Lateral Plating of SER / Weber B Frx



- 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 in order 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.
- 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.



   

   

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Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Monday, November 26, 2012 3:15 pm