Tibia and fibula, distal: extraarticular multifragmentary distal tibial fracture—43-A3 in combination with a multifragmentary distal fibular fracture

10.1055/b-0034-87665

Tibia and fibula, distal: extraarticular multifragmentary distal tibial fracture—43-A3 in combination with a multifragmentary distal fibular fracture

Apipop Kritsaneephaiboon

Case description

A 46-year-old fisherman was injured by a sling on the right lower leg while working on a ship, sustaining a Gustilo-Anderson type IIIA open fracture of the right distal tibia (43-A3) without neurovascular or tendon injuries.

Indication for MIPO

An unstable fracture of the distal tibial metaphysis is a good indication for plate fixation because the short distal fragment and wide medullary canal make for a more difficult intramedullary nailing surgical technique.

Meanwhile, MIPO is considered a safe option in open fractures after initial wound debridement and stabilization using an external fixator. The procedure is also straightforward especially if the fracture has been well reduced and maintained with an external fixator. However, in this case the soft-tissue condition did not allow for the standard medial or lateral approaches to the distal tibia. The soft tissue on the posterior aspect of the ankle was in good condition so it was planned to apply the plate on the posterolateral aspect of the distal tibia using MIPO technique (see Fig 21.5-4 ).

a Preoperative images of the right lower leg show severe soft-tissue injury with open wound. b–c X-rays show the comminuted fracture at the distal tibia and fibula with displacement.

a–d Postoperative x-rays show the fracture in good anatomical alignment.

Two weeks after sustaining the injury, the soft-tissue condition was satisfactory and bone alignment was good. Definitive treatment by MIPO technique was then undertaken with the external fixator left in place to stabilize the fracture reduction during the operation.

a–c Postoperative soft-tissue condition around the right ankle: medial (a), lateral (b), and posterior (c) views.

Anatomical study of the posterolateral approach to the distal tibia using MIPO technique

The minimally invasive medial and lateral approaches to the distal tibia have been described in the chapter 21.1 Tibia and fibula, distal—introduction. An anatomical study is included here to demonstrate the minimally invasive distal posterolateral approach, including the neurovascular structures.

The flexor hallucis longus (FHL) is recognized by the very distal extension of its muscle belly. It can also be identified by moving the big toe. With sharp dissection of the FHL along its lateral border, the entire posterior aspect of the tibial surface can be exposed by retracting this muscle medially, which also protects the posteromedial neurovascular bundle.

Distal incision: a 2.5 cm skin incision is made between the posteromedial border of the distal fibula and the lateral border of the Achilles tendon. The incision starts from the tip of the lateral malleolus and extends proximally to the distal fibular shaft. It is important to identify the sural nerve and the lesser saphenous vein which are under the superficial fascial layer and are usually included in the lateral flap (see **Fig 21.5-6** ).

Exposure of the posterior aspect of the distal tibia is achieved by separating the interval between the peroneal tendons laterally, and muscles of the FHL medially.

Cross-section of the distal tibia shows the interval plane between peroneal muscles and FHL.

Proximal incision: a 2.5 cm skin incision is made about one fingerbreadth below the posterolateral border of the fibula in the same line as the distal incision.

Exposure of the posterior aspect of the midtibia is started by developing the interval between the peroneal tendons and muscles laterally and the FHL medially. Then, the surgeon makes a sharp dissection of the FHL muscle from the lateral fibula border. The tibialis posterior muscle lies medial to the FHL along the interosseous membrane and is attached to the posteromedial aspect of tibia. The entire posterior aspect of the midtibial surface can be exposed by retracting the FHL and tibialis posterior muscle medially, also protecting the posteromedial neurovascular bundle (tibial nerve and posterior tibial vessels).