Extraarticular, bifocal closed fracture—42-A1, and articular trimalleolar ankle fracture—44-C2.3 (closed transverse fracture of the medial malleolus, lateral malleolus, and posterior malleolus)
A 36-year-old woman sustained a spiral fracture of the distal tibia and ipsilateral ankle fracture of her left leg when she fell while playing sport.
Indication for MIPO
In this case, conservative treatment of the tibial fracture is unlikely because the displaced ankle fracture is an indication for operative treatment for anatomical reduction and fixation. The tibial fracture can be treated by plating or nailing by the principle of relative stability. The configuration and level of the tibial fracture is a typical case for closed intramedullary nailing. However, the procedure for intramedullary nailing may cause further displacement of the ankle fracture during manipulation as there is no fibular fracture at the level of the tibial fracture. This may make reduction of the tibial fracture problematic. Minimally invasive plate osteosynthesis is an alternative indicated in the presence of a trimalleolar closed ankle fracture in the same limb. Furthermore, Latin American and Asian patients frequently have a very narrow intramedullary canal, so MIPO is a good choice for treatment to avoid extensive reaming to insert the intramedullary nail.
Once a decision has been made that the case is suitable for MIPO, a good preoperative plan helps facilitate the subsequent execution of the surgical procedure. The plan should include a graphic representation of the fracture fragments, the reduction technique, the surgical approach, the most appropriate implant, and the steps required in its application ( Fig 20.2-2 ).
Minimally invasive plate osteosynthesis surgery of the tibia is performed first using a 10-hole DCP because this patient had good bone quality. The ankle fixation is performed after fixation of the tibia with open reduction and internal fixation and is not discussed in detail here.
Bridge plating principle for the tibia
Patient is positioned supine
Medial proximal and distal approaches
Open reduction and internal fixation of medial malleolus
Fixation with two 2.7 mm screws (18 and 20 mm long)
Open reduction and internal fixation of lateral malleolus (fibula)
One-third tubular plate
Push-pull technique using compression device
Fixation of the posterior malleolus using a 4.0 mm cancellous screw fixed from anterior to posterior