Reduction of distal tibial and fibular fractures may be difficult. Support from at least one assistant, providing countertraction and stabilizing the proximal leg, may be helpful.
With the knee flexed and stabilized, apply longitudinal traction through the foot.
Correct translation and angulation of the fracture and confirm reduction clinically and with an image intensifier if available.
The position of the foot and ankle is important in some metaphyseal fractures.
Placing the foot and ankle in a neutral position may produce an apex posterior deformity in unstable fractures.
Insert the initial K-wire from the medial malleolus.
Advance the K-wire across the physis after confirming a trajectory that will gain sufficient metaphyseal engagement on AP and lateral views.
Engage the K-wire in the far cortex.
A second parallel or divergent medial K-wire may be inserted.
Inserting a K-wire too far posteriorly may damage the posterior tibial neurovascular bundle.
On the lateral side, the insertion point for the second K-wire is just anterior to the fibula.
A small incision with blunt dissection is recommended to avoid damage to the superficial branch of the peroneal nerve.
A second medial K-wire may be inserted in an antegrade direction.
If the distal metaphyseal fragment is large enough, placing both K-wires entirely within the metaphysis may be possible. This has the advantage of avoiding the joint and minimizing the risk of physeal disturbance.
Avoid inserting the K-wire at the edge of the physis as this may damage the perichondrial ring by direct trauma or indirect pressure.
K-wire cutting and dressing
Bend the K-wires approximately 1 cm from the skin to allow for swelling.
Cut the K-wires and apply a dressing to protect the skin.
Release tethered skin around the K-wire by extending the incision.
Alternatively, the K-wire may be placed under the skin with the bent end on the surface of the bone.
6. Fibular fracture management
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
The type of fracture pattern dictates the fixation of the fibular fracture.
K-wires are inserted in a standard manner. Multiple passes of the K-wire through the physis should be avoided.
In an unstable tibial eversion fracture, an associated diaphyseal fibular fracture may require plate fixation.
7. 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
Non-weight-bearing or touch weight-bearing is encouraged for unstable injuries.
Older children may be able to use crutches or a walker.
Younger children may require a period of bed rest followed by mobilization in a wheelchair.
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.
Cast and K-wire removal
Distal tibial and fibular fractures heal rapidly. Cast and K-wires are typically removed 3–6 weeks after injury, depending on the age and weight of the patient.
Once K-wires and cast are removed, gradual 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.