Radiological outcomes of surgical treatment of closed distal tibia fractures

Introduction: Closed distal third tibia fractures are common injuries in South Africa, where there is a high incidence of pedestrian and motor vehicle accidents. The surgical options of treating these fractures include intramedullary nail (IMN), open reduction and locking plate fixation, tibial cannulated screw fixation with fibular plating, and external fixation. We undertook the study to review the radiologic outcomes of closed extraarticular fractures treated surgically with intramedullary nailing or anatomical locking plate. Methods: This was a retrospective cohort study of patients with distal tibial extraarticular fractures treated surgically with intramedullary nail or anatomical locking plate fixation. Data was collected from hospital records over a 24-month period. The radiological evaluation and measurements were made on Picture Archiving and Communication System (PACS). Results: A total of 100 patients were included in the study. Most of the patients were males 61 (61%) patients were male. The age range of patients was 18 years to 77 years (median 38yrs). Eighty patients (80%) were treated with intramedullary nailing and those treated with plating were 20 (20%). The immediate post-operative anteroposterior (AP) view showed that 73 participants had an acceptable alignment, and 27 patients had malalignment. Lateral view showed that 98 participants had acceptable alignment (98%), with malalignment in only two patients (2%). The RUST score showed 96% (n=96) of the patients had union, and 4% (n=4) had non-union. At the final follow up at 9 months, one patient that initially had good alignment ended up with malunion. Four patients had non-union - one was amputated and three had revisions. Of the four patients that had non-union, three were fixed with anterolateral plate and one treated with IMN. In the 28 patients that had malunion, 26 were treated with intramedullary nailing and two with anterolateral plate. IMN had 32.5% (26/80) malunion rate, plating had 10% (2/20) malunion rate. The methods of fixation were statistically significant (p-value 0.045) in malunion outcomes, with IMN having a higher malunion rate. Plating resulted in a significantly higher rate of nonunion of 15% compared to 1.3% after IMN (p-value 0.005.) Conclusion: Intramedullary nail treatment results in significantly higher malunion rate as compared to locking plate fixation. Plate fixation leads to significantly higher non-union rate compared to intramedullary nail fixation. These methods of fixations were statistically significant in outcomes of malunion and nonunion. More careful consideration is recommended intra-operatively when intramedullary nailing is done, to avoid malalignment. Plating should be recommended only when IMN is contraindicated because of the risk of non-union.