Plating, elastic stable intramedullary nailing (ESIN), divergent intramedullary nailing (DIN), percutaneous pinning, external fixation and intrafocal pinning, all are debatable choices for surgery and each procedure has its own pros and cons. Therefore, there isn't a "gold standard" surgical technique, and thus, the choice remains controversial. The poor soft tissue coverage, the poor blood supply, and the distality of the fracture, arise a challenge in discerning what type of surgical intervention should be carried out. Indications for surgical treatment were defined as a recurvatum or a procurvatum of more than 10 degrees, a valgus or a varus of more than 5 degrees, or a misalignment of more than 40%. However, when conservative methods don't offer the optimal reduction and stability, surgical intervention is required to restore the length of the bone and correct its rotational angulation and alignment. When the displacement is acceptable, nonoperative treatment by closed reduction and a long leg cast for 6 to 8 weeks is the treatment of choice. A fibular fracture, present or absent, will not affect the final outcome no matter what type of care is provided. An intact fibula will lessen the severity of tibial displacement. Concomitant fibula fracture is a common finding and the pattern of its displacement mirrors the tibial one mentioned before. Due to the thickness of the periosteum, a similar lesion would displace the distal fragment generally in a recurvatum and valgus angulation nevertheless, a deformity by procurvatum and varus can occur. The majority of these fractures are greenstick injuries with a broken cortex posteriorly and a crushed cortex anteriorly. However, distal metaphyseal or supramalleolar fractures are not very common with an approximate incidence of 0.4%. Tibia fractures are frequent during childhood, ranked as the third most common fractures in children, with an incidence of 15%. To best of our knowledge, no cases of intrafocal pinning for DTMF in children were described in literature before. We compare afterwards our procedure to the other interventions in terms of advantages, disadvantages and final outcome. We describe in this article the pathophysiology of this type of fractures as well as the technique applied. This a case of a traumatic progressively displaced DTMF despite cast immobilization in an 11-years-old child, who was treated in our institute by intrafocal pinning and followed for 15 months. However, the choice of the surgical procedure if indicated, remains controversial, and many options of osteosynthesis are still considered. Distal tibial metaphyseal fractures (DTMF) are rare fractures among children, and are usually treated by closed methods for 6 to 8 weeks with reported satisfactory outcomes.
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