Published: 2017-09-28

Ankle spanning external fixator with limited internal fixation for distal tibial extra-articular fractures

Siddharth Goel, Abhay Elhence


Background: Fractures of the distal tibia are among the most difficult fractures to treat. The short distal segment presents difficulty in choosing the appropriate fixation method. The greatest challenge lies in the relatively tight soft tissue around the ankle. As a result, it has been a recent interest in treating these fractures with external fixation and limited internal fixation. The external stable fixation methods used are tubular or ring fixators, with or without immobilising the ankle. This minimally invasive nature of the surgery can avoid catastrophic wound complications like dehiscence, implant exposure and infection.

Methods: 18 patients with extra-articular distal tibial fractures (AO Type 43A) were treated with the technique of ankle spanning external fixation. Lag screws or K-wires were supplemented for limited internal fixation when required. Fibula was stabilised in all cases. Intra- articular and Compound fractures were excluded. In addition to union at fracture site, ankle pain and motion was noted in each follow-up.

Results: The mean follow-up was 25 months. Of the 18 patients included all but one fractures united with an average healing time of 16 to 18 weeks. Ankle pain and motion was graded according to Mazur modified by Teeny and Wiss clinical scoring system. 15 of them had excellent or good results, 2 had fair results. One patient had poor result. Five pin tract infections occurred. 17 patients had no evidence of osteoarthritis after completing follow up of at least 2 years.

Conclusions: Distal tibial fractures are complex injuries, not only regarding the bony component, but also in terms of the management of the soft tissue problem. Ankle Spanning External Fixator with Limited Internal fixation is a relatively simple and cost-effective method for treating these fractures, achieving union and also maintaining ankle function.


Ankle spanning, Distal tibia, Extra-articular fractures, Non-hinged external fixator

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Teeny S, Wiss DA. Open reduction and internal fixation of tibial plafond fractures. Clin Orthop. 1993;292:108-17.

Ovaida DN, Beals RK. Fractures of the tibial plafond. J Bone Joint Surg. 1986;68-A:453-551.

Bourne RB. Pilon fractures of the distal tibia. Clin Orthop. 1989;240:42-6.

Wyrsch B, McFerran M, McAndrew M. Operative treatment of fractures of the tibial plafond. A randomized prospective study. J Bone Joint Surg. 1996;78-A:1646-57.

Barbieri R, Schenk R, Koval K. Hybrid external fixation in the treatment of tibial plafond fractures. Clin Orthop. 1996;332:16-22.

Marsh JL, Bonar S, Nepola JV. Use of an articulated external fixator for fractures of the tibial plafond. J Bone Joint Surg. 1995;77-A:1498-509.

Bone L, Stegemann P, McNamara K. External fixation of severely comminuted and open tibial pilon fracures. Clin Orthop. 1993;292:101-7.

Marsh JL, Weigel DP, Dirschl DR. Tibial plafond fractures: how do these ankles function over time? J Bone Joint Surg. 2003;85-A:287-95.

Tornetta P, Weiner L, Bergman M. Pilon fractures: treatment with combined internal and external fixation. J Orthop Trauma. 1993;7:489-96.

Haidukewych GJ. Temporary external fixation for the management of complex intra-and periarticular fractures of the lower extremity. J Orthop Trauma. 2002;11:678-85.

Patterson MJ, Cole DJ. Two-staged delayed open reduction and internal fixation of severe pilon fractures. J Orthop Trauma. 1999;2:85-91.

Sirkin M, Sanders R, DiPasquale T, Herscovici D. A staged protocol for soft tissue management in the treatment of complex pilon fractures. J Orthop Trauma. 1999;2:78-84.

Koval KJ, Clapper MF, Brumback RJ. Complications of reamed intramedullary nailing of the tibia. J Orthop Trauma. 1991;5:184-9.

Robinson CM, McLauchlan GJ, McLean IP, Court-Brown CM. Distal metaphyseal fractures of the tibia with minimal involvement of the ankle. Classification and treatment by locked intramedullary nailing. J Bone Joint Surg Br. 1995;77:781-7.

Mazur JM, Schwartz E, Sheldon RS. Ankle arthrodesis: Long-term follow-up with gait analysis. J Bone Joint Surg. 1979;61-A:964-75.

Ruedi TP, Allgower M. The operative treatment of intraarticular fractures of the lower end of the tibia. Clin Orthop. 1979;138:105-10.

Etter G, Ganz R. Long-term results of tibial plafond fractures treated with open reduction and internal fixation. Arch Orthop Trauma Surg. 1991;110:277-83.

Mcferran M, Smith S, Boulas HJ. Complications encountered in the treatment of pilon fractures. J Orthop Trauma. 1992; 6:195-200.

Marsh JL, Mueling V, Dirschl DR, Hurwitz S, Brown TD, Nepola J. Tibial plafond fracture: Articulated external fixation with and without motion similar, J Orthop Trauma. 2006;20(8):536-41.

Okcu G, Aktuglu K. Intra-articular fractures of the tibial plafond a comparison of the results using articulated and ring external fixators. J Bone Joint Surg. 2004;86-B:868-75.

Kapukaya A, Subasi M, Arslan H. Management of comminuted closed tibial plafond fractures using circular external fixators. Acta Orthop Belg. 2005;71:582-9.

Antoci V, Voor MJ, Seligson D, Roberts CS. Biomechanics of external fixation of distal tibial extra-articular fractures: is spanning the ankle with a foot plate desirable? J Orthop Trauma. 2004;18(10):665-73.

Pugh KJ, Wolinsky PR, McAndrew PM, Johnson KD. Tibial pilon fractures: a comparison of treatment methods. J Trauma. 1999;47:937-42.

Leung KL, Kwok HY, Pun TS, Chow SP. Open reduction and Ilizarov external fixation in the treatment of distal tibial fractures Injury. 2004;35:278-83.

Varsalona R, Liu GT. Fibular fixation in distal tibial metaphyseal fractures. Strat Traum Limb Recon. 2006;1:42-50.