Tibia and fibula, shaft: wedge fracture, spiral wedge—42-B1

10.1055/b-0034-87658

Tibia and fibula, shaft: wedge fracture, spiral wedge—42-B1

Chang-Wug Oh

Case description

A 47-year-old woman injured her right lower leg in a motor vehicle accident sustaining an open (Gustilo-Anderson type I) spiral wedge fracture of the tibial shaft.

Indication for MIPO

In this case, conservative treatment would seem to be very difficult as the fracture is highly unstable. The fracture can be treated by applying the principle of relative stability using plating or nailing. Since the fracture is located in the proximal one third of the tibia achieving alignment with nailing is problematic. Plating can easily achieve good alignment. Also many Latin American and Asian patients have a very narrow intramedullary canal. These patients’ tibias require extensive reaming before nail insertion is possible, so MIPO is the best treatment choice for them as it helps to preserve the blood supply to the fracture fragments.

a–b Preoperative AP and lateral x-rays show the spiral wedge diaphyseal fracture of the tibia. c 1 cm wound on the anterior aspect of the leg.

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, the surgical approach, the reduction technique, the most appropriate implants and the steps required in their application ( Fig 20-4.2 ).

Screw number 1 is inserted first to approximate the plate to the bone and ensure the proximal part of the tibia matches the anatomy of the bone at the correct level. The other screws may be fixed alternately proximally and distally. Screw number 5 may be needed to decrease the gap between the butterfly fragment and the main bone fragments. Manual traction is performed to align the diaphyseal fractures in the correct alignment and axis, then cortex screw number 2 is inserted to reduce the bone to the plate. Axis, length, and rotation are verified. The cortical reduction screw is inserted to pull the wedge fragment close to the main fragment. The proximal LHSs (4–7) are inserted. The remaining screws are then inserted.