1 Principles topenlarge
In B3.3 fractures there is a multifragmentary fracture on the lateral side, associated with a fracture of the posterolateral tibia, and a transverse fracture on the medial side.
As the tibial fractures are intra-articular injuries, they should be fixed anatomically.
It is possible to obtain good access to the posterolateral fracture and fibular fracture through a single posterolateral approach. Direct reduction of the Volkmann's fragment is possible, facilitating anatomic reduction and fixation. This requires the patient to be positioned prone.
Alternatively, the fibular fracture can be fixed through a standard lateral approach and the Volkmann's fragment can be indirectly reduced by dorsiflexing the ankle and then secured with screws inserted through anterior stab incisions.
Order of fixation
In these factures the talus is often unstable within the ankle mortise, so it may be preferable to fix the Volkmann's fragment and fibular fracture through one incision first, then fix the medial side through a medial approach.
If the surgeon prefers to fix the Volkmann's fragment with screws inserted from the anterior surface, this is usually performed after the medial and lateral side has been fixed through two separate approaches. The choice of fixing the medial or lateral side first may be dictated by the surgeon's preference.
Choice of implant – Lateral fixation
As this is a multifragmentary fracture, a bridging plate is the most appropriate method of fixation.
Anatomic plates are available and their lower profile may reduce postoperative discomfort due to prominent hardware. As these plates use locking screws, they may provide more secure fixation in osteoporotic bone.
Choice of implant – Medial fixation
Medial malleolar fractures are usually fixed with lag screws. If the fragment is too small or in poor quality bone, K-wires and tension band wiring may be better.
2 Patient preparation top
Depending on the approach, the patient may be placed in the following positions:
3 Approaches topenlarge
If the direct reduction and fixation of the Volkmann's fragment is chosen, a posterolateral approach is used, both for this fragment and the fibular fracture.
Alternatively, the fibular fracture may be approached directly through a standard lateral approach with additional anterior stab incisions.
The medial fragment is addressed through a medial approach.
4 Fixation topenlarge
As the lateral side in B3.3 fractures is comminuted, these fractures are best fixed with a bridging plate and relative stability.
Fixation of Volkmann's fragment
This may be fixed through direct reduction via a posterolateral approach with lag screws.
If indirect reduction is chosen, sagittal lag screws are inserted through separate stab incisions.
Most medial fractures are fixed with lag screws, which should be inserted perpendicular to the plane of the fracture.
If the fragment is too small or in poor quality bone, K-wires and tension band wiring may be better.
5 Check of osteosynthesis top
Check the completed osteosynthesis by image intensification.
Make sure the intra articular components of the fracture have been anatomically reduced.
Make sure none of the screws are entering the joint. This needs to be confirmed in multiple planes.