Intra-articular Fractures of Distal Tibia & Ankle...Fibula -Locking plate Posterior Tibia –VLP 2nd...
Transcript of Intra-articular Fractures of Distal Tibia & Ankle...Fibula -Locking plate Posterior Tibia –VLP 2nd...
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Intra-articular Fractures of Distal
Tibia
Aradhyula N Murty
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Starting point
• Difficult
• Initial injury determines outcome
• Infection and wound healing
• Stiffness and loss of function
• Unhappy patient
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Principles
• Span
• Scan
• Plan
• Anatomical reduction
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Span
• External fixator
• Two pins in tibia
• 2 distal to the ankle
• Foot plantigrade
• Distract
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Scan
• When in doubt : scan
• Reconstructions
• Workstation
• Review scan prior to surgery
• Have scan available in theatre
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Plan
• Fracture pattern
• Approaches
• Soft tissues
• Stages-Timing
• Implants
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Implants
Synthes
Medial
lateral
Pilon plate
Fibula
Locking plate
Post fixation
SN VLP
Circular Frames
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Approaches
• Fibula
• Tibia• Anterior through EHL
• Med to TIB Ant
• Medial
•Posterolateral
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Fracture Pattern
• No fibular Fracture
• Fibular Fracture : Weber A
• Fibular Fracture High
• Diaphyseal extension
• F*********
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No Fibular Fracture
• Easy
• Span (Percuataneously reduction)
• Scan
• 2-3 weeks fix
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contd
• Anterior approach
• EHL
• Open the book/reduce/ineterfragmentary
• Plate
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Anterolateral approach
• Longitudinal incision over lateral tibia, 3rd/4th
metatarsals
• Superficial peroneal n
• Incise ext retinaculum
• EHL
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Fibular fracture -A
• Easy
• ? Spanning
• CT
• Timing ?
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Anteromedial approach
• Incise retinaculum
• Retract tib ant laterally
• Saphenous bundle
• Deep peroneal nerve and ant tibial artery between EHL and EDL
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Weber A
• Anterior approach/ Tib Ant
• Open Medial Malleolus/Reduce
• Buttress plate
• Fibula - Cancellous screw (compression )
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High Fibula
• SPAN
• SCAN
• PLAN
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PLAN
• Is there Diastasis
• Is there a posterior fragment
• What is the level of the fibular fracture
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Keys
• Anatomic reduction of fibula- Not just length
• Reduction of posterior fragment –template
• Staged reconstruction-soft tissues
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Implants
• Satge 1
Fibula - Locking plate
Posterior Tibia – VLP
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2nd stage
• 2-3 weeks
• Anterior approach
• Bone graft
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Post op
• POP for 2 weeks
• ROM exercises - at 2weeks
• ROS 2-3/4 weeks
• Wt bearing delayed to 10-12 weeks
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Not all go well
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What i have learnt
• Some are more difficult
• Most do well in the short/medium term
• Infection and soft tissues problems are no
more common than most surgeries
• Functional outcome satisfactory
• Pts are as unhappy as any other patient.