Diagnosing Fractures of the Distal Tibial Articular Surface in Tibia Shaft Fractures: Is Computed Tomography Always Necessary?

Abstract

Objectives: To identify the incidence of distal articular fractures in a series of distal third tibia shaft fractures and to report the utility of both computed tomography (CT) scans and Radiographic Investigation of the Distal Extension of Fractures into the Articular Surface of the Tibia (RIDEFAST) ratios for identification of articular involvement.

What Is the Rate of Displacement of Occult Posterior Malleolus Fractures in Nailed Tibial Shaft Fractures?

“…This is consistent with other recent literature reports that show that the prevalence of clinically significant fractures is high but can be frequently detected on plain x-ray alone. 14 There are several limitations to this study. Although we have x-rays at time of union in most patients (74% of patients with at least 3-month follow-up and 55% of patients with 6-month follow-up), the retrospective nature of this study means that we do not have patient-reported outcomes, making us unable to definitively evaluate the clinical impact of these injuries.…”

“…This is consistent with other recent literature reports that show that the prevalence of clinically significant fractures is high but can be frequently detected on plain x-ray alone. 14…”

“…3,7–11 For certain fracture patterns, some surgeons have advocated the use of routine computed tomography (CT) scans to screen for these occult injuries 3,12,13 because of concern that an occult, nondisplaced articular fracture might displace during nail insertion, so early detection could allow for prophylactic fixation, 10,12 while others have questioned what value CT adds over x-rays alone. 14…”

“…3,[7][8][9][10][11] For certain fracture patterns, some surgeons have advocated the use of routine computed tomography (CT) scans to screen for these occult injuries 3,12,13 because of concern that an occult, nondisplaced articular fracture might displace during nail insertion, so early detection could allow for prophylactic fixation, 10,12 while others have questioned what value CT adds over x-rays alone. 14 Although there has been substantial research demonstrating the presence of radiographically detectable fractures with advanced imaging, there has been less work demonstrating the clinical relevance of these imaging modalities in identifying the presence of occult fractures which are (1) likely to displace and (2) would potentially make a meaningful impact on clinical outcomes. At our trauma center, we have not routinely performed CT scans of tibial shaft fractures to look for an occult posterior malleolus fracture (PMF) when there was no radiographic concern on plain imaging.…”

Value Challenge: A Bottoms-Up Approach to Minimizing Cost and Waste in Orthopaedic Surgery

“…Over time, the utilization of advanced imaging has escalated 21-23 . Modern day CT scanning machines are readily available and efficient, and new trainees are in the habit of obtaining scans on many injuries.…”