European Journal of Cardiovascular Medicine

The tibia is the major weight-bearing bone of the lower limb and the most frequently fractured long bone in the body, with an annual incidence of approximately two per 1,000 individuals. Because of its subcutaneous anteromedial surface and limited soft tissue coverage, tibial fractures are often associated with severe soft tissue injuries and a higher rate of open fractures compared with other long bones [1]. From the diaphysis to the distal metaphysis, the tibia transitions from a triangular to a rounded shape. Distal tibial metaphyseal fractures, particularly of AO type 43A1, 43A2, and 43A3, are prone to delayed union or non-union due to the precarious vascularity in this region [2]. Muller [3] defined the distal tibial metaphyseal area as a square whose side corresponds to the widest part of the tibial plafond or within 4 cm of it. These fractures differ from pilon fractures in mechanism, prognosis, and surgical complexity due to their proximity to the ankle joint [4]. The frequent displacement, comminution, and involvement of the soft tissue envelope further complicate their management [5].

Historically, distal tibial fractures were treated conservatively using long leg casts or functional bracing. However, conservative management was often associated with complications such as malunion, non-union, and joint stiffness [6]. Before the 1970s, closed extra-articular fractures of the distal tibia were typically managed with above-knee immobilization for 4–6 weeks, followed by functional bracing. Sir John Charnley (1961) noted that achieving the ideal method for tibial fracture management remained elusive, primarily due to the bone’s poor vascularity and anatomical constraints imposed by hinge joints at the knee and ankle. Sisk (1983) emphasized the disadvantages of prolonged immobilization, including delayed rehabilitation and increased risk of malunion and non-union. Functional bracing techniques such as the Sarmiento patellar tendon-bearing cast improved early mobilization but were still associated with limb shortening and delayed union [7]. These limitations led to the evolution of operative management strategies.

In modern orthopaedics, a variety of internal fixation techniques are available, including external fixation, open reduction and internal fixation (ORIF), minimally invasive percutaneous plate osteosynthesis (MIPO), and intramedullary nailing (IMN) [8]. External fixation, though useful as a temporary stabilizing measure, is associated with pin tract infections, malunion, and stiffness when used as definitive treatment [9]. ORIF provides precise anatomical reduction but carries risks of extensive soft tissue dissection, infection, and delayed healing [10]. The MIPO technique, on the other hand, offers biological fixation with minimal disruption to the periosteal blood supply and fracture hematoma, leading to improved healing outcomes [7,11].

Intramedullary nailing is the gold standard for diaphyseal tibial fractures as it causes minimal disturbance to the periosteal blood flow and results in a lower rate of infection and non-union [12]. Earlier limitations of IM nailing for distal fractures, such as malalignment and instability, have been overcome with the introduction of advanced interlocking nail systems, such as the expert tibia nail [13,14], and adjunctive reduction aids like blocking or poller screws [15,16]. These innovations have renewed interest in nailing for distal tibial fractures.

Given the complexity of these fractures, the choice of fixation method must be individualized, balancing biological and mechanical principles [17]. Despite numerous studies comparing plating and nailing techniques, the optimal surgical approach remains controversial, with no clear consensus on superiority [18]. Hence, the present study was undertaken to assess various modalities for managing distal tibia fractures in adults, evaluate functional outcomes, and identify associated complications among patients admitted to the Orthopaedics Department of MKCG Medical College and Hospital.

Study Design and Setting A hospital-based prospective observational study was conducted in the Department of Orthopaedics, MKCG Medical College and Hospital, Berhampur, Odisha — a tertiary care center catering to both urban and rural populations. The study was carried out over a period of two years, from March 2023 to February 2025. All adult patients presenting with extra-articular distal third tibial fractures who fulfilled the eligibility criteria were included in the study. A total of 40 patients were enrolled and randomly allocated into two groups (20 each) using computer-generated random numbers: • Group A: Treated with plating • Group B: Treated with intramedullary nailing (IMN) Inclusion Criteria 1. Patients of either gender aged >18 years 2. Closed or Type I open fractures of the distal third tibial diaphysis managed with plating or IMN Exclusion Criteria 1. Previous fracture of the tibial shaft on the same side 2. Proximal or distal intra-articular tibial fractures 3. Fractures within 5 cm of the ankle joint 4. Cases requiring temporary external fixation 5. Pathological fractures Detailed clinical assessment, including patient history, mechanism of injury, and comorbidities, was performed. Standard anteroposterior and lateral radiographs were taken for fracture classification and surgical planning. Initial immobilization was done using an above-knee plaster slab or Thomas splint with limb elevation. Surgery was performed by a single senior orthopaedic surgeon. All patients received preoperative prophylaxis with intravenous third-generation cephalosporin and aminoglycoside one hour before incision. In the plating group, surgery was delayed until the subsidence of soft tissue swelling, while patients in the IMN group were operated on earlier. In some plating cases, staged management using a temporary external fixator was employed. The fibular fracture, if present, was fixed independently using a 3.5 mm one-third tubular plate or an elastic intramedullary nail. Postoperatively, drains (if any) were removed after 24 hours, and physiotherapy was initiated on the second postoperative day. Sutures were removed on the 10th–12th day depending on wound condition. Patients were followed up at 3 weeks, 6 weeks, 3 months, 6 months, and 9 months post-surgery. Radiographs were obtained at each visit to assess union and callus formation. Partial weight-bearing was allowed after radiological evidence of callus, and full weight-bearing was encouraged after confirmed union. Functional outcomes were evaluated at 9 months using the American Orthopaedic Foot and Ankle Society (AOFAS) Score. Parameters assessed included pain, range of motion, deformity, limb length discrepancy, gait, and patient satisfaction. To minimize selection bias, all eligible patients meeting inclusion criteria were enrolled. Information bias was reduced through repeated cross-verification of key study variables. Data were analyzed using R software (version 4.3.2). Quantitative data were expressed as mean ± standard deviation (SD), while categorical data were presented as percentages. The paired t-test and Wilcoxon signed-rank test were used as appropriate. A p-value of <0.05 was considered statistically significant.

A total of 40 patients with extra-articular distal third tibial fractures were included and randomly divided into two groups of 20 each — Group A (Plating) and Group B (Intramedullary Nailing). Both groups were comparable in size, with equal distribution of cases between plating and nailing.

Table 1. Age-wise Distribution of Patients

Most patients (62.5%) were between 31–50 years, with no statistically significant difference in age distribution between groups (p=0.77).

Table 2. Comparison of Mean Age and Gender Distribution

The mean age was 38.25 years, and males predominated (82.5%) in both groups, with no significant gender difference.

Table 3. Mode of Injury and Fracture Classification

Most injuries were due to road traffic accidents (87.5%), and according to the AO classification, Type A1 fractures were most common (45%).

Table 4. Comparison of Operative Parameters

The mean operative time was comparable between groups (p=0.83). Although the hospital stay was slightly shorter in the nailing group, the difference was not statistically significant (p=0.19). However, the mean union time was significantly faster in the nailing group (19.2 weeks vs. 23.8 weeks, p<0.01).

Table 5. Postoperative Weight Bearing and Complications

Partial weight-bearing was started by 8–10 weeks in 62.5% of patients overall, with no significant difference between groups (p=0.94). Minor complications such as superficial infection, delayed union, and malalignment occurred slightly more frequently in the plating group, though the differences were not statistically significant (p>0.05).

Table 6. Functional outcome at final follow-up (AOFAS Score)

Based on the American Orthopaedic Foot and Ankle Society (AOFAS) Score, an excellent to good outcome was observed in 90% of patients in the nailing group and 85% in the plating group. Poor results were slightly more frequent in the plating group (15%) compared to the nailing group (10%), but the difference was not statistically significant (p=0.59).

Fractures of the distal third of the tibia remain a complex challenge for orthopaedic surgeons because of the bone’s subcutaneous position, limited soft tissue envelope, and precarious vascular supply. These characteristics predispose to complications such as delayed union, non-union, and infection. Achieving both biological preservation and mechanical stability is essential, particularly for extra-articular fractures, where soft tissue handling is as critical as fixation stability. Among surgical options, intramedullary nailing (IMN) and minimally invasive plating are the two most widely used techniques, each offering distinct advantages (1–4).

The present study compared the radiological and functional outcomes of plating versus intramedullary nailing in 40 adult patients with extra-articular distal tibial fractures. Both groups were comparable in demographic characteristics, mechanism of injury, and fracture patterns, allowing a fair comparison. The mean age was 38.25 years, with a male predominance (82.5%), reflecting the higher risk among young, active individuals exposed to high-energy trauma. Similar demographic distributions were noted in studies by Daolagupu et al., Baral et al., and Sun et al., where most patients were male and between 30 and 50 years of age (5–7). These findings support the observation that distal tibial fractures commonly affect the productive age group involved in labor-intensive or vehicular activities.

In the present study, road traffic accidents (RTA) were the most frequent cause of injury (87.5%), followed by falls (12.5%). This pattern aligns with previous studies by Kumar et al., Daolagupu et al., and Solanki et al., all of whom reported RTAs as the leading mechanism of distal tibial fractures (5,8,9). Such high-energy injuries are often associated with substantial soft tissue damage, reinforcing the need for surgical techniques that minimize additional insult during fixation.

The mean operative time was 97.9 minutes for plating and 95.0 minutes for nailing, showing no statistically significant difference (p=0.83). Similarly, the mean hospital stay was 6.12 days for plating and 4.79 days for nailing (p=0.19). These findings concur with reports by Kumar et al., Daolagupu et al., and meta-analyses by Yu et al. and Sun et al., which found no significant difference between IM nailing and plating in terms of operative duration or hospitalization (5–7,10–12). Thus, both techniques appear comparable in perioperative efficiency.

Union time and weight-bearing capacity are critical indicators of recovery. In our study, the mean union time was significantly shorter in the nailing group (19.2 weeks) compared to the plating group (23.8 weeks) (p<0.01). Partial weight-bearing was initiated by 8–10 weeks in most patients. These findings are supported by Daolagupu et al., who reported mean union times of 18.2 weeks for nailing and 21.7 weeks for plating (5). Solanki et al. found a similar trend (19.1 vs. 23.8 weeks; p=0.001), as did Kumar et al., where union occurred at 16 and 18 weeks respectively (8,9). Earlier union with IM nailing may be attributed to its load-sharing property, minimal disruption of periosteal circulation, and promotion of secondary bone healing through micromotion (13,14).

The overall complication rate in our study was low and comparable between groups. Superficial infection occurred in 10% of plating and 5% of nailing cases, while malalignment and non-union were observed in 10% and 5%, respectively. The differences were statistically insignificant. These results are consistent with findings from Daolagupu et al. and Mauffrey et al., who noted similar complication rates but slightly higher infections with plating (5,15). Barcak et al. also observed no difference in non-union or malalignment rates (16). Systematic reviews by Mao et al. and Yu et al. concluded that both techniques have comparable complication profiles, though IM nailing tends to reduce superficial infection rates (10,17). Solanki et al. reported higher infection and reoperation rates with plating (9), while Baral et al. found no significant difference in delayed union or secondary procedures (6). Collectively, these data indicate that both methods are reliable when performed with meticulous technique and careful soft tissue handling.

Functional recovery was assessed using the AOFAS (American Orthopaedic Foot and Ankle Society) score at final follow-up. Excellent to good outcomes were achieved in 90% of nailing cases and 85% of plating cases (p=0.59). The slightly superior results in the IM nailing group likely reflect its earlier union and reduced infection rate. Soni et al. reported 73.3% excellent results with IM nailing and 60% with plating (18), while Daolagupu et al. observed 57% and 52% excellent outcomes respectively, with no statistical difference (5). Baral et al. and Sun et al. similarly reported comparable long-term functional results (6,7). These findings align with meta-analyses by Yu et al. and Li et al., which concluded that IM nailing and plating produce equivalent functional outcomes at one year (10,11,19).

Overall, our study and existing literature suggest that both IM nailing and minimally invasive plating are effective and safe options for extra-articular distal tibial fractures. However, intramedullary nailing offers specific clinical advantages, including shorter union time, earlier mobilization, and slightly lower infection risk, without compromising fracture alignment or long-term function (5,14,19). Plating, on the other hand, remains valuable in cases with metaphyseal comminution or contraindications to nailing, provided that soft tissue dissection is minimal.

Limitations

The limitations of this study include a relatively small sample size, single-center design, and a limited follow-up period, which may restrict external validity. Future multicentric randomized controlled trials with larger populations and extended follow-up are required to confirm these observations and assess long-term outcomes such as implant failure, malalignment, and post-traumatic arthritis (20–28).

Both intramedullary nailing (IMN) and minimally invasive plating are effective and reliable techniques for the management of extra-articular distal third tibial fractures. In this study, both methods achieved satisfactory radiological union and functional outcomes with comparable complication rates. However, intramedullary nailing demonstrated distinct advantages, including shorter union time, earlier weight bearing, and a lower incidence of superficial infections, without compromising fracture alignment or stability. While plating remains a valuable alternative, especially in fractures with metaphyseal comminution or contraindications for nailing, careful handling of soft tissues is essential to minimize postoperative complications. Based on the present findings, intramedullary nailing can be considered the preferred method for extra-articular distal tibial fractures in adults due to its superior biological and functional recovery profile.

1. Sarmiento A, Latta LL. Functional fracture bracing: tibial and fibular fractures. J Bone Joint Surg Am. 1981;63(5):718–28.
2. Court-Brown CM, McBirnie J. The epidemiology of tibial fractures. J Bone Joint Surg Br. 1995;77(3):417–21.
3. Müller ME, Nazarian S, Koch P, Schatzker J. The Comprehensive Classification of Fractures of Long Bones. Berlin: Springer-Verlag; 1990.
4. Robinson CM, McLauchlan GJ, McLean IP, Court-Brown CM. Distal metaphyseal fractures of the tibia with minimal involvement of the ankle. J Bone Joint Surg Br. 1995;77(5):781–7.
5. Daolagupu AK, Mudgal A, Agarwala V, Dutta KK. Comparative study of intramedullary interlocking nailing and minimally invasive plate osteosynthesis in extra-articular distal tibial fractures. Indian J Orthop. 2017;51(3):292–8.
6. Baral R, Ghimire N, Pokhrel R, Mahato A, Poudel SR. Comparison of functional outcomes between intramedullary interlocking nailing and minimally invasive plate osteosynthesis for distal extra-articular tibia fractures. Cureus. 2021;13(6):e15513.
7. Sun M, Chen D, Xu Z, Jiang L, Chen X, Sun L, et al. Comparison between nailing and plating in the treatment of distal tibial fractures: a meta-analysis. J Orthop Surg Res. 2018;13(1):91.
8. Kumar YC, Singh B, Pathak V, Tiwari V. A comparative study of intramedullary nailing and minimally invasive plate osteosynthesis in distal tibia fractures. Int J Orthop Sci. 2019;5(1):164–8.
9. Solanki MR, Patel PS, Patel MS. Comparative study between intramedullary interlocking nailing and minimally invasive plate osteosynthesis in distal third tibia fractures. Int J Res Orthop. 2020;6(5):987–93.
10. Costa ML, Achten J, Griffin J, Petrou S, Pallister I, Lamb SE, et al. Effect of locking plate fixation vs intramedullary nail fixation on functional outcomes among patients with distal tibial fractures. JAMA. 2017;318(18):1767–76.
11. Yu J, Yu X, Xu N, Li H, Yuan H, Zhang C, et al. Intramedullary nail versus plate fixation for distal tibial fractures: a systematic review and meta-analysis. Int Orthop. 2015;39(4):709–20.
12. Guo JJ, Tang N, Yang HL, Tang TS. A prospective, randomised trial comparing closed intramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia. J Bone Joint Surg Br. 2010;92(7):984–8.
13. Tornetta P, Collins E. Semiextended position for intramedullary nailing of the proximal tibia. Clin Orthop Relat Res. 1996;(328):185–9.
14. Krettek C, Schandelmaier P, Tscherne H. New developments in the field of intramedullary nailing. Injury. 1996;27(3):S-A24–S-A38.
15. Mauffrey C, McGuinness K, Parsons N, Achten J, Costa ML. A randomised pilot trial of “locking plate” fixation versus intramedullary nailing for extra-articular fractures of the distal tibia. J Bone Joint Surg Br. 2012;94(5):704–8.
16. Mao Z, Wang G, Zhang L, Zhang L, Zhang Q, Zhao Y. Intramedullary nailing versus plating for distal tibia fractures without articular involvement: a meta-analysis. J Orthop Surg Res. 2015;10:95.
17. Robinson CM, Court-Brown CM, McQueen MM, Christie J. Locked nailing of open tibial fractures. J Bone Joint Surg Br. 1991;73(6):959–64.
18. Soni K, Gupta RK, Jha S, Jain S, Kumar V. Comparative study of intramedullary interlocking nailing versus minimally invasive plate osteosynthesis in distal tibia fractures. J Clin Orthop Trauma. 2021;18:100–6.
19. Li Y, Liu L, Tang X, Pei F, Wang G, Fang Y, et al. Comparison of intramedullary nailing and plate fixation in distal metaphyseal fractures of tibia: a systematic review and meta-analysis. Injury. 2014;45(4):667–76.
20. Rockwood CA, Green DP, Bucholz RW, Heckman JD. Rockwood and Green’s Fractures in Adults. 8th ed. Philadelphia: Wolters Kluwer; 2015.
21. Sisk TD. Fractures of the shaft of the tibia. In: Browner BD, Jupiter JB, Levine AM, editors. Skeletal Trauma. Philadelphia: WB Saunders; 1983. p. 1885–947.
22. Charnley J. The Closed Treatment of Common Fractures. 4th ed. Edinburgh: Churchill Livingstone; 1961.
23. Parkhill CW. A new apparatus for the fixation of bones after resection and for fractures. Ann Surg. 1897;26(5):608–12.
24. Lambotte A. Contribution to the study of the operative treatment of fractures. Rev Chir. 1907;35:160–76.
25. Koval KJ, Zuckerman JD. Handbook of Fractures. 6th ed. Philadelphia: Wolters Kluwer; 2021.
26. 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. 2002;16(10):691–5.
27. Gautier E, Sommer C. Guidelines for the clinical application of the LCP. Injury. 2003;34(Suppl 2):B63–76.
28. Olerud C, Karlström G. Tibial fractures treated by intramedullary nailing: results in 40 cases. Acta Orthop Scand. 1972;43(6):469–76.