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