Blisters, biology and rings: single-stage Ilizarov fixation for a high energy AO/OTA 42C3 tibial shaft fracture in an octogenarian: a case report

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Abstract
High-energy tibial shaft fractures in geriatric patients present significant challenges due to osteoporotic bone, compromised soft tissues and multiple medical comorbidities. Conventional fixation methods may be limited in the presence of fracture blisters or poor physiological reserve, making minimally invasive strategies increasingly relevant. An 88-year-old previously independent male with hypertension and prior cerebrovascular accident sustained a high-velocity road traffic injury resulting in an AO/OTA 42C3 comminuted tibial shaft fracture and 4F2B fibula fracture with ipsilateral rib fractures. Early circumferential fracture blebs precluded plating and staged external fixation was avoided due to advanced age and comorbidities. A single-stage four-ring Ilizarov circular fixator was applied using tensioned wires and selective Schanz pins, prioritizing biological fixation and soft-tissue preservation. Postoperatively, the patient followed a staged rehabilitation protocol with adjunctive teriparatide therapy. Radiographs demonstrated progressive callus formation and fracture union at one year with acceptable varus and recurvatum alignment. The postoperative course was uneventful and implant removal was performed after consolidation. Functional outcomes beyond one year could not be assessed due to loss to follow-up. Single-stage Ilizarov circular fixation can be an effective definitive option for complex high-energy tibial fractures in medically complex elderly patients when conventional fixation is contraindicated. Careful consideration of soft-tissue status, comorbidities and biological fixation principles is essential to optimize outcomes.

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