Figure 3.1
Injury films AP, mortise, and lateral
Figure 3.2
Post-reduction films AP, mortise, lateral
Treatment and Timing of Surgery
In this patient because the ankle was reduced in an expeditious manner, there was minimal swelling about the ankle. Thus, the patient was able to be taken to the operating room the same day for operative fixation of her ankle. Had there been significant swelling about the ankle or a delay in closed reduction that would have predisposed the patient to significant swelling about the ankle, then delayed operative fixation would have been reasonable until the swelling subsided.
In terms of fixation strategy, the fracture pattern of the fibula was amenable to lag-screw fixation of the short oblique fibula fracture and neutralization of this screw with a laterally based plate adhering to principles of absolute stability fixation. Similarly, the transverse nature of the medial malleolar fracture was amenable to lag-screw fixation to compress the fracture also providing absolute stability.
Surgical Tact
Position
The patient is positioned supine on the operating room table with a small bump under the ipsilateral hip to internally rotate the leg such that the patella is pointing directly towards the ceiling. The leg is elevated off the table with a ramp of sheets placed under the thigh and tibia such that the knee is flexed 30° and the tibia remains parallel to the ground. A thigh tourniquet is utilized and is set to 100 mmHg above the systolic blood pressure (generally around 250 mmHg). The fluoroscopy machine is situated on the contralateral side of the injured extremity and the surgical implants and tools are situated on the ipsilateral side.
Approach: Medial Malleolus
A 4 cm incision centered over the medial malleolus and curved slightly anteriorly at the tip of the medial malleolus is used to expose the fracture site. Dissection is carried down to the fracture site with care taken to protect the saphenous vein and nerve.
Fracture Reduction and Fixation
After displacing the medial malleolus, removing any debris from the tibia-talar joint space, and clearing the fracture site of interposed clot and/or periosteum, fracture reduction is performed. First, a pilot hole is drilled with a 2.5 mm drill into the medial tibia 1 cm proximal to the fracture and in the midline of the fracture. A small pointed bone reduction clamp is then used to reduce the fracture anatomically with care taken to ensure that the visualized anterior and medial cortices of the fracture key in perfectly. After the fracture is reduced, fluoroscopic images are obtained to confirm the reduction.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
