- Discussion:
- when the frx is sufficiently oblique & is not comminuted, it can be treated w/
a
lag screw to produce intrafragmentary compression, and neutralization plate
placed laterally to prevent frx from slippling;
- disadvantages of lateral plating:
- prominent lateral screws may cause symptoms or wound necrosis;
- possibility of distal intra-articular screw insertion, and on the contrary,
there is the possibility of inadequate fixation if distal screws are too short;
- may not allow adequate fixation in osteoporotic bone;
- may interfere w/ syndesmotic screw insertion (especially when two syndesmoic
screws are to be used);
-
preoperative considerations:
-
fracture dislocations of the ankle
-
open ankle fractures:
-
trimalleolar frx (
posterior malleolar frx);
-
syndesmotic injury:
- consider ahead of time how and where the syndesmotic screw(s) will
transverse the plate;
-
alternattive fixation techniques:
-
fixation w/ two lag screws:
-
posterior antiglide plate:
- supplemental K wire fixation:
- w/ significant osteopenia, there may be a higher incidence of hardware failure;
- consider use of preliminary 0.62 K wires which are inserted from the tip
across the frx to penetrate the medial cortex of the proximal fragment;
- one wire is placed anteriorly and one is placed posteriorly inorder to
allow insertion of plate screws between the K wires;
- the distal exposed K wires are bent and cut;
-
ref: A new technique for complex fibula fracture fixation in the elderly:
a clinical and biomechanical evaluation.
Koval et al. J. Orthop. Trauma. Vol 11(1): 28-33, 1997. Jan.
- Operative Technique:
- patient position:
- supine,
tourniquet, hip bump to internally rotate the leg, and pelvic strap to
allow tilting of table if needed;
- flouroscopy is required if there is a
syndesmotic injury or if there is
extensive comminution (so that reduction of fibula can be judged based
on the congruency with the talus);
-
medial malleolus fracture:
- should be fixed first because the anatomic reduction is easy, and helps guide
the
reduction of the fibulur frx;
-
4.0 mm cancellous bone screws, or 4.0-4.5 mm cannulated screws are used for
fixation of medial malleolus & posterolateral tibial fragment;
- alternatively use K wires, 1.6 mm diameter, and 1.2 mm cerclage wires
for tension band wiring of the medial malleolus;
- exploration of ankle joint:
- need to look for
osteochondral fragments;
- after exposure of frx & anterior surface of fibula, joint is explored;
- this should be repeated during the approach to the lateral malleolus;
-
lateral malleolus frx
-
3.5 mm cortex screws are used as
lag screws in oblique fractures of the fibula;
- screws must engage posterior cortex for secure fixation but should not
protrude far enough to encroach on peroneal tendon sheaths;
-
one third tubular plate is applied to the lateral malleolus, using 3.5 mm cortical
screws proximally and 4.0 mm cancellous screws distally;
-
surgical approach of lateral malleolus:
-
fracture reduction:
-
comminution:
- w/ extensive comminution is can be difficult to achieve reduction and
it is difficult to know when the frx is out to length;
- failure to restore normal length & rotation of fibula often leads
to a poor result;
- fibula is brought out to length and the reduction is judged based
on the congruency of the distal fibula w/ the talus;
- provisional K wire is placed from fibula into talus or into tibia to
hold the reduction;
- plate is contoured to span the area of comminution;
-
bone graft is applied if necessary;
-
plate position
-
plate contouring:
- plate must be contoured to accommaodate lateral fibular bow to prevent
medial displacement of frx or excessive compression of the mortise;
-
plate application:
- see:
bone healing w/ plates
-
one third tubular plate is applied to lateral (or
posterolateral) fibular surface and is held w/ a bone holding clamp;
- plate is secured w/
3.5 mm cortex screws proximally and
4.0 mm cancellous screws distally;
- it is usually possible to place 2 or 3 screws distal to frx and 3 screws
proximal to the fracture;
- distal screws should engage the medial cortex of the fibula but not protrude
into the fibulotalar joint;
- there is no reason, however, to grossly undersize these screws;
-
wound closure:
- attempt to cover plate w/ periosteum and/or the superficial fascia;
- take care not to pass sutures into the peroneal tendon sheath since
this will lead to postoperative peroneal tendinitis;
The Dorsal Antiglide Plate in the Treatment of Danis-Weber Type-B Fractures
of the Distal Fibula.
Rush rods versus plate osteosyntheses for unstable ankle fractures in the elderly.
*** 
