Tibia and fibula, proximal: metaphyseal simple fracture—41-A2
Case description
A 44-year-old man injured his right leg in a ski accident sustaining a closed proximal tibial fracture. The fracture consisted of an intraarticular fracture with a minimally displaced vertical split component between the medial and lateral condyles and an extraarticular wedge fracture. This fracture is classified as 41-C1, however, with fixation of the nondisplaced intraarticular component, the fracture can be converted into a 41-A2 ( Fig 19.2-1 ).
Initial management
The patient was transferred from another hospital 3 days after injury in a long-leg splint. The x-rays taken 3 days after injury showed no significant further displacement. Clinically the swelling was moderate. The leg was elevated and the operation performed 7 days after injury when the soft-tissue condition was optimal. A temporary bridging external fixator could have been used to facilitate the recovery of the soft-tissue and to maintain length and alignment.
Indication for MIPO
Operative treatment is mandatory as the metaphyseal fracture plane is in the oblique coronal plane, causing instability from the traction force coming from the patellar tendon. Intramedullary nailing is not recommended because of the intraarticular fracture. Both conventional open reduction and MIPO with plate fixation can be performed. Because significant muscle stripping is involved when open reduction is performed, MIPO seems to be the better option. As the size of the proximal fragments seemed to be long enough to place at least five 5.0 mm locked screws from the lateral side, a unilateral locked plating with LCP-PLT is planned.
Preoperative planning
Step 1: Articular reconstruction. The focal depression on the lateral plateau was not in the weight-bearing area and therefore surgical elevation is not needed. Percutaneous direct reduction of the split component and a subchondral raft of 3.5 mm cortex screws are planned—the screws to be placed so as to support the depressed area ( Fig 19.2-2 ).
Step 2: As the metaphyseal component is a long oblique fracture and located in the oblique coronal plane, metadiaphyseal reduction is achieved by percutaneous direct reduction using a collinear reduction clamp. To secure reduction and not to obstruct the C-arm view during the operation a lag screw is applied as a reduction screw to hold the oblique fracture ( Fig 19.2-2d ).
Step 3: Plate application. Once the articular and metaphyseal oblique fractures are reduced and fixed, submuscular plating can be easily performed as the reduction is maintained with these screws. The preoperative plan for the sequence of screw placement for plate fixation is shown in Fig 19.2-2e .
Operating room setup
Anesthesia
General anesthesia is administered.
Patient and image intensifier positioning
The patient is positioned supine on a radiolucent operating table. A roll is placed under the buttock. The uninjured leg is placed in neutral rotation on the operating table. Alternatively the uninjured leg may be placed on a leg holder with the hip and knee flexed around 90°. The knee of the operated side is supported in 30° flexion. A sterilized tour-niquet is prepared if required.
The image intensifier is placed at the side of the uninjured leg so that the surgeon can see the monitor screen during the procedure ( Fig 19.2-3 ).
Surgical approach
An anterolateral approach for proximal tibia is used.
Reduction and fixation
Articular reduction
The vertical split between the medial and lateral condyles is reduced percutaneously with a pointed reduction forceps ( Fig 19.2-4 ).
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