
fractures, and complex metaphyseal fractures had lower
scores on some of the subscales compared with the other
patients and the general population. Delayed union had no
January 2007

External Fixation of Distal Tibial Fractures

Table 1 Comparison of IOWA Ankle Scores and RAND 36-item Health Survey Scores Between Different
Subpopulations
Subscale

General population
(n 1,529)
Our series (n 38)
Age- and sex-adjusted
difference (Rand-36)
AO/OTA class A
fracture (n 10)
AO/OTA class C
fracture (n 28)
Closed fracture
(n 30)
Open fracture
(n 8)
Low-energy fracture
(n 19)
High-energy fracture
(n 19)
Union (n 27)
Delayed union
(n 11)
Simple metaphyseal
fracture (n 26)
Complex metaphyseal
fracture (n 12)

IOWA Ankle
Score

Physical
Functioning

Role
Limitations:
Physical

Role
Limitations:
Emotional

Vitality

Mental
Health

Social
Functioning

Somatic
Pain

General
Health

90

74

78

65

81

83

78

68

79 (19)

78 (23)
3.6 (24)

76 (37)
4.9 (37)

84 (31)
1.4 (19)

71 (21)
7.1 (22)

75 (20)
1.5 (20)

84 (19)
2.7 (19)

74 (27)
0.7 (27)

64 (22)
3 (19)

87 (11)

10 (21)

24 (22)

19 (16)

18 (15)

7.7 (14)

12 (18)

15 (12)

9.4 (11)

75 (21)

7.6 (24)

1.3 (39)

7.2 (35)

3.5 (24)

0.5 (21)

0.5 (21)

3.9 (29)

0.9 (21)

82 (17)

3.1 (20)

9.6 (32)

9.6 (31)

12.7 (18)

4.8 (17)

6.2 (18)

3.2 (26)

5.7 (19)

10.8 (24)

9.9 (20)
10.6 (15)

64 (23)
85 (17)
72 (20)

26.5 (25)*
5.6 (18)
12.4 (26)*

1.3 (49)

12.6 (35) 12.1 (25)*

13.8 (31)

12.9 (29)

14.3 (17)

6.7 (15)

3.5 (41)

7.6 (35)

0.8 (25)

3.6 (23)

8.3 (32) 6.9 (19)

9 (20)

5.2 (14)

4.7 (21)*

7.2 (31)

1 (23)

81 (18)
74 (22)

6 (22)
3.1 (30)

1.3 (37)
21.9 (33)

8.7 (32)
14.3 (34)

8.8 (20)
2.8 (29)

1.8 (20)
0.5 (21)

3.1 (20)
1.7 (20)

1.4 (26)
1.2 (32)

3.4 (22)
1.8 (14)

84 (15)

3.3 (20)

14 (27)

12.5 (28)

4.2 (19)

4.2 (19)

9 (17)

4.5 (28)

5.5 (16)

14.7 (46)

5.6 (39)

1.4 (22)

4.2 (20)

65 (23)*

18.7 (27)*

10.3 (19)*

7.2 (25) 2.4 (25)

Values are mean (SD) or age- and sex-adjusted mean difference (SD). The general population consisted of the Finnish population aged 18
to 64 years. The bolded numbers indicate the differences between our series and the age- (10-year interval) and sex-adjusted general Finnish
population.
* p 0.05.

negative influence on the functional outcome. Differences in

the range of motion between the injured and uninjured ankles
are shown in Figure 3 and ankle osteoarthritis scores in Figure
4. There were only marginal decreases in the range of motion in
the AO/OTA fracture types other than type C3. The lowest
osteoarthritis scores were seen, as expected, in the fracture types
C2 and C3. Four cases had malunion. Once corrective osteotomy was done, but the other patients refused further operations.
None of the patients in the follow-up study had a shortening of
more than 10 mm compared with the uninjured leg.

Complications
Eighteen patients had pin-tract problems. Fifteen of these
had at least one pin-tract infection diagnosed as discharge,
redness, swelling, and pain at the pin site and verified by
bacterial culture. Four pins were replaced and one was removed. One patient who had the frame and all pins removed
because of fulminant pin infection 8 weeks after the injury
already displayed bridging callus, and the infection healed
rapidly after the procedure. One patient had local osteomyelitis in a diaphyseal pin tract. Local revision and bone
grafting were done, and the infection resolved. Other pin-tract
infections resolved after local revision and oral cefalexine
(750 mg three times per day).
Volume 62 Number 1

There were six other complications and ten reoperations

because of hardware problems. Broken distal wires were
replaced in a noncooperative woman. The fracture united in
19 weeks without any other complications. One patient with
a serious grade 3B open fracture had penetration of the distal
pins through the tibialis posterior and extensor tendons, and
they were replaced in an early phase. One patient had irritation of the tibialis posterior nerve, which resolved after replacement of the distal wire. One patient had superficial
peroneal nerve injury during plating of the fibula, and one
patient during wire insertion. Hypoesthesia after nerve injuries
remained permanent in both cases. One patient with type C3
fracture, comminution, and bone defect resulting from impaction
had deep infection after joint line reconstruction and primary
bone grafting. The infection resolved and the fracture united
after seven revisions, treatment with intravenous vancomysin
(Vancosin) 2 g twice daily, and delayed bone grafting.

Risk Factors Predicting Delayed Union

The risk factors significantly associated with a longer
time to fracture union according to univariate analysis were
translational displacement ( p 0.010, r 0376) and current
smoking ( p 0.013). According to linear regression analysis, the degree of translation was the only independent pre179

The Journal of TRAUMA Injury, Infection, and Critical Care

Fig. 3. Boxplot diagram of range of motion. Median and 25th and 75th percentiles. The y axis represents difference in degrees compared
with uninjured ankle.

Fig. 4. Boxplot diagram of ankle osteoarthritis scores in the different AO/OTA fracture classes. Median and 25th and 75th percentiles.

180

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External Fixation of Distal Tibial Fractures

dictor of longer union time (regression coefficient 3.9; 95%
confidence interval [CI]: 2.15.7; p 0.001). Smoking delayed fracture union by 10 weeks (regression coefficient 10.1,
95% CI: 121; p 0.070).
According to univariate analysis, the risk factors for
reoperation because of delayed healing were residual translational displacement after reduction ( p 0.0001), fibular
fracture fixation ( p 0.025), and number of cigarettes
smoked per day ( p 0.043). Multivariate logistic regression
analysis showed that the degree of translation (odds ratio
[OR] 2.1; 95% CI: 1.33.5; p 0.004) and fibular fracture
fixation (OR 19.4; 95% CI: 1.1340; p 0.043) increased
the risk for reoperation. Reoperation was performed on 50%
of the patients who underwent fibular fixation and on 15% of
the patients who did not undergo fibular fixation.
The area under the ROC curve was 0.883 for the degree
of residual translation after reduction in predicting reoperation (95% CI: 0.71.03; p 0.001). Its best cutoff value was
3 mm (sensitivity 83.3%, specificity 94.3%), under which
value (translation 3 mm) the rate of reoperation was 6%,
whereas above that value (translation 3 mm), it was 83%
( p 0.001). Fifty percent of the patients having had a
translation 3 mm had fibular fixation, and 22.9% of those
with a translation 3 mm had fibular fixation ( p 0.14).
There were no differences between the high- and low-energy
fractures in the number of cases with translation 3 mm
(42% versus 58%, p 0.56) or fibular fixation (43% versus
57%, p 0.59). Clinical characteristics of the patients with
and without delayed union are presented in Table 2.
There were two diabetic patients and four patients who
were on corticosteroids treatment for concomitant illnesses. One
patient with rheumatoid arthritis had sodium aurathiomalate
(Myocrisin) medication. None of these patients needed reoperation as a result of delayed healing. In this series, obesity or low
body mass index did not have any negative influence on fracture
union.

DISCUSSION
We found that hybrid external fixation of distal tibial
fractures is associated with a considerably high rate of delayed unions. Translational displacement seems to be the
most important factor leading to delayed union. Fixation of

an associated fibular fracture did not help to achieve better

contact in the metaphyseal fracture of the tibia. In fact,
fixation of the fibular fracture was associated with delayed
union. Translational displacement has been recognized as a
risk factor for delayed union in the treatment of tibial shaft
fractures,13 but it has received no attention in distal tibial
fractures.
The rates of delayed union or nonunion of distal tibial
fractures treated with external fixation have varied markedly
in recent reports, ranging from 8% to 40%.6,15,16,28 Anglen15
treated 63 distal fractures of the tibial plafond with either
internal fixation (27 fractures) or hybrid external fixation (34
fractures). Twenty-nine patients in the hybrid group were
followed up, and despite the high rate of primary bone grafting (5/29 fractures), six fractures had nonunion. Bone et al.,8
in their series of ankle-bridging external fixation, found that
3 out of 20 fractures had nonunion. They reported that nonunion mostly occurred in the most proximal fracture line, but
did not occur when this area was bone grafted primarily.
They did not mention how many fractures were bone grafted
primarily. Barbieri et al.16 bone grafted 12 out of 37 fractures,
and three showed nonunion. Pugh et al.28 compared 21 fractures treated with ankle-spanning external fixation, 15 fractures treated with a single-ring hybrid fixator and 24 fractures
with ORIF. Although there were no nonunions in the hybrid
group, seven patients required bone grafting to promote
union. Our results are in accordance with these reports. We
agree also with the earlier authors that soft tissue disruption,
comminution and displacement of the fracture as well as
compromised vascular supply of the distal tibia are important
factors for delayed union in high-energy fractures.
An interesting finding was the relatively high number of
delayed unions in simple (spiral, oblique, or simple wedge)
metaphyseal fractures. About one third of simple metaphyseal fractures displayed delayed union. Half of these fractures
were relatively low-energy injuries. This reflects the difficulties in controlling translational displacement in simple fractures, which may be because of a relatively intact soft tissue
envelope resisting reduction. The tolerance for displacement
is small, only 3 mm, thus even the fracture hematoma may
block closed reduction. Metaphyseal fracture is mostly obliquely or spirally oriented. In the external fixation device

Table 2 Clinical Characteristics of Patients Without or With Delayed Union

Group

No Delayed Union (n 35)

Delayed Union (n 12)

p Value

Mean age (SD)

Male
Current smoker
Open fracture
Class A fracture/Class C fracture
Bone defect
Fracture with diaphyseal extension
Simple metaphyseal fracture
No. of fixed fibula fractures
Low-energy injury

47 (15)
22 (63%)
9 (26%)
8 (23%)
11 (31%)/24 (69%)
4 (11%)
3 (9%)
21 (62%)
7 (20%)
18 (51%)

55 (12)
7 (58%)
7 (58%)
2 (17%)
5 (42%)/7 (58%)
1 (17%)
3 (25%)
10 (83%)
7 (58%)
6 (50%)

0.143
0.326
0.075
0.645
0.725
0.741
0.165
0.285
0.025
1.000

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The Journal of TRAUMA Injury, Infection, and Critical Care

used here, interfragmentary movement mostly consists of
shearing rather than axial loading, which is generally thought
to be beneficial for fracture healing.
The literature concerning the fixation of associated fibular fractures is controversial. In experimental studies, the
fixation of associated fibular fractures has been shown to add
structural stability whenever external fixation of the tibial
fracture is used.29,30 The other theoretical benefits are that the
length of the extremity can be preserved and the rotation of
the tibial fracture can be controlled. Some authors have fixed
associated fibular fractures in conjunction with the external
fixation of distal tibial fractures,8,31 but there are no unambiguous recommendations for this in the clinical studies.
Williams et al.32 found that there were significantly more
serious complications in the cases where the fibular fracture
was fixed compared with those where it was not fixed. They
did not find any significant differences in the mean union
times of tibial fractures. In our series, fibular fixation was an
independent factor leading to additional operations caused by
delayed fracture union. We hypothesize that fibular fixation
might delay the healing of the tibial metaphyseal fracture by
keeping the fibula at full length and not permitting axial
loading of the tibial fracture. This hypothesis was supported
by some experimental and clinical studies,29,30,33 which
showed that axial loading of the tibia is significantly decreased when the fibular fracture is stabilized.
Delayed union had no remarkable effect on functional outcome. This is explained by the facts that a relatively high
proportion of delayed unions were simple fractures expected to
result in a good functional outcome, and that the evaluation of
functional outcome was done when the delayed union had
healed.
The weakness of the treatment method used here is the
insufficient control of translational displacement. It has been
suggested that plate and screw fixation would be better in this
respect. In two recent studies, the two-stage method of initial
external fixation and consequent plating of the distal tibial
fracture after healing of the soft tissues resulted in good
fracture union and an acceptable rate of complications.34,35
Furthermore, the modern intramedullary nails enabling nailing of very distal tibial fractures seem like an attractive
alternative, but there are no reports of their use in the very
distal tibial fractures available yet. Although hybrid external
fixation in this study was shown to be safe in the most
severely comminuted fractures with soft-tissue injury, its
applicability can be questioned in the treatment of the simple
metaphyseal fractures.
In conclusion, in patients with distal tibial fractures
treated with a hybrid external fixator, every effort should be
made to avoid more than 3-mm translational displacement. If
this is not feasible, early bone grafting or other methods for
accelerating fracture union should be considered. Fixation of
the associated fibular fracture is not recommended.
182

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