Distal Tibia & Fibula Fracture

Today, we are going to discuss a very interesting case, which one of our surgeons came across last week. A 56 year old male presented with swelling around ankle on the day of injury. He had twisted his ankle. After the X-ray, it was diagnosed as Comminuted fracture medial malleolus with comminuted fracture fibula shaft. The surgeon planned to treat him with Open reduction & internal fixation through GPC fixLOCK Medial distal tibia plate with tab & Medial malleolus screw fixation. However, intra-operatively, due to unstable ankle injury, the treatment plan was changed.

Clinical History

• 56 year old male
• History of twisting injury around ankle
• Presented on the day of injury
• Pain and swelling over left leg
• Co-morbidities – hypertension

Diagnosis & Treatment Planning

Diagnosis

• Comminuted fracture medial malleolus with comminuted fracture fibula shaft

Plan

• Medial tibial plate with tab
• Medial malleolus screw fixation + neutralization plate

Change in Treatment Planning

Diagnosis

• Comminuted fracture Medial Malleolus (Vertical and Horizontal split) with posterior malleolus fracture with Posterior Subluxation of ankle with comminuted fracture fibula shaft

Plan:

• Medial malleolus screw fixation + neutralization plate
• Stabilization of ankle joint

Anatomical reconstruction of joint

• Ankle joint reduced and fixed with K wire
• Posterior malleolus temporarily held with clamp and fixed with screw
• Medial malleolus horizontal split fragment fixed with screws
• Vertical split fragment had numerous small fragments
• GPC Medical Ltd. Distal Radius T-plate used
• Horizontal Limb of T-plate is curved to match the distal tibia and buttress the anterior and posterior aspects
• Volar tilt of T-plate is reversed.

Minimal Soft tissue stripping
Preserved Bone Blood supply
Early return to function

Distal Tibia Fracture- What is the ideal treatment plan?

Should I choose Nailing or Plating technique?

A 52 YO male, visited ER with swelling & pain on the right leg. He had RTA on the same day.

What is the ideal treatment plan?

PRE-OP X-RAY

• Ideal line of management of distal tibial spiral fractures includes Computed Tomograph of the ankle joint to look for intraarticular extension of the fracture and/ or fracture of the posterior malleolus.
• Studies have demonstrated the importance of CT scan in detecting previously unreported injuries as seen on plain radiographs.

• However, in this scenario no CT scan were done, lateral view on plain radiograph demonstrated fracture line extending to intraarticular region (marked by yellow arrow)

Should I choose nailing or plating?

• In this case, Plating by MIPPO technique was used
• We have included two notable findings, which need to be addressed regarding surgical decision about the mode of fixation and their outcomes as noted in the recent studies.

• Procedure done by MIPPO technique using GPC fixLOCK Anteromedial distal tibial plate (without tab).
• Lag screw placement to achieve fracture reduction and fixation.
• Lag screw placed directly perpendicular to fracture site apart from plate construct.
• Second lag screw placed through the combi hole of the locking plate.
• We recommend treatment as per AO principles of fracture fixation with anatomical reduction of the intraarticular fracture, soft tissue handling (fracture environment), preserving blood supply, and early restoration of function.