The Journal of Foot & Ankle Surgery xxx (2015) 1–4
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Tips, Quips, and Pearls “Tips, Quips, and Pearls” is a special section in The Journal of Foot & Ankle SurgeryÒ, which is devoted to the sharing of ideas to make the practice of foot and ankle surgery easier. We invite our readers to share ideas with us in the form of special tips regarding diagnostic or surgical procedures, new devices or modifications of devices for making a surgical procedure a little bit easier, or virtually any other “pearl” that the reader believes will assist the foot and ankle surgeon in providing better care.
Elastic Bandage Traction Technique for Reduction of Distal Tibial Fractures Quanyu Dong, MD 1, Do Yeong Hong, MD 2, Yong Wook Park, MD, PhD 2, Hyong Nyun Kim, MD, PhD 2 1 2
Department of Orthopaedic Surgery, The Second Hospital, Jilin University, Changchun, China Department of Orthopaedic Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, South Korea
a r t i c l e i n f o
a b s t r a c t
Keywords: ankle traction minimally invasive plate osteosynthesis pediatric physeal injury
In the present technique report, we describe a useful noninvasive traction technique that uses a 6-inch elastic bandage that can be obtained in every operating room and can be easily applied around the patient’s ankle and the surgeon’s waist to offer a stable traction force during minimally invasive plate fixation of distal tibial fractures. This technique frees the surgeon’s hands to focus on applying other forces, such as rotational, varus, or valgus forces, to reduce the fracture and stabilize the reduction and alignment during percutaneous insertion and fixation of the plate. This technique, although simplistic and old-fashioned, is also useful for the closed reduction of distal tibial physeal injuries in children, because it can provide a significant amount of traction force while allowing the surgeon to apply other forces for fracture reduction. This technique can be used in the emergency room, where an ankle distractor is not usually present, and in some cases could be useful during ankle arthroscopy. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Minimally invasive plating using indirect fracture reduction has been successfully used to treat distal tibial fractures (1–4). Minimally invasive techniques have a biologic advantage compared with open plating techniques. However, it is more demanding operatively than the open reduction technique because the reduction is achieved using closed, indirect methods. Misalignment has been reported in the case of distal tibial fractures that were treated with minimally invasive plate osteosynthesis (5). Several techniques have been introduced for the successful reduction of the fracture and maintenance of the reduction during subcutaneous insertion of the plate (6–9). The patient can be positioned on a traction table and the reduction performed using transcalcaneal skeletal traction, or the patient can be positioned on a standard table and the reduction performed using a temporary external fixator (tibiocalcaneal fixation). However, these techniques are rather invasive and have the potential to cause neurovascular injury and iatrogenic fractures. Moreover, the attending surgeon can apply manual traction with both hands holding the ankle. However, it is difficult for surgeons to pull the ankle manually and Address correspondence to: Hyong Nyun Kim, MD, PhD, Department of Orthopaedic Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 948-1, Dalim-1 dong, Yeungdeungpo-gu, Seoul 150-950, South Korea. E-mail address: [email protected] (H.N. Kim).
Fig. 1. Noninvasive traction is applied using a 6-in. elastic bandage around the patient’s ankle and the surgeon’s waist to offer a stable traction force during reduction of distal tibial fractures. This technique frees the surgeon’s hands to focus on the application of other forces, such as rotational, varus, or valgus forces, to reduce the fracture and stabilize the reduction and alignment during percutaneous insertion and fixation of the plate.
1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.12.031
2
Q. Dong et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–4
Fig. 2. (A) The 6-in. elastic bandage (EB) is folded in half, and the scrub nurse holds 1 end and the surgeon circles around holding the other end such that the elastic bandage will go around the surgeon’s waist (similar to the manner in which a surgeon puts on a sterile gown). A loop is created at one end. (B) The ends of the EB are put through the loop. (C) The loop is tightened. (D) The EB is placed over the ankle. (E) The 2 ends of the EB are circled around the back of the ankle. One end is inserted into the space between the ankle and the EB and the other end is placed outside the EB. (F) A knot is made and tied 2 or 3 times.
simultaneously apply other forces, such as rotational, varus, or valgus forces, to reduce the fracture. Occasionally, the reduction will be lost during insertion of the plate when the surgeon’s hands have been removed from performing manual traction. An ankle distractor (normally used for noninvasive distraction during ankle arthroscopy) can be used during these procedures. However, not all hospitals have an ankle distractor, and it can be quite expensive to prepare one if it is not readily available. Furthermore, an ankle distractor placed at the end of the operating table will block the surgeon from standing in front of the ankle or from moving freely at the end of the operating table. Still further, it will require time to setup an ankle distractor. Some noninvasive distraction techniques without an ankle distractor have been developed for ankle arthroscopy, and several different
materials can be used, including a noninvasive strap, KerlixÔ Gauze Bandage Roll (Kendall Division, Convidien Plc, Dublin, Ireland), any simple roll bandage, and others. These noninvasive distraction techniques can be used for ankle distraction during the reduction of distal tibial fractures. However, some are cumbersome and difficult to apply and can require special devices and training. We used a noninvasive traction technique using a 6-in. elastic bandage (EB) that can be easily obtained in every operating room. This bandage can easily be applied around the patient’s ankle and the surgeon’s waist to offer a stable traction force (Fig. 1) during the reduction of distal tibial fractures. This traction technique frees the surgeon’s hands to apply other forces to reduce the fracture and to facilitate percutaneous plate fixation. An ankle arthroscope can also
Q. Dong et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–4
Fig. 3. An ankle arthroscope can also be inserted into the ankle joint with this traction technique to assess the anatomic reduction or evaluate intra-articular injuries or intraarticular fractures.
be inserted into the ankle joint with this traction technique to assess the anatomic reduction for intra-articular fractures. This technique will also be useful for the closed reduction of distal tibial physeal injuries in children because it produces a significant amount of traction force and simultaneously allows the surgeon to apply other forces for fracture reduction. It reduces the risk of iatrogenic physeal damage during fracture reduction, because several reduction attempts without a significant amount of traction force can further damage the growth plate.
Surgical Technique Under general or spinal anesthesia, the patient is placed on the operating table in a supine position. Care should be taken to ensure that the fracture can be clearly visualized on the anteroposterior and lateral views of the C-arm image intensifier. A radiolucent cushion is placed under the injured limb to elevate it to enable a clear lateral view and avoid interference from the other leg on the C-arm images. After routine preparation and draping, the surgeon creates ankle distraction straps using a sterile roll of 6-in. EB. The bandage should
3
be folded in half. The scrub nurse holds 1 end, and the surgeon turns in place holding the other end such that the EB goes around the surgeon’s waist (similar to the manner in which a surgeon puts on a sterile gown). A loop is created at 1 end (Fig. 2A), the other ends of the EB are placed into the loop (Fig. 2B), and the loop is tightened (Fig. 2C). The EB is placed over the ankle (Fig. 2D). The 2 ends of the EB are circled around the back of the ankle. One end is inserted into the space between the ankle and the EB, and the other end is placed outside the EB (Fig. 2E). A knot is made and tied 2 or 3 times (Fig. 2F). The surgeon and scrub nurse should be concerned with the potential contamination of the strap at the surgeon’s back, because that particular area of the surgical gown is not considered sterile. This point must be considered when the strap is applied to the surgeon and the patient. Therefore, care must be taken when the strap is applied and when it is removed. When the strap is no longer needed, it should be cut at the anterior aspect of the surgeon, and the posterior portion should be allowed to fall to the floor and handled as if contaminated. The surgeon can lean backward to apply stable traction and can apply other forces, such as rotational, varus, or valgus forces, to facilitate fracture reduction. The amount of traction and reduction can be assessed through the C-arm images. For minimally invasive plating, the reduction can be stabilized by the traction resulting from this method and by placing a small support underneath the heel or fracture site. Both of the surgeon’s hands will then be free to concentrate on keeping the limb aligned while inserting an anatomically contoured locking plate through a small incision (Fig. 1). The reduction will be maintained by the EB traction around the surgeon’s waist. Locking screws can be inserted through small percutaneous incisions. An ankle arthroscope can also be inserted into the ankle joint using this traction technique to assess the anatomic reduction or evaluate intra-articular injuries or intra-articular fractures (Fig. 3). This technique can be used during the closed reduction of distal tibial physeal injuries in children. A significant amount of traction force can be applied by leaning backward, and at the same time, the surgeon can apply other forces for fracture reduction (Fig. 4). Discussion Ankle distraction techniques can be invasive or noninvasive. Invasive techniques have the potential for neurovascular injury and iatrogenic fracture, just as do noninvasive methods, although generally to a lesser degree. Several noninvasive ankle distraction techniques using different materials, including a KerlixÔ roll (Kendall
Fig. 4. (A) Intraoperative fluoroscopic image showing a distal tibial physeal injury. (B) A significant amount of traction force can be applied by leaning backward with the elastic bandage traction applied around the ankle and the surgeon’s waist. The surgeon can also apply other forces for fracture reduction.
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Q. Dong et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–4
Division, Convidien Plc), a simple roll bandage, and a strap distractor, have been introduced for use during ankle arthroscopy (10–14). Thus, the technique is not new, but is one that has rarely been used, to our knowledge, for fracture reduction. We applied this noninvasive distraction technique for the reduction of distal tibial fractures and believed it was worthy of mention, because many surgeons do not seem to think of using it. Some of the other distraction techniques are cumbersome to learn or require special devices. With the technique we have described in the present report, using a 6-in.-wide EB that can be easily obtained in every operating room, sufficient traction can be applied for the reduction of the fracture, and the reduction can be stabilized during the insertion and fixation of a plate when the surgeon leans back against the patient’s foot. Instead of pulling the ankle manually, the surgeon can focus on correcting the rotation or varus or valgus to facilitate fracture reduction. The surgeon could manually pull the ankle for the reduction and temporarily fix the reduction with several Kirschner wires, but the Kirschner wire can block insertion of the plate. However, without sufficient traction force, the reduction could be lost during insertion or fixation of the plate. We have used this method of ankle traction in a series of 28 distal tibial fractures treated from May 2013 to September 2014, stabilizing the reduction using the EB traction technique and temporarily placing Kirchner wire fixation through the plate holes, such that none of the cases experienced a loss of reduction during percutaneous insertion and fixation of the plate. We believe this technique is useful for the closed reduction of distal tibial physeal injuries in children. It can be difficult for surgeons to pull the ankle manually for several minutes and simultaneously apply other forces to reduce the fracture. Applying other forces without a sufficient amount of traction to reduce the fracture can further damage the physis. Ideally, the reduction should be achieved in 1 attempt. Some surgeons have suggested using an ankle distractor, typically used for ankle arthroscopy, to assist with the reduction of displaced distal physeal injuries in children. If combined with relaxation under general anesthesia and ankle traction provided by the ankle distractor, physeal reduction can be achieved on the first reduction attempt and iatrogenic epiphyseal damage can be decreased during the facilitating process (15). With our technique, sufficient distraction is possible without requiring the time to set up an ankle distractor. Our technique can also be performed in the emergency room, where an ankle distractor is not commonly present. Of 6 consecutive patients with a pediatric distal tibial physeal injury who required operative treatment from July 2013 to August 2014, we achieved closed reduction in 5 patients using this noninvasive EB traction technique. One patient required open reduction because the periosteum and soft tissue had become inserted into the displaced physis, blocking the closed reduction. Contusion neuropraxia of the superficial and deep peroneal nerves is a potential complication of EB compression and ankle distraction. However, in our case series, none of our patients developed nerve symptoms after ankle distraction.
In conclusion, restoring and maintaining the alignment in unstable fractures of the distal tibia can be difficult using indirect fracture reduction and fixation. Misalignment has been recognized as a potential limitation because of the indirect visualization of bone reduction (1–4,16). In our series, using the EB traction technique, no patient had an axis deviation of >10 compared with the normal contralateral ankle. We believe these favorable results were obtained because reduction was achieved and could be stabilized during the percutaneous insertion and fixation of the plate using this technique. The EB traction technique we have described can facilitate the reduction and stabilization of distal tibial fractures during the percutaneous insertion and fixation of the plate. This technique is also useful for closed reduction of distal tibial physeal injuries in children. Although this method is simple and inexpensive, and somewhat crude compared with more sophisticated methods using specialized devices, we have found it to be very useful. Thus, we believe that it should be reported to other surgeons treating the foot and ankle.
References 1. Borg T, Larsson S, Lindsjo U. Minimally invasive plating of distal tibia fractures: preliminary results in 21 patients. Injury 35:608–614, 2004. 2. Krackhardt T, Dilger J, Flesch I, Hontzsch D, Eingartner C, Weise K. Fractures of the distal tibia treated with closed reduction and minimally invasive plating. Arch Orthop Trauma Surg 125:87–94, 2005. 3. Oh CW, Kyung HS, Park IH, Kim PT, Ihn JC. Distal tibia metaphyseal fractures treated by percutaneous plate osteosynthesis. Clin Orthop 3:286–291, 2003. 4. Toms AD, McMurtie A, Maffulli N. Minimally invasive plating of the distal tibia. J Foot Ankle Surg 43:199–203, 2004. 5. Collinge C, Kuper M, Larson K, Protzman R. Minimally invasive plating of highenergy metaphyseal distal tibia fractures. J Orthop Trauma 21:355–361, 2007. 6. Casteleyn PP, Handelberg F. Distraction for ankle arthroscopy. Arthroscopy 11:633– 634, 1995. 7. Cox PJ, Clarke NM. Juvenile Tillaux fracture of the ankle associated with a tibial shaft fracture: a unique combination. Injury 27:221–222, 1996. 8. Imade S, Takao M, Nishi H, Uchio Y. Arthroscopy-assisted reduction and percutaneous fixation for triplane fracture of the distal tibia. Arthroscopy 20:e123–e128, 2004. 9. Miller MD. Arthroscopically assisted reduction and fixation of an adult Tillaux fracture of the ankle. Arthroscopy 13:117–119, 1997. 10. Van Dijk CN, Verhagen RA, Tol HJ. Resterilizable noninvasive ankle distraction device. Arthroscopy 17:1–5, 2001. 11. Cameron SE. Noninvasive distraction for ankle arthroscopy. Arthroscopy 13:366– 369, 1997. 12. Takao M, Ochi M, Shu N, Naito K, Matsusaki M, Tobita M, Kawasaki K. Bandage distraction technique for ankle arthroscopy. Foot Ankle Int 20:389–391, 1999. 13. Miyamoto W, Takao M, Komatu F, Uchio Y. Technique tip: the bandage distraction technique for arthroscopic arthrodesis of the ankle joint. Foot Ankle Int 29:251– 253, 2008. 14. Yates CK, Grana WA. A simple distraction technique for ankle arthroscopy. Arthroscopy 4:103–105, 1988. 15. Jay RC. Distal tibial and fibular fractures. In: Rockwood and Wilkins’ Fractures in Children, pp. 1004–1005, edited by JH Beaty, JR Kasser, Lippincott Williams & Wilkins, Philadelphia, 2010. 16. Borrelli J Jr, Prickett W, Song E, Becker D, Ricci W. Extraosseous blood supply of the tibia and the effects of different plating techniques: a human cadaveric study. J Orthop Trauma 16:691–695, 2002.
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Tips, Quips, and Pearls “Tips, Quips, and Pearls” is a special section in The Journal of Foot & Ankle SurgeryÒ, which is devoted to the sharing of ideas to make the practice of foot and ankle surgery easier. We invite our readers to share ideas with us in the form of special tips regarding diagnostic or surgical procedures, new devices or modifications of devices for making a surgical procedure a little bit easier, or virtually any other “pearl” that the reader believes will assist the foot and ankle surgeon in providing better care.
Elastic Bandage Traction Technique for Reduction of Distal Tibial Fractures Quanyu Dong, MD 1, Do Yeong Hong, MD 2, Yong Wook Park, MD, PhD 2, Hyong Nyun Kim, MD, PhD 2 1 2
Department of Orthopaedic Surgery, The Second Hospital, Jilin University, Changchun, China Department of Orthopaedic Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, South Korea
a r t i c l e i n f o
a b s t r a c t
Keywords: ankle traction minimally invasive plate osteosynthesis pediatric physeal injury
In the present technique report, we describe a useful noninvasive traction technique that uses a 6-inch elastic bandage that can be obtained in every operating room and can be easily applied around the patient’s ankle and the surgeon’s waist to offer a stable traction force during minimally invasive plate fixation of distal tibial fractures. This technique frees the surgeon’s hands to focus on applying other forces, such as rotational, varus, or valgus forces, to reduce the fracture and stabilize the reduction and alignment during percutaneous insertion and fixation of the plate. This technique, although simplistic and old-fashioned, is also useful for the closed reduction of distal tibial physeal injuries in children, because it can provide a significant amount of traction force while allowing the surgeon to apply other forces for fracture reduction. This technique can be used in the emergency room, where an ankle distractor is not usually present, and in some cases could be useful during ankle arthroscopy. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Minimally invasive plating using indirect fracture reduction has been successfully used to treat distal tibial fractures (1–4). Minimally invasive techniques have a biologic advantage compared with open plating techniques. However, it is more demanding operatively than the open reduction technique because the reduction is achieved using closed, indirect methods. Misalignment has been reported in the case of distal tibial fractures that were treated with minimally invasive plate osteosynthesis (5). Several techniques have been introduced for the successful reduction of the fracture and maintenance of the reduction during subcutaneous insertion of the plate (6–9). The patient can be positioned on a traction table and the reduction performed using transcalcaneal skeletal traction, or the patient can be positioned on a standard table and the reduction performed using a temporary external fixator (tibiocalcaneal fixation). However, these techniques are rather invasive and have the potential to cause neurovascular injury and iatrogenic fractures. Moreover, the attending surgeon can apply manual traction with both hands holding the ankle. However, it is difficult for surgeons to pull the ankle manually and Address correspondence to: Hyong Nyun Kim, MD, PhD, Department of Orthopaedic Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 948-1, Dalim-1 dong, Yeungdeungpo-gu, Seoul 150-950, South Korea. E-mail address: [email protected] (H.N. Kim).
Fig. 1. Noninvasive traction is applied using a 6-in. elastic bandage around the patient’s ankle and the surgeon’s waist to offer a stable traction force during reduction of distal tibial fractures. This technique frees the surgeon’s hands to focus on the application of other forces, such as rotational, varus, or valgus forces, to reduce the fracture and stabilize the reduction and alignment during percutaneous insertion and fixation of the plate.
1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.12.031
2
Q. Dong et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–4
Fig. 2. (A) The 6-in. elastic bandage (EB) is folded in half, and the scrub nurse holds 1 end and the surgeon circles around holding the other end such that the elastic bandage will go around the surgeon’s waist (similar to the manner in which a surgeon puts on a sterile gown). A loop is created at one end. (B) The ends of the EB are put through the loop. (C) The loop is tightened. (D) The EB is placed over the ankle. (E) The 2 ends of the EB are circled around the back of the ankle. One end is inserted into the space between the ankle and the EB and the other end is placed outside the EB. (F) A knot is made and tied 2 or 3 times.
simultaneously apply other forces, such as rotational, varus, or valgus forces, to reduce the fracture. Occasionally, the reduction will be lost during insertion of the plate when the surgeon’s hands have been removed from performing manual traction. An ankle distractor (normally used for noninvasive distraction during ankle arthroscopy) can be used during these procedures. However, not all hospitals have an ankle distractor, and it can be quite expensive to prepare one if it is not readily available. Furthermore, an ankle distractor placed at the end of the operating table will block the surgeon from standing in front of the ankle or from moving freely at the end of the operating table. Still further, it will require time to setup an ankle distractor. Some noninvasive distraction techniques without an ankle distractor have been developed for ankle arthroscopy, and several different
materials can be used, including a noninvasive strap, KerlixÔ Gauze Bandage Roll (Kendall Division, Convidien Plc, Dublin, Ireland), any simple roll bandage, and others. These noninvasive distraction techniques can be used for ankle distraction during the reduction of distal tibial fractures. However, some are cumbersome and difficult to apply and can require special devices and training. We used a noninvasive traction technique using a 6-in. elastic bandage (EB) that can be easily obtained in every operating room. This bandage can easily be applied around the patient’s ankle and the surgeon’s waist to offer a stable traction force (Fig. 1) during the reduction of distal tibial fractures. This traction technique frees the surgeon’s hands to apply other forces to reduce the fracture and to facilitate percutaneous plate fixation. An ankle arthroscope can also
Q. Dong et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–4
Fig. 3. An ankle arthroscope can also be inserted into the ankle joint with this traction technique to assess the anatomic reduction or evaluate intra-articular injuries or intraarticular fractures.
be inserted into the ankle joint with this traction technique to assess the anatomic reduction for intra-articular fractures. This technique will also be useful for the closed reduction of distal tibial physeal injuries in children because it produces a significant amount of traction force and simultaneously allows the surgeon to apply other forces for fracture reduction. It reduces the risk of iatrogenic physeal damage during fracture reduction, because several reduction attempts without a significant amount of traction force can further damage the growth plate.
Surgical Technique Under general or spinal anesthesia, the patient is placed on the operating table in a supine position. Care should be taken to ensure that the fracture can be clearly visualized on the anteroposterior and lateral views of the C-arm image intensifier. A radiolucent cushion is placed under the injured limb to elevate it to enable a clear lateral view and avoid interference from the other leg on the C-arm images. After routine preparation and draping, the surgeon creates ankle distraction straps using a sterile roll of 6-in. EB. The bandage should
3
be folded in half. The scrub nurse holds 1 end, and the surgeon turns in place holding the other end such that the EB goes around the surgeon’s waist (similar to the manner in which a surgeon puts on a sterile gown). A loop is created at 1 end (Fig. 2A), the other ends of the EB are placed into the loop (Fig. 2B), and the loop is tightened (Fig. 2C). The EB is placed over the ankle (Fig. 2D). The 2 ends of the EB are circled around the back of the ankle. One end is inserted into the space between the ankle and the EB, and the other end is placed outside the EB (Fig. 2E). A knot is made and tied 2 or 3 times (Fig. 2F). The surgeon and scrub nurse should be concerned with the potential contamination of the strap at the surgeon’s back, because that particular area of the surgical gown is not considered sterile. This point must be considered when the strap is applied to the surgeon and the patient. Therefore, care must be taken when the strap is applied and when it is removed. When the strap is no longer needed, it should be cut at the anterior aspect of the surgeon, and the posterior portion should be allowed to fall to the floor and handled as if contaminated. The surgeon can lean backward to apply stable traction and can apply other forces, such as rotational, varus, or valgus forces, to facilitate fracture reduction. The amount of traction and reduction can be assessed through the C-arm images. For minimally invasive plating, the reduction can be stabilized by the traction resulting from this method and by placing a small support underneath the heel or fracture site. Both of the surgeon’s hands will then be free to concentrate on keeping the limb aligned while inserting an anatomically contoured locking plate through a small incision (Fig. 1). The reduction will be maintained by the EB traction around the surgeon’s waist. Locking screws can be inserted through small percutaneous incisions. An ankle arthroscope can also be inserted into the ankle joint using this traction technique to assess the anatomic reduction or evaluate intra-articular injuries or intra-articular fractures (Fig. 3). This technique can be used during the closed reduction of distal tibial physeal injuries in children. A significant amount of traction force can be applied by leaning backward, and at the same time, the surgeon can apply other forces for fracture reduction (Fig. 4). Discussion Ankle distraction techniques can be invasive or noninvasive. Invasive techniques have the potential for neurovascular injury and iatrogenic fracture, just as do noninvasive methods, although generally to a lesser degree. Several noninvasive ankle distraction techniques using different materials, including a KerlixÔ roll (Kendall
Fig. 4. (A) Intraoperative fluoroscopic image showing a distal tibial physeal injury. (B) A significant amount of traction force can be applied by leaning backward with the elastic bandage traction applied around the ankle and the surgeon’s waist. The surgeon can also apply other forces for fracture reduction.
4
Q. Dong et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–4
Division, Convidien Plc), a simple roll bandage, and a strap distractor, have been introduced for use during ankle arthroscopy (10–14). Thus, the technique is not new, but is one that has rarely been used, to our knowledge, for fracture reduction. We applied this noninvasive distraction technique for the reduction of distal tibial fractures and believed it was worthy of mention, because many surgeons do not seem to think of using it. Some of the other distraction techniques are cumbersome to learn or require special devices. With the technique we have described in the present report, using a 6-in.-wide EB that can be easily obtained in every operating room, sufficient traction can be applied for the reduction of the fracture, and the reduction can be stabilized during the insertion and fixation of a plate when the surgeon leans back against the patient’s foot. Instead of pulling the ankle manually, the surgeon can focus on correcting the rotation or varus or valgus to facilitate fracture reduction. The surgeon could manually pull the ankle for the reduction and temporarily fix the reduction with several Kirschner wires, but the Kirschner wire can block insertion of the plate. However, without sufficient traction force, the reduction could be lost during insertion or fixation of the plate. We have used this method of ankle traction in a series of 28 distal tibial fractures treated from May 2013 to September 2014, stabilizing the reduction using the EB traction technique and temporarily placing Kirchner wire fixation through the plate holes, such that none of the cases experienced a loss of reduction during percutaneous insertion and fixation of the plate. We believe this technique is useful for the closed reduction of distal tibial physeal injuries in children. It can be difficult for surgeons to pull the ankle manually for several minutes and simultaneously apply other forces to reduce the fracture. Applying other forces without a sufficient amount of traction to reduce the fracture can further damage the physis. Ideally, the reduction should be achieved in 1 attempt. Some surgeons have suggested using an ankle distractor, typically used for ankle arthroscopy, to assist with the reduction of displaced distal physeal injuries in children. If combined with relaxation under general anesthesia and ankle traction provided by the ankle distractor, physeal reduction can be achieved on the first reduction attempt and iatrogenic epiphyseal damage can be decreased during the facilitating process (15). With our technique, sufficient distraction is possible without requiring the time to set up an ankle distractor. Our technique can also be performed in the emergency room, where an ankle distractor is not commonly present. Of 6 consecutive patients with a pediatric distal tibial physeal injury who required operative treatment from July 2013 to August 2014, we achieved closed reduction in 5 patients using this noninvasive EB traction technique. One patient required open reduction because the periosteum and soft tissue had become inserted into the displaced physis, blocking the closed reduction. Contusion neuropraxia of the superficial and deep peroneal nerves is a potential complication of EB compression and ankle distraction. However, in our case series, none of our patients developed nerve symptoms after ankle distraction.
In conclusion, restoring and maintaining the alignment in unstable fractures of the distal tibia can be difficult using indirect fracture reduction and fixation. Misalignment has been recognized as a potential limitation because of the indirect visualization of bone reduction (1–4,16). In our series, using the EB traction technique, no patient had an axis deviation of >10 compared with the normal contralateral ankle. We believe these favorable results were obtained because reduction was achieved and could be stabilized during the percutaneous insertion and fixation of the plate using this technique. The EB traction technique we have described can facilitate the reduction and stabilization of distal tibial fractures during the percutaneous insertion and fixation of the plate. This technique is also useful for closed reduction of distal tibial physeal injuries in children. Although this method is simple and inexpensive, and somewhat crude compared with more sophisticated methods using specialized devices, we have found it to be very useful. Thus, we believe that it should be reported to other surgeons treating the foot and ankle.
References 1. Borg T, Larsson S, Lindsjo U. Minimally invasive plating of distal tibia fractures: preliminary results in 21 patients. Injury 35:608–614, 2004. 2. Krackhardt T, Dilger J, Flesch I, Hontzsch D, Eingartner C, Weise K. Fractures of the distal tibia treated with closed reduction and minimally invasive plating. Arch Orthop Trauma Surg 125:87–94, 2005. 3. Oh CW, Kyung HS, Park IH, Kim PT, Ihn JC. Distal tibia metaphyseal fractures treated by percutaneous plate osteosynthesis. Clin Orthop 3:286–291, 2003. 4. Toms AD, McMurtie A, Maffulli N. Minimally invasive plating of the distal tibia. J Foot Ankle Surg 43:199–203, 2004. 5. Collinge C, Kuper M, Larson K, Protzman R. Minimally invasive plating of highenergy metaphyseal distal tibia fractures. J Orthop Trauma 21:355–361, 2007. 6. Casteleyn PP, Handelberg F. Distraction for ankle arthroscopy. Arthroscopy 11:633– 634, 1995. 7. Cox PJ, Clarke NM. Juvenile Tillaux fracture of the ankle associated with a tibial shaft fracture: a unique combination. Injury 27:221–222, 1996. 8. Imade S, Takao M, Nishi H, Uchio Y. Arthroscopy-assisted reduction and percutaneous fixation for triplane fracture of the distal tibia. Arthroscopy 20:e123–e128, 2004. 9. Miller MD. Arthroscopically assisted reduction and fixation of an adult Tillaux fracture of the ankle. Arthroscopy 13:117–119, 1997. 10. Van Dijk CN, Verhagen RA, Tol HJ. Resterilizable noninvasive ankle distraction device. Arthroscopy 17:1–5, 2001. 11. Cameron SE. Noninvasive distraction for ankle arthroscopy. Arthroscopy 13:366– 369, 1997. 12. Takao M, Ochi M, Shu N, Naito K, Matsusaki M, Tobita M, Kawasaki K. Bandage distraction technique for ankle arthroscopy. Foot Ankle Int 20:389–391, 1999. 13. Miyamoto W, Takao M, Komatu F, Uchio Y. Technique tip: the bandage distraction technique for arthroscopic arthrodesis of the ankle joint. Foot Ankle Int 29:251– 253, 2008. 14. Yates CK, Grana WA. A simple distraction technique for ankle arthroscopy. Arthroscopy 4:103–105, 1988. 15. Jay RC. Distal tibial and fibular fractures. In: Rockwood and Wilkins’ Fractures in Children, pp. 1004–1005, edited by JH Beaty, JR Kasser, Lippincott Williams & Wilkins, Philadelphia, 2010. 16. Borrelli J Jr, Prickett W, Song E, Becker D, Ricci W. Extraosseous blood supply of the tibia and the effects of different plating techniques: a human cadaveric study. J Orthop Trauma 16:691–695, 2002.
