A key determination to make is whether the fracture is extra-articular or intra-articular. Radiographs of the entire tibia and ankle are required for a complete assessment of the fracture pattern and bone quality. Multiple treatment options exist for fractures of the distal tibia in the elderly. (Reproduced with permission from Marsh JL et al. Despite only achieving moderate overall interobserver reliability scores, both of these systems can be useful clinically (for effective communication among healthcare workers, determining an appropriate treatment plan and preoperative planning) and for research purposes.įigure 41.1 AO/OTA Classification System for Distal Tibia and Fibula Fractures. 8 showed that the interobserver reliability of the AO/OTA classification system was highest for determining fracture type (A, B or C, kappa = 0.57) and lower for fracture group (kappa = 0.43) and subgroup (kappa = 0.41). 7 demonstrated better interobserver reliability with the AO/OTA classification system (kappa = 0.60) than with the Rüedi and Allgöwer system (kappa = 0.46), Swiontkowski et al. With its 27 resultant fracture types, the AO/OTA classification system is a comprehensive descriptive system designed to include all possible fractures of the distal tibia, both extra-articular and intra-articular. 6 Fractures in each type are then classified on the basis of fracture comminution into one of three groups, each of which can be further subdivided into three subgroups based upon other fracture characteristics. The AO/OTA classification system divides fractures of the distal tibia into three main types: extra-articular (type a), partial articular (type b) and complete articular (type c) as depicted in Figure 41.1. Type III fractures are displaced intra-articular fractures with significant comminution, often involving articular impaction. Type II fractures involve displacement of the distal tibial articular surface without significant comminution. Non-displaced intra-articular fractures are classified as type I fractures. The Rüedi and Allgöwer system, first published in 1968 in German 4 but subsequently translated and published in English in 1969, 5 is a relatively simple descriptive classification system that divides intra-articular fractures of the distal tibia into three types. Unlike with many other fragility fractures, the incidence of distal tibia fractures did not increase significantly with advancing age ( Table 41.1).įractures of the distal tibia and fibula are characterized using two main classification systems. Of the 16 distal tibia fractures, 15 occurred as the result of low energy falls, and one occurred spontaneously (Court-Brown CM, personal communication). 3 In this series of 4,786 fractures that occurred over 24 months of data collection, only 16 (0.33%) occurred in the distal tibia, representing an overall incidence of 8.2 per 100,000 population per year (3.9 in males and 11.0 in females). have recently published a detailed epidemiologic analysis of fractures in patients 65 years of age and older. 2Īlthough the majority of recent literature examining changes in the incidence of fragility fractures has focused on the classic fragility fractures described above, Court-Brown et al. Measurements of BMD obtained from the tibial diaphysis and epiphysis have been shown to predict clinical fracture risk as accurately as BMD measurements obtained from the hip or lumbar spine, substantiating the fact that osteopenia and osteoporosis are manifest in the entire skeleton. 1Īlthough much less common than the classic fragility fractures of the proximal femur, pelvis, proximal humerus and distal radius, fractures of the distal tibia and fibula in the elderly most commonly result from similar mechanisms of injury – ground level falls. 1 Other risk factors for osteoporotic fractures include vitamin D deficiency, malnutrition, chronic inflammatory conditions, physical deconditioning and poor balance. In addition to decreasing bone mineral density (BMD), multiple explanations have been proposed for the increased incidence of fractures in the aging population including ‘frailty’, a condition defined by a diminished capacity to perform activities of daily living and often characterized by inactivity and weight loss. As the proportion of elderly individuals increases due to longer average life expectancies, fracture incidence in this population is on the rise.
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