Distal tibial fractures, particularly those involving the tibial plafond (also known as pilon fractures), are among the most complex orthopedic injuries due to their anatomical and biomechanical characteristics. These fractures often result from high-energy trauma such as road traffic accidents or falls from height, leading to significant bony and soft tissue damage. They account for approximately 1% of lower extremity fractures and 3–10% of all tibial fractures, with a considerable proportion being open or comminuted in nature [1,2].

The management of these fractures presents unique challenges due to difficulty in achieving anatomical reduction, restoring mechanical alignment, and preventing complications such as infection, malunion, non-union, and post-traumatic arthritis [3]. Traditional conservative approaches, including cast immobilization, often result in prolonged immobilization and poor functional outcomes due to joint stiffness and malalignment [4].

Open reduction and internal fixation (ORIF) has evolved as a standard modality in the treatment of distal tibial fractures, particularly with the advent of anatomically contoured locking compression plates (LCPs). LCPs provide angular stability and allow for biological fixation through minimally invasive techniques, thereby reducing soft tissue disruption and preserving periosteal blood supply [5,6]. Moreover, studies have reported improved union rates, alignment, and early mobilization with locking plates compared to conventional plating or external fixation [7,8].

Despite advancements, the complication rates remain non-negligible, especially in open fractures or those associated with comorbidities such as diabetes or osteoporosis. Therefore, patient selection, precise surgical technique, and diligent post-operative care play a crucial role in determining the success of treatment [9].

This study aims to evaluate the functional and radiological outcomes of distal tibial fractures treated with locking plate osteosynthesis, and to correlate the findings with existing literature.

This prospective interventional study was conducted in the Department of Orthopaedics at Medical College and SSG Hospital, Vadodara, from 2023 to 2024. A total of 30 adult patients with distal tibial fractures were enrolled based on inclusion and exclusion criteria. The inclusion criteria comprised patients above 18 years of age presenting with closed or Gustilo-Anderson Grade I to III open fractures of the distal tibia who provided informed consent and agreed to participate in follow-up. Patients with neurovascular compromise, pathological fractures, or age below 18 years were excluded from the study.

Preoperative evaluation included thorough clinical assessment, radiographic imaging (X-rays and, where needed, CT scans), and classification of fractures using the AO/OTA system. The surgical intervention involved open reduction and internal fixation using anatomical locking compression plates (LCPs), with the choice of medial or anterolateral approach based on fracture morphology and soft tissue condition. Standard perioperative protocols including antibiotic prophylaxis and thromboprophylaxis were followed. Intraoperatively, care was taken to minimize soft tissue handling and preserve the fracture hematoma.

Postoperative management involved limb elevation, pain control, and early mobilization. Patients were monitored for surgical site complications, and follow-up radiographs were taken at regular intervals to assess union. Partial weight-bearing was initiated as per fracture stability and radiological evidence of healing. Clinical and functional outcomes were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) score, along with documentation of time to union, range of motion, and complications such as infection, malunion, delayed union, or non-union. Data were collected systematically and analyzed descriptively.

A total of 30 patients with distal tibial fractures treated with locking plate osteosynthesis were included in the study. The mean age group of the patients ranged from 20 to 60 years, with a predominance of males. The most common mode of injury was road traffic accidents. Fractures were categorized using the AO/OTA classification system, and most cases belonged to the extra-articular type (43-A). The majority of fractures were closed injuries, and radiological union was achieved in most patients within 14 weeks. Postoperative complications were minimal, and functional outcomes measured by the AOFAS score showed favorable results in the majority of cases.

Table 1: Age Distribution

Most patients were in the 30–50 age group, indicating that middle-aged adults are more commonly affected.

Table 2: Gender Distribution

The study had a male predominance, likely due to greater exposure to outdoor and occupational hazards.

Table 3: Mode of Injury

Road traffic accidents were the most common cause, followed by falls and slips.

Table 4: Fracture Classification (AO/OTA)

Extra-articular fractures (43-A) were the most prevalent type in this study.

Table 5: Injury Type

Closed fractures accounted for nearly three-fourths of cases.

Table 6: Union Time

Majority of fractures united within 10–14 weeks.

Table 7: Union Status

Union was achieved in 87% of cases, with no reported non-union.

Table 8: Complications

Only 3 patients experienced complications, indicating a low complication rate.

Table 9: Final Outcome (AOFAS Score)

70% of patients had good to excellent outcomes according to AOFAS scoring.

The present study highlights that locking plate osteosynthesis is a reliable and effective method for treating distal tibial fractures, particularly in achieving satisfactory anatomical alignment and functional recovery. In our cohort, the majority of patients were middle-aged males, consistent with existing literature which identifies males in the 30–50-year age group as being at greater risk due to higher involvement in outdoor occupations and road traffic activities [10,11].

The predominance of road traffic accidents as the primary mechanism of injury mirrors findings in prior studies by Shrestha et al. and Shah et al., who also reported high-energy trauma as the most frequent cause of distal tibial fractures [12,13]. This underscores the need for public health interventions focused on road safety and trauma prevention.

The AO/OTA classification revealed that extra-articular fractures (43-A) were most common, aligning with the findings of Kumar et al., who noted better outcomes and fewer complications in 43-A fractures compared to intra-articular types [14]. Our results also reflect this trend, as the majority of our patients had type A fractures and demonstrated earlier radiological union and better functional scores.

Radiological union was achieved in 87% of patients by 14 weeks, which corresponds with the outcomes reported by Redfern et al., who documented an average union time of 13–15 weeks for similar fractures treated using minimally invasive percutaneous plate osteosynthesis (MIPPO) [15]. Moreover, none of our patients developed non-union, reinforcing the stability and biological advantages of LCPs in fracture healing.

The incidence of complications in our study was low (10%), with only two cases of superficial surgical site infections and one malunion. These results are comparable to studies by Im and Tae, and Krettek et al., who emphasized the importance of careful soft tissue handling and early intervention in minimizing infection risks [7,9].

Functionally, 70% of patients had good to excellent outcomes as per AOFAS scores. This is in agreement with Helfet et al. and Egol et al., who reported similarly favorable functional outcomes following locking plate fixation [5,16]. Patients were able to regain satisfactory ranges of motion, especially plantarflexion, and dorsiflexion, enabling a return to routine activities.

Despite the positive results, certain limitations must be acknowledged. The relatively small sample size and single-center nature of the study may limit the generalizability of the findings. Moreover, long-term follow-up beyond one year was not conducted, thus precluding evaluation of late complications such as post-traumatic arthritis or hardware failure.

Nonetheless, the study supports existing evidence that locking plate osteosynthesis, when performed with meticulous technique and appropriate case selection, offers excellent union rates, functional recovery, and a low incidence of complications in distal tibial fractures.

Locking plate osteosynthesis for distal tibial fractures provides good functional and radiological outcomes. Proper patient selection, timely intervention, and adherence to surgical principles and post-operative care are key determinants of success.

1. Rüedi TP, Allgöwer M. The operative treatment of intra-articular fractures of the lower end of the tibia. Clin Orthop Relat Res. 1979;(138):105–10.
2. Bucholz RW, Heckman JD, Court-Brown CM, Tornetta P. Rockwood and Green’s Fractures in Adults. 9th ed. Philadelphia: Wolters Kluwer; 2019.
3. Teeny SM, Wiss DA. Open reduction and internal fixation of tibial plafond fractures. Clin Orthop Relat Res. 1993;(292):108–17.
4. Bourne RB. Pilon fractures of the distal tibia. Clin Orthop Relat Res. 1989;(240):42–6.
5. Helfet DL, Shonnard PY, Levine D, Borrelli J Jr. Minimally invasive plate osteosynthesis of distal fractures of the tibia. Injury. 1997;28 Suppl 1:A42–7.
6. AO Foundation. Locking Compression Plate (LCP): Technique Guide. Synthes; 2003.
7. Im GI, Tae SK. Distal metaphyseal fractures of tibia: Minimally invasive plate osteosynthesis versus open reduction and internal fixation. Injury. 2005;36(1):33–9.
8. Redfern DJ, Syed SU, Davies SJ. Fractures of the distal tibia: minimally invasive plate osteosynthesis. Injury. 2004;35(6):615–20.
9. Krettek C, Miclau T, Schandelmaier P, Tscherne H. The minimally invasive percutaneous plate osteosynthesis (MIPPO) technique: Surgical technique and preliminary clinical results. Injury. 1997;28 Suppl 1:A1–6.
10. Court-Brown CM, Caesar B. Epidemiology of adult fractures: A review. Injury. 2006;37(8):691–7.
11. Jagdev S, Lakhwinder S, Dhillon KS. Outcome of locking compression plate fixation in distal tibia fractures. Int J Orthop Sci. 2020;6(1):330–4.
12. Shrestha D, Acharya BM, Shrestha PM. Distal tibia fracture treated with locking compression plate. J Nepal Med Assoc. 2011;51(183):66–70.
13. Shah RK, Shah KB, Gupta PK. Outcome of fracture distal tibia treated by minimally invasive percutaneous plate osteosynthesis (MIPO) technique. Nepal Orthop Assoc J. 2013;3(1):18–22.
14. Kumar A, Jain SK, Dhammi IK, Singh A. Treatment of distal tibial fractures using locking compression plate. J Clin Orthop Trauma. 2014;5(3):149–55.
15. Redfern DJ, Syed SU, Davies SJ. Fractures of the distal tibia: minimally invasive plate osteosynthesis. Injury. 2004;35(6):615–20.
16. Egol KA, Tejwani NC, Capla EL, Wolinsky PL, Koval KJ. Minimally invasive plate osteosynthesis in distal tibia fractures: Results of a prospective study. J Orthop Trauma. 2006;20(9):595–601.