Confirm the location of the physis with an image intensifier and protect the perichondral ring and adjacent periosteum.
Removal of impediments
It may be necessary to remove interposed soft tissue and periosteum, without devitalizing the fracture fragments.
This is performed under direct vision, prior to fracture reduction.
Direct reduction can be performed with:
Pointed reduction forceps
A Hohmann retractor, used as a lever to correct translation
K-wires, used as a joystick to control the distal fragment
If needed, temporarily stabilize the fracture with K-wire(s).
Confirm anatomical reduction of the articular surface visually and of the physis with an image intensifier.
5. Plate fixation
Apply the plate, inserting the distal screw first.
The periosteum and perichondral ring should not be disturbed.
To protect the perichondral ring, a dissector or elevator may be used to offset the plate during screw insertion.
If an anatomical plate is selected, locking screws should be used adjacent to the physis to prevent compression of the perichondral ring.
The dissector or elevator is removed after screw fixation.
Check the final construct with an image intensifier.
6. Fibular fracture management (Plating)
Most fibular fractures do not require treatment. Indications for fixation include:
Augmentation of the stability of tibial fracture fixation
Significant displacement of the fibular fracture
Fibular fractures may be stabilized with plate fixation.
If screws are inserted on both sides of the physis, compression should be avoided and the periosteum and perichondral ring not be disturbed. To protect the perichondral ring, a dissector or elevator may be used to offset the plate during screw insertion. The plate should be removed soon after the fracture has healed.
7. Assessment of the syndesmotic complex
After appropriately stabilizing the tibial fracture, check the stability and reduction of the syndesmotic complex.
Assess AP and lateral translation of the fibula by stressing the ankle joint with a combination of lateral translation and external rotation with an image intensifier. If there is evidence of instability, stabilization of the syndesmosis may be necessary.
8. Final assessment
Recheck the fracture alignment and implant position clinically and with an image intensifier before anesthesia is reversed.
Confirm stability of the fixation by moving the ankle through a range of dorsi/plantar flexion.
A molded below-knee cast or fixed ankle boot is recommended for a period of 2–6 weeks as the strength of fixation may not provide sufficient stability for unrestricted weight-bearing.
Immediate postoperative care
Toe-touch weight-bearing is encouraged.
Elevation is recommended for the first 2–5 days to decrease soft-tissue swelling.
Patients tend to be more comfortable if the limb is splinted.
Routine pain medication is prescribed for 3–5 days after surgery.
The patient should be examined frequently to exclude neurovascular compromise or evolving compartment syndrome.
Discharge follows local practice and is usually possible within 48 hours.
The first clinical and radiological follow-up is usually undertaken 5–7 days after surgery to check the wound and confirm that reduction has been maintained.
A cast or boot can be removed 2–6 weeks after injury.
After cast removal, graduated weight-bearing is usually possible.
Patients are encouraged to start range-of-motion exercises. Physiotherapy supervision may be required in some cases but is not mandatory.
Sports and activities that involve running and jumping are not recommended until full recovery of local symptoms.
Implant removal is not mandatory and requires a risk-benefit discussion with patient and carers.
Follow-up for growth disturbance
All patients with distal tibial physeal fractures should have continued clinical and radiological follow-up to identify signs of growth disturbance.
Compare alignment and length clinically with the uninjured leg.
A Harris growth arrest line, parallel to the physis, is radiological evidence of continuation of normal growth.