Tibia and fibula, distal: intraarticular complex fracture of the distal tibia—43-C3 with multifragmentary fracture of the distal fibula

10.1055/b-0034-87664

Tibia and fibula, distal: intraarticular complex fracture of the distal tibia—43-C3 with multifragmentary fracture of the distal fibula

Christoph Sommer

Case description

A 46-year-old man injured his right lower leg in a motor vehicle accident and sustained a complex intraarticular pilon fracture. There was a small anterolateral wound (Gustilo-Anderson type I) and medially marked initial swelling. The patient was initially managed in a small hospital, where an ankle bridging external fixator was applied after irrigation of the wound. On day 5 postinjury he was transferred to the author‘s institution.

Indication for MIPO

Operative stabilization of the tibia and fibula is mandatory in this case. To achieve the goal of anatomical reduction and stable fixation of the articular part of the tibia, open reduction using direct and indirect maneuvers is necessary (limited ORIF). To minimize the soft-tissue damage, multiple short incisions can be made to reach the articular key fragments and percutaneously insert plates for bridging the metaphysis (partial MIPO). To minimize additional soft-tissue injury, a MIPO technique for application of a bridge plate to the comminuted fibular fracture may be a good alternative to classical ORIF.

a–l Three-dimensional and two-dimensional CT scans on day 5 postinjury (with external fixator from tibia-calcaneus-midfoot) show the mutlifragmented articular surface of the distal tibia (six fragments). The medial malleolus is fractured into three pieces. The fibula is also comminuted. This fracture pattern could be addressed by an anteromedial articular approach to the tibia and a second posterolateral approach to the fibula, but the soft-tissue condition (see **Fig 21.4-2** ) must be considered before a definitive decision can be made. Three-dimensional and two-dimensional CT scans on day 5 postinjury (with external fixator from tibia-calcaneusmidfoot) show the mutlifragmented articular surface of the distal tibia (six fragments). The medial malleolus is fractured into three pieces. The fibula is also comminuted. This fracture pattern could be addressed by an anteromedial articular approach to the tibia and a second posterolateral approach to the fibula, but the soft-tissue condition (see **Fig 21.4-2** ) must be considered before a definitive decision can be made.

a–c Appearance of soft tissues upon the patient‘s arrival at the author‘s hospital. A small, clean wound can be seen anterolaterally (b). Hemorrhagic fracture blisters medially prohibit a formal anteromedial approach.

Preoperative planning

The timing of definitive surgery is crucial. It usually takes between 7–10 days from the initial injury for the soft-tissue swelling to settle down. The skin should start to wrinkle.

Once a decision has been made that the case is suitable for (at least partial) 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 surgical approach, the reduction technique, the most appropriate implants, and the steps required in its application.

In this case where two fractures need to be stabilized, it is crucial to decide the sequence. In general, the simple fracture should be addressed first and the complex fracture second. The rule of fixing the fibula first is advised only when the fibular fracture is simple. In this situation, with a complex fibular fracture, it may be better to start with the tibia and finish with the fibula ( Fig 21.4-3 ).

As with all complex pilon fractures, it is also important to consider the main approach needed for articular reconstruction. This decision must be based not only on the fracture pattern, studied in detail on the CT scan, but also on the soft-tissue conditions. In this case the fracture anatomy would lead the surgeon to plan an anteromedial approach, however, the fracture blisters in this precise region prevent a large incision there. Therefore, an anterolateral main approach is chosen for joint reconstruction and application of an anterolateral plate. This plate can be fixed at the diaphysis by percutaneously inserted screws (partial MIPO), in combination with a small separate incision for the medial malleolus. The fibula may be reduced and fixed by a posterolateral approach using an ORIF technique, but this may be risky when using an anterolateral approach for the tibia (small skin bridge). A MIPO technique for the fibula may be preferable.