Tibia and fibula, distal: extraarticular unifocal fracture of the distal tibia—42-A1, in combination with a multifragmentary fracture of the distal fibula—44-C2

10.1055/b-0034-87662

Tibia and fibula, distal: extraarticular unifocal fracture of the distal tibia—42-A1, in combination with a multifragmentary fracture of the distal fibula—44-C2

Christoph Sommer

Case description

A 54-year-old man injured his right lower leg in a motor vehicle accident sustaining a fracture of the distal lower leg and ankle. It was a closed fracture (Tscherne grade II) with a soft-tissue injury on the lateral aspect of the leg.

Indication for MIPO

Operative stabilization of the tibia and fibula is advisable due to the probable involvement of the syndesmosis. Intramedullary nail fixation of the tibia may be an option, but the fracture is quite distal which may make nailing difficult. Plate fixation is a good alternative, but precise reduction of the unifocal simple tibial fracture is mandatory. When there are good soft-tissue conditions, classical plate fixation using an open technique is standard, but a more minimal access can prevent wound edge necrosis and healing problems. The multifragmented fibula is best fixed with a bridge plate. The goals of reduction of the fibula in this case are functional alignment with correct length, rotation, and axis in both planes. This could be achieved by an open technique, but a MIPO procedure can be performed to prevent further skin damage to the already traumatized region (Tscherne closed grade II soft-tissue injury laterally). It is advantageous to use an LCP 3.5 or smaller with locking screws in the short distal fragment of the fibula.

a–d Preoperative x-rays show a torsional fracture of the distal diaphysis with extension into the metaphysis (Müller AO Classification 42-A1) and a small nondisplaced posterolateral avulsion fracture of the distal tibia (Volkmann) in combination with a multifragmentary fracture of the distal fibula (Müller AO Classification 44-C2). The medial and lateral clear spaces seem to be normal.

Preoperative planning

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, surgical approach, reduction technique, most appropriate implants, and steps required in its application.

In this case where two fractures require stabilization, it is crucial to decide on the sequence of fixation. In general, the simple fracture should be addressed first and the complex fracture second. Fixing the fibula first is advised only when the fibula fracture is simple ( Fig 21.2-2 ).