Tibia and fibula, distal: intraarticular simple fracture of the distal tibia—43-C1 with multifragmentary fracture of the distal fibula

10.1055/b-0034-87663

Tibia and fibula, distal: intraarticular simple fracture of the distal tibia—43-C1 with multifragmentary fracture of the distal fibula

Christoph Sommer

Case description

A 52-year-old man injured his right lower leg after a fall from a height of over 2 m onto hard ground. The patient was referred to the author‘s hospital 7 hours after injury with marked circumferential swelling. The patient had a serious soft-tissue injury with massive swelling. Preliminary bridging external fixation is applied to treat the soft-tissue condition.

a–b Preoperative x-rays show a simple torsional fracture of the metaphysis of the tibia with extension into the anterolateral part of the ankle joint. There are separate articular fragments at that region (Tillaux-Chaput). The fibula is multifragmented in its distal part. The tibia is shortened and in varus malalignment. Initial stabilization was performed using an ankle-bridging external fixator and this was followed by a CT scan to allow detailed preoperative planning.

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, a (limited) open access through an anterolateral portal is necessary. Using a lateral (extended) approach (Grose, Helfet) both the fibula and (anterolateral) distal tibia can be treated. The long torsional fracture spike extending to the medial diaphysis requires a separate short medial approach at the proximal end of the fracture to obtain correct reduction of this large articular fragment. The application of a second plate medially, functioning as an antiglide plate for additional support, is an excellent solution. This medial plate can easily be inserted using a MIPO technique. The fibula must be precisely reduced. It is best bridged with a long LCP 3.5 or smaller implant. Locking screws in the short distal fragment of the fibula are of great advantage.

a–e The CT scans after application of an ankle bridging external fixator demonstrates the joint involvement at the anterolateral region and the displaced complex distal fibular fracture. Furthermore, it shows a large medial fragment of the distal tibia, involving more than 80% of the articular surface. In addition an asymptomatic old talar flake is visible medially.

Preoperative planning

The timing of definitive surgery is crucial. Usually it takes 7–10 days after initial injury for the soft-tissue swelling to reduce. 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 ( Fig 21.3-3 ).

In this case where two fractures need to be stabilized, it is crucial to decide the sequence of fixation. In general, the simple fracture should be addressed first and the complex fracture second. The rule of fixing the fibula first is advised in simple fractures only. In this situation, with a complex fibular fracture, it may be better to start with the tibia and finish with the fibula. Reducing and fixing the large main medial articular fragment with proximal extension first with a medial antiglide plate effectively converts this Müller AO Classification 43-C fracture pattern into a 43-B fracture pattern, simplifying the anterolateral articular reconstruction of the tibia.