Translating innovation into impact: a national policy dialogue on scaling and integrating evidence-based supportive text messaging into Canada's mental health care systems.

Extra-articular distal tibial fracture refers to a fracture occurring within approximately 4–11 cm above the ankle joint. It is commonly caused by high-energy trauma such as traffic accidents or falls from height and accounts for approximately 7.2%–32% of all tibial fractures (, ). The management of extra-articular distal tibial fracture remains challenging due to the complexity of fracture patterns, the limited soft tissue envelope, and the proximity to the ankle joint (). For unstable extra-articular distal tibial fracture, surgical fixation is the primary treatment modality. Currently, the most commonly employed surgical techniques are plate fixation and intramedullary nailing. Plate fixation, particularly via open reduction and internal fixation (ORIF), allows for direct visualization and anatomical reduction of the fracture and generally provides good mechanical stability. However, due to the relatively thin soft tissue envelope over the distal tibia, ORIF with plates increases the risk of skin necrosis and postoperative infection. Moreover, excessive periosteal stripping may negatively affect fracture healing (). Intramedullary nailing (IMN) has emerged as a widely accepted method for managing extra-articular distal tibial fracture due to its minimally invasive nature, preservation of periosteal blood supply, and load-sharing biomechanics. However, conventional antegrade intramedullary nailing (AIN) has certain limitations. The distal tibial medullary canal is relatively wide, which makes it difficult to achieve accurate reduction and alignment of the fracture ends (). This may also lead to concerns regarding inadequate fixation stability. Additionally, anterior knee pain is a common postoperative complaint associated with the proximal entry point, particularly in younger and more active patients (). To address the limitations of conventional approaches, retrograde intramedullary nailing (RIN) has recently been introduced as an alternative method for the fixation of extra-articular distal tibial fracture (–). This technique involves a distal entry point through the medial malleolus, allowing direct access to the fracture zone. Biomechanical studies have demonstrated that RIN offers superior control of micromotion at the fracture site and greater structural stability of the fixation compared to AIN or distal tibial plating (, , ). Moreover, by minimizing proximal soft tissue disruption and avoiding knee joint violation, RIN may promote faster recovery and improved patient comfort. Nevertheless, the application of RIN remains a subject of concern due to complications associated with the medial malleolar entry point, such as iatrogenic fractures, injury to the posterior tibial tendon or potential damage to the articular cartilage of the ankle joint.