International Orthopaedics (SICOT) (2015) 39:2227–2237 DOI 10.1007/s00264-015-2903-7
ORIGINAL PAPER
Locking compression plate as an external fixator in the treatment of closed distal tibial fractures Yu Zhou 1 & Yanbiao Wang 1 & Lifeng Liu 1 & Zhenyu Zhou 1 & Xuecheng Cao 1
Received: 30 May 2015 / Accepted: 22 June 2015 / Published online: 17 July 2015 # SICOT aisbl 2015
Abstract Background Tibial fractures often follow high-energy trauma, and although soft tissue can remain intact, poor blood supply can lead to skin necrosis, infections and potential amputation. We used closed reduction and locking compression plates as external fixators for treating closed distal tibial fractures with soft tissue compromise. The method aims to avoid those potential complications. Methods A retrospective series of 23 closed distal tibial fractures were treated using locking compression plates as external fixators. Protecting the blood supply was an essential intraoperative consideration, and postoperative physical therapy and partial weight bearing were encouraged early. Patients were followed at regular intervals and evaluated radiographically and clinically. Results The average time to radiological bony union was 29.4 weeks (range, 14–52 weeks). No infections were seen. Fractures in 22 cases (95.65 %) united, and most fractures healed in an acceptable position. All patients had good functional
Yu Zhou and Yanbiao Wang contributed equally to this work. * Lifeng Liu [email protected] Yu Zhou [email protected] Yanbiao Wang [email protected] Zhenyu Zhou [email protected] Xuecheng Cao [email protected] 1
Orthopaedic Department, The General Hospital of Jinan Military Command, Jinan 250031, China
results and were fully weight bearing with a well-healed tibia at the final follow-up. Conclusions Locking compression plates can be used as external fixators and provide a high rate of union, comfortable clinical course and excellent ankle-joint motion. Although indications are limited, this method is a suitable surgical approach for treating closed distal tibial fractures with soft tissue compromise. Keywords Closed repair . Locking compression plate . Fracture . Tibia
Introduction The tibia is easily exposed during direct violent trauma because of its unique position. Although the injury itself is not life-threatening, tibial fractures are a concern because union requires an extended recovery period and malunion can lead to permanent dysfunction of the lower extremities, especially when the fracture site is at the distal third of the tibial shaft, near the ankle. Furthermore, open fractures and related skin and muscle damage are common because of the relatively thin, soft tissue coverage of the distal tibia. Although the skin may remain intact following mild trauma, the poor blood supply in this area can result in skin necrosis, infection, bone exposure and post-operative osteomyelitis. Treatment methods vary according to fracture severity and can be challenging in terms of technology and surgeon experience. Choosing the optimal repair method when managing distal tibial fractures has historically been one of the most controversial issues in fracture treatment. Treatment modalities include non-operative management, internal fixation and the use of external fixation devices [1]. Non-operative management of a segmental distal tibial fracture may require a
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long period of immobilisation in a cast, which can lead to fracture redisplacement during healing. When compromised soft tissue occurs with distal tibial fractures, immediate open reduction and internal fixation (ORIF) using plates and screws can result in wound complications, including partial- or fullthickness skin necrosis, wound dehiscence, osteomyelitis and potential amputation [2, 3]. Intramedullary nailing is a common and acceptable method if the fracture is not within 7 cm of the ankle joint, with advantages that include less disability, improved fixation construction and maintenance of anatomical length and alignment [4, 5]. However, when the distal tibial length is 50 % visible bridging callus across the fracture on conventional radiographs. The length of the affected extremity was compared with the other by measuring the distance of the anterior superior spine and prominence of the medial malleolus, respectively; >2 cm difference was defined as shortening.
Results Follow-up in the 23 patients ranged from five to 38 months (average, 19.6 months). Average time to radiological bony union was 29.4 weeks, ranging from 14–52 weeks. Fractures in 22 cases (95.65 %) united, and most of them healed in an acceptable position. In one patient (case 21 in Table 1), delayed union occurred in the distal tibia because of both proximal and distal severe comminuted fracture on admission. Due to poor skin and soft tissue conditions, two LCPs were used as external fixators on the medial aspect of the tibia to fix the fractures. At eight months’ follow-up, the proximal fracture united but the distal one did not. Then, the external fixator was removed and replaced with an internal plate with iliac bone graft. The fracture eventually united without complications.
Post-operatively there were late infections, including superficial screw-track infections in two patients, which resolved with antibiotic treatment orally and care of screw sites. We defined deep infections as subcutaneous soft tissue and bone infections, which must be managed by incision or debridement; no deep infections or flap failures occurred. No clinically relevant malrotation or limb-length discrepancies were observed, and no fixator loosening or failure was seen. The skin tolerated the titanium screws and plate well and even adhered to the screws. All patients had good functional results and were fully weight bearing with a well-healed tibia at the final follow-up.
Case report Case 1 A 25-year-old man (No. 14 in Table 1) suffered automobile accident trauma and was admitted to a local hospital with a right distal tibial fracture (Fig. 1). Non-operative management, including primary plaster fixation, was applied because of the degree of lower-extremity swelling and severe skin and soft tissue injury, with several ulcers. Thirteen
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International Orthopaedics (SICOT) (2015) 39:2227–2237
Fig. 3 Appearance of the transferred pedicle flap
Case 2
Fig. 1 X-ray of an AO/OTA 42-B3 fracture of the right tibia
days later, he presented to our institution with a chief complaint of skin necrosis (1 cm×2 cm) and unstable fracture fixation. Pre-operatively, an anteromedial local pedicle flap was designed to cover the wound (Fig. 2). When the flap was transferred, the LCP was applied as an external fixator to repair the fracture (Figs. 3 and 4). Intra-operative X-ray showed acceptable alignment post-operatively. Antibiotics IV were used for 48 hours post-operation, and non-weightbearing exercise was encouraged thereafter. At follow-up ∼ten days later, the flap had survived and the wound had healed well. At the one month follow-up, no infection or loosening of the fixation was seen, and at the nine month follow-up, complete bony union had occurred and the external fixator was removed (Figs. 5 and 6).
Fig. 2 Design of the anteromedial local pedicle flap (2 cm×4 cm)
A 46-year-old man (No. 22 in Table 1) sustained an AO/ASIF C I, AO/OTA 43-C2 fracture of the right tibia and a fibular fracture after falling from a height (Fig. 7). On admission, he had slight swelling and several skin and soft tissue contusions in the lower extremity (Fig. 8). Because he was admitted within two hours of the trauma, there was no extreme swelling; therefore, ORIF was performed on the fibula, and an LCP was used as an external fixator for the tibia to allow for further postoperative swelling. To gain anatomic reduction of the Bpilon^ surface and better stability, a Kirschner wire and a standard compression screw were placed, with reduction of the distal infra-articular fracture using bone tenacula (Fig. 9). One week later, the degree of active motion in the right ankle was similar to the contralateral joint. At the six month follow-up, after bone union, the external fixator was removed easily (Fig. 10) and the patient was walking normally without a brace. Case 3 A 17-year-old man (No. 5 in Table 1) presented with an AO/ AISF C II and AO/OTA 42-C1 distal tibial fracture (Fig. 11). On admission, swelling was apparent in the distal limb, with skin damage, ankle deformity and a dramatic purple skin color, especially in the toes (Fig. 12). Immediate reduction and
Fig. 4 Appearance of the external plate
International Orthopaedics (SICOT) (2015) 39:2227–2237
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Fig. 5 X-ray showing complete bone union at the 9-month followup
fixation was performed to relieve the venous compression symptoms and promote reperfusion, taking care to avoid incisions that would damage the vascular system. Based on preoperative radiographs, we determined that the distal tibial
segment was too small to insert two large Schanz screws, so an LCP was applied. Skin color returned to normal on the second postoperative day (Fig. 13). Radiological union was confirmed at the three month follow-up (Fig. 14), and at nearly five months of follow-up, the external fixator was removed, and excellent functional outcome was obtained (Fig. 15).
Discussion
Fig. 6 X-ray at the 9-month follow-up after external fixator removal
Treating distal tibial fractures remains controversial and challenging for orthopaedic surgeons. Vascularity of the soft tissue sleeve surrounding the distal tibia is tenuous, and aggressive handling with extensive periosteal stripping disturbs nutrition to the myocutaneous tissue and underlying bone [10]. Although Ruedi and Allgower demonstrated good outcomes in their cases by reduction and rigid internal fixation, their results were biased in that the majority of fractures were low-energy injuries [11]. Similar treatment in injuries resulting from highenergy trauma with severe soft tissue compromise or extensive bony communication does not yield good results. Kellam and Waddell reported that 53 % of patients with high-energy compressive fractures had good function compared with 84 % in low-energy injuries [12]. Dillin and Slabaugh also advocated rigid internal fixation only for lower-energy injuries when they had an alarming 55 % infection rate in their series of 11 high-energy trauma patients [13]. Since these reports, reducing devitalisation of soft tissue or bone and minimally
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International Orthopaedics (SICOT) (2015) 39:2227–2237
Fig. 7 X-ray of an AO/OTA 43C2 fracture of the right tibia
invasive operations have become popular, with many authors choosing to use external fixation [14–16]. This management technique is acceptable in tibial fractures complicated with severe soft tissue injury because of the advantages of less secondary iatrogenic injury, ease of application and the ability to dynamise the fixator to promote union [17]. However, stability created by the external fixator cannot be compared with that provided by an LCP. Also, it is impossible to insert Schanz screws when distal tibial length is insufficient or the
Fig. 8 Appearance of the injured leg
fracture line reaches the distal tibial surface. In these cases, ankle-spanning systems can be considered if the surgeon insists on using standard external fixators. However, patients treated with spanning frames have loss of reduction more often than those treated with sparing frames [18]. Also, large pins are associated with a higher risk of soft tissue complications, and ankle-joint articulation affects post-operative mobilisation. Alternatively, many authors have used the Ilizarov circular external fixator for treating such injuries. These frames have smaller pins and do not cross the ankle joint, and it is possible to stabilise the fracture soon after injury. The main disadvantages of the Ilizarov method are the lengthy treatment time and long-term obstruction to walk properly with the frame on. The fixator is also more awkward and bulky than standard external fixators and may cause more discomfort. The minimally invasive plate osteosynthesis technique causes less damage to the blood supply of the injured tibia but would still have caused a skin problem on the medial side of the tibia, particularly distally [5]. When the affected limb is swollen, insertion of a less invasive stabilisation system (LISS) plate more often results in osteofascial compartment syndrome. Reynder et al. [19] reported 23 type 42-C2 fractures treated with LISS plates using the minimally invasive plate osteosynthesis technique. In that series, three patients developed compartment syndrome after immediate plate
International Orthopaedics (SICOT) (2015) 39:2227–2237
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Fig. 9 Immediately post-operative X-ray of the fracture fixation
fixation, and five patients developed post-operative neural palsy of the extensor hallucis longus muscle. Therefore, the authors stressed that long LISS plates cannot be used to stabilise the distal segment in patients with short distal segmental fracture of the tibia and that immediate fixation should be avoided. Although Ma et al. [1] inserted an LCP in a retrograde fashion on the medial aspect of the tibia to prevent nerve and tendon injury, the procedure was performed after the soft tissue had healed or the flap had incorporated well. Two issues in treating distal tibial fractures remain: (1) minimal invasion and (2) developing a repair method that decreases the negative effects of compromised soft tissue that delays timely operation. Sven et al. were the first to describe the use of an LCP as external fixation [20], with Kloen stating that when an LCP is used as an internal fixator, stable connection of the locking screws to the plate does not rely on friction between plate and bone [8]. The principle is similar to the external fixator, which has angle-stabilising properties. Therefore, LCPs are being used as external fixators with increasing frequency. Recently, a number of surgeons demonstrated excellent outcomes in the treatment of infected nonunion, open fractures and bone defects and concluded that the subcutaneous plate osteosynthesis technique combined with an LCP provides adequate stability and is associated with decreased rates of infection and soft tissue complications [5, 8, 9, 20, 21].
In this study, we described closed reduction using LCPs as external fixators for treating closed distal tibial fractures with compromised soft tissue. Clinical outcomes were satisfactory, and we gained experience using this technique. The plate device with locking screws in our series is a minimally invasive approach that maximises tissue preservation. In all cases, we made no incisions (except for fibular fixation, fascial compartment syndrome decompression and flap elevation) near the tibia to achieve tibial reduction, thus preventing damage to the periosteal blood supply. Promising results were shown by Leonard et al., who found that early intervention (
ORIGINAL PAPER
Locking compression plate as an external fixator in the treatment of closed distal tibial fractures Yu Zhou 1 & Yanbiao Wang 1 & Lifeng Liu 1 & Zhenyu Zhou 1 & Xuecheng Cao 1
Received: 30 May 2015 / Accepted: 22 June 2015 / Published online: 17 July 2015 # SICOT aisbl 2015
Abstract Background Tibial fractures often follow high-energy trauma, and although soft tissue can remain intact, poor blood supply can lead to skin necrosis, infections and potential amputation. We used closed reduction and locking compression plates as external fixators for treating closed distal tibial fractures with soft tissue compromise. The method aims to avoid those potential complications. Methods A retrospective series of 23 closed distal tibial fractures were treated using locking compression plates as external fixators. Protecting the blood supply was an essential intraoperative consideration, and postoperative physical therapy and partial weight bearing were encouraged early. Patients were followed at regular intervals and evaluated radiographically and clinically. Results The average time to radiological bony union was 29.4 weeks (range, 14–52 weeks). No infections were seen. Fractures in 22 cases (95.65 %) united, and most fractures healed in an acceptable position. All patients had good functional
Yu Zhou and Yanbiao Wang contributed equally to this work. * Lifeng Liu [email protected] Yu Zhou [email protected] Yanbiao Wang [email protected] Zhenyu Zhou [email protected] Xuecheng Cao [email protected] 1
Orthopaedic Department, The General Hospital of Jinan Military Command, Jinan 250031, China
results and were fully weight bearing with a well-healed tibia at the final follow-up. Conclusions Locking compression plates can be used as external fixators and provide a high rate of union, comfortable clinical course and excellent ankle-joint motion. Although indications are limited, this method is a suitable surgical approach for treating closed distal tibial fractures with soft tissue compromise. Keywords Closed repair . Locking compression plate . Fracture . Tibia
Introduction The tibia is easily exposed during direct violent trauma because of its unique position. Although the injury itself is not life-threatening, tibial fractures are a concern because union requires an extended recovery period and malunion can lead to permanent dysfunction of the lower extremities, especially when the fracture site is at the distal third of the tibial shaft, near the ankle. Furthermore, open fractures and related skin and muscle damage are common because of the relatively thin, soft tissue coverage of the distal tibia. Although the skin may remain intact following mild trauma, the poor blood supply in this area can result in skin necrosis, infection, bone exposure and post-operative osteomyelitis. Treatment methods vary according to fracture severity and can be challenging in terms of technology and surgeon experience. Choosing the optimal repair method when managing distal tibial fractures has historically been one of the most controversial issues in fracture treatment. Treatment modalities include non-operative management, internal fixation and the use of external fixation devices [1]. Non-operative management of a segmental distal tibial fracture may require a
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long period of immobilisation in a cast, which can lead to fracture redisplacement during healing. When compromised soft tissue occurs with distal tibial fractures, immediate open reduction and internal fixation (ORIF) using plates and screws can result in wound complications, including partial- or fullthickness skin necrosis, wound dehiscence, osteomyelitis and potential amputation [2, 3]. Intramedullary nailing is a common and acceptable method if the fracture is not within 7 cm of the ankle joint, with advantages that include less disability, improved fixation construction and maintenance of anatomical length and alignment [4, 5]. However, when the distal tibial length is 50 % visible bridging callus across the fracture on conventional radiographs. The length of the affected extremity was compared with the other by measuring the distance of the anterior superior spine and prominence of the medial malleolus, respectively; >2 cm difference was defined as shortening.
Results Follow-up in the 23 patients ranged from five to 38 months (average, 19.6 months). Average time to radiological bony union was 29.4 weeks, ranging from 14–52 weeks. Fractures in 22 cases (95.65 %) united, and most of them healed in an acceptable position. In one patient (case 21 in Table 1), delayed union occurred in the distal tibia because of both proximal and distal severe comminuted fracture on admission. Due to poor skin and soft tissue conditions, two LCPs were used as external fixators on the medial aspect of the tibia to fix the fractures. At eight months’ follow-up, the proximal fracture united but the distal one did not. Then, the external fixator was removed and replaced with an internal plate with iliac bone graft. The fracture eventually united without complications.
Post-operatively there were late infections, including superficial screw-track infections in two patients, which resolved with antibiotic treatment orally and care of screw sites. We defined deep infections as subcutaneous soft tissue and bone infections, which must be managed by incision or debridement; no deep infections or flap failures occurred. No clinically relevant malrotation or limb-length discrepancies were observed, and no fixator loosening or failure was seen. The skin tolerated the titanium screws and plate well and even adhered to the screws. All patients had good functional results and were fully weight bearing with a well-healed tibia at the final follow-up.
Case report Case 1 A 25-year-old man (No. 14 in Table 1) suffered automobile accident trauma and was admitted to a local hospital with a right distal tibial fracture (Fig. 1). Non-operative management, including primary plaster fixation, was applied because of the degree of lower-extremity swelling and severe skin and soft tissue injury, with several ulcers. Thirteen
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International Orthopaedics (SICOT) (2015) 39:2227–2237
Fig. 3 Appearance of the transferred pedicle flap
Case 2
Fig. 1 X-ray of an AO/OTA 42-B3 fracture of the right tibia
days later, he presented to our institution with a chief complaint of skin necrosis (1 cm×2 cm) and unstable fracture fixation. Pre-operatively, an anteromedial local pedicle flap was designed to cover the wound (Fig. 2). When the flap was transferred, the LCP was applied as an external fixator to repair the fracture (Figs. 3 and 4). Intra-operative X-ray showed acceptable alignment post-operatively. Antibiotics IV were used for 48 hours post-operation, and non-weightbearing exercise was encouraged thereafter. At follow-up ∼ten days later, the flap had survived and the wound had healed well. At the one month follow-up, no infection or loosening of the fixation was seen, and at the nine month follow-up, complete bony union had occurred and the external fixator was removed (Figs. 5 and 6).
Fig. 2 Design of the anteromedial local pedicle flap (2 cm×4 cm)
A 46-year-old man (No. 22 in Table 1) sustained an AO/ASIF C I, AO/OTA 43-C2 fracture of the right tibia and a fibular fracture after falling from a height (Fig. 7). On admission, he had slight swelling and several skin and soft tissue contusions in the lower extremity (Fig. 8). Because he was admitted within two hours of the trauma, there was no extreme swelling; therefore, ORIF was performed on the fibula, and an LCP was used as an external fixator for the tibia to allow for further postoperative swelling. To gain anatomic reduction of the Bpilon^ surface and better stability, a Kirschner wire and a standard compression screw were placed, with reduction of the distal infra-articular fracture using bone tenacula (Fig. 9). One week later, the degree of active motion in the right ankle was similar to the contralateral joint. At the six month follow-up, after bone union, the external fixator was removed easily (Fig. 10) and the patient was walking normally without a brace. Case 3 A 17-year-old man (No. 5 in Table 1) presented with an AO/ AISF C II and AO/OTA 42-C1 distal tibial fracture (Fig. 11). On admission, swelling was apparent in the distal limb, with skin damage, ankle deformity and a dramatic purple skin color, especially in the toes (Fig. 12). Immediate reduction and
Fig. 4 Appearance of the external plate
International Orthopaedics (SICOT) (2015) 39:2227–2237
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Fig. 5 X-ray showing complete bone union at the 9-month followup
fixation was performed to relieve the venous compression symptoms and promote reperfusion, taking care to avoid incisions that would damage the vascular system. Based on preoperative radiographs, we determined that the distal tibial
segment was too small to insert two large Schanz screws, so an LCP was applied. Skin color returned to normal on the second postoperative day (Fig. 13). Radiological union was confirmed at the three month follow-up (Fig. 14), and at nearly five months of follow-up, the external fixator was removed, and excellent functional outcome was obtained (Fig. 15).
Discussion
Fig. 6 X-ray at the 9-month follow-up after external fixator removal
Treating distal tibial fractures remains controversial and challenging for orthopaedic surgeons. Vascularity of the soft tissue sleeve surrounding the distal tibia is tenuous, and aggressive handling with extensive periosteal stripping disturbs nutrition to the myocutaneous tissue and underlying bone [10]. Although Ruedi and Allgower demonstrated good outcomes in their cases by reduction and rigid internal fixation, their results were biased in that the majority of fractures were low-energy injuries [11]. Similar treatment in injuries resulting from highenergy trauma with severe soft tissue compromise or extensive bony communication does not yield good results. Kellam and Waddell reported that 53 % of patients with high-energy compressive fractures had good function compared with 84 % in low-energy injuries [12]. Dillin and Slabaugh also advocated rigid internal fixation only for lower-energy injuries when they had an alarming 55 % infection rate in their series of 11 high-energy trauma patients [13]. Since these reports, reducing devitalisation of soft tissue or bone and minimally
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International Orthopaedics (SICOT) (2015) 39:2227–2237
Fig. 7 X-ray of an AO/OTA 43C2 fracture of the right tibia
invasive operations have become popular, with many authors choosing to use external fixation [14–16]. This management technique is acceptable in tibial fractures complicated with severe soft tissue injury because of the advantages of less secondary iatrogenic injury, ease of application and the ability to dynamise the fixator to promote union [17]. However, stability created by the external fixator cannot be compared with that provided by an LCP. Also, it is impossible to insert Schanz screws when distal tibial length is insufficient or the
Fig. 8 Appearance of the injured leg
fracture line reaches the distal tibial surface. In these cases, ankle-spanning systems can be considered if the surgeon insists on using standard external fixators. However, patients treated with spanning frames have loss of reduction more often than those treated with sparing frames [18]. Also, large pins are associated with a higher risk of soft tissue complications, and ankle-joint articulation affects post-operative mobilisation. Alternatively, many authors have used the Ilizarov circular external fixator for treating such injuries. These frames have smaller pins and do not cross the ankle joint, and it is possible to stabilise the fracture soon after injury. The main disadvantages of the Ilizarov method are the lengthy treatment time and long-term obstruction to walk properly with the frame on. The fixator is also more awkward and bulky than standard external fixators and may cause more discomfort. The minimally invasive plate osteosynthesis technique causes less damage to the blood supply of the injured tibia but would still have caused a skin problem on the medial side of the tibia, particularly distally [5]. When the affected limb is swollen, insertion of a less invasive stabilisation system (LISS) plate more often results in osteofascial compartment syndrome. Reynder et al. [19] reported 23 type 42-C2 fractures treated with LISS plates using the minimally invasive plate osteosynthesis technique. In that series, three patients developed compartment syndrome after immediate plate
International Orthopaedics (SICOT) (2015) 39:2227–2237
2233
Fig. 9 Immediately post-operative X-ray of the fracture fixation
fixation, and five patients developed post-operative neural palsy of the extensor hallucis longus muscle. Therefore, the authors stressed that long LISS plates cannot be used to stabilise the distal segment in patients with short distal segmental fracture of the tibia and that immediate fixation should be avoided. Although Ma et al. [1] inserted an LCP in a retrograde fashion on the medial aspect of the tibia to prevent nerve and tendon injury, the procedure was performed after the soft tissue had healed or the flap had incorporated well. Two issues in treating distal tibial fractures remain: (1) minimal invasion and (2) developing a repair method that decreases the negative effects of compromised soft tissue that delays timely operation. Sven et al. were the first to describe the use of an LCP as external fixation [20], with Kloen stating that when an LCP is used as an internal fixator, stable connection of the locking screws to the plate does not rely on friction between plate and bone [8]. The principle is similar to the external fixator, which has angle-stabilising properties. Therefore, LCPs are being used as external fixators with increasing frequency. Recently, a number of surgeons demonstrated excellent outcomes in the treatment of infected nonunion, open fractures and bone defects and concluded that the subcutaneous plate osteosynthesis technique combined with an LCP provides adequate stability and is associated with decreased rates of infection and soft tissue complications [5, 8, 9, 20, 21].
In this study, we described closed reduction using LCPs as external fixators for treating closed distal tibial fractures with compromised soft tissue. Clinical outcomes were satisfactory, and we gained experience using this technique. The plate device with locking screws in our series is a minimally invasive approach that maximises tissue preservation. In all cases, we made no incisions (except for fibular fixation, fascial compartment syndrome decompression and flap elevation) near the tibia to achieve tibial reduction, thus preventing damage to the periosteal blood supply. Promising results were shown by Leonard et al., who found that early intervention (
