What is the treatment for a posterior distal tibia fracture?

Treatment of Posterior Distal Tibia Fractures

Posterior distal tibia fractures require open reduction and internal fixation (ORIF) with plate stabilization, using either a direct posterior approach or a medial approach depending on fragment location and associated injuries. 1, 2

Surgical Approach Selection

The choice of surgical approach is critical and should be based on the fracture pattern:

For Isolated Posterior (Volkmann) Fragments

• Use a medial tibial approach when the posterior fragment involves >25% of the articular surface 2
• This approach provides direct visualization of posterior rim fragments while respecting the soft tissue envelope 2
• The medial approach allows simultaneous fixation of associated medial column fractures without requiring multiple incisions 2

For Combined Posterior and Lateral Injuries

• Consider a single lateral approach that can access both the distal tibia and fibula through one incision 3, 1
• Lateral plating demonstrates significantly lower complication rates (P=0.047) and fewer hardware problems (P<0.001) compared to traditional medial plating 1
• This approach respects the angiosomes of the distal leg and reduces wound complications 3

Fixation Strategy

Definitive Fixation Requirements

• Perform ORIF for any fracture with >3mm displacement or >10° of angulation 4, 5
• Use antiglide plating techniques for posterior fragments to prevent displacement 6
• Ensure anatomic reduction of articular surfaces to minimize post-traumatic arthritis risk 2

Timing Considerations

• If soft tissue conditions are compromised (Tscherne grade 2-3), use temporary external fixation followed by planned conversion to ORIF 7
• The mean time from external fixation to definitive ORIF is 5 days (range 1-23 days), allowing soft tissue recovery 7
• This staged approach achieves 91% union rates while avoiding the 16% infection rate associated with immediate ORIF in compromised soft tissues 7

Critical Technical Points

Reduction Technique

• Position the patient prone for posteromedial approaches to facilitate reduction maneuvers 6
• Apply knee extension and valgus stress combined with direct fragment manipulation for posterior fragments 6
• Obtain a true lateral radiograph post-reduction to assess alignment 4

Immediate Post-Operative Management

• Initiate active finger and toe motion exercises immediately after surgery 4, 8
• This prevents stiffness without adversely affecting adequately stabilized fractures 4
• Do not routinely begin early wrist motion following stable fixation, but ensure digital motion is unrestricted 4

Common Pitfalls to Avoid

• Never use removable splints for displaced or comminuted distal tibia fractures—these require rigid fixation 5
• Avoid anterior approaches when possible, as they carry higher wound complication rates compared to lateral approaches 1
• Do not delay recognition of posterior fragments, as they compromise overall construct stability if left unfixed 6
• Monitor for deep infection (16% rate in open fractures) and be prepared for aggressive debridement 7

Expected Outcomes

With appropriate surgical technique:

• Union rates of 91% can be achieved with staged protocols 7
• Most patients achieve good range of motion and functional scores 1, 2
• Grade 2 osteoarthritis occurs in approximately 17% of patients at 12-month follow-up 2