1 Principles topenlarge
In unstable A3-type fracture patterns consider the tibia as having a medial and lateral column. Therefore the medial and the lateral side has to be stabilized when using conventional plates. A large fragment anterolateral plate is supported by a posteromedial small fragment plate.
High degree of medial comminution
If you have a high degree of medial comminution combined with a bad soft-tissue injury do not use conventional plates. This is an indication for the use of the LISS locking plate.
If the LISS plate is unavailable to you then consider a lateral bridge plate plus a medial external fixator (temporary 6 weeks). The disadvantage of the external fixator is the risk of sepsis with the use of periarticular Schanz screws.
In these x-rays the position of the proximal Schanz screw is dangerously close to the joint. The preferred position for this screw is at least 14 mm below the joint line.
This shows the lateral projection.
2 Reduction topenlarge
Place distractor opposite of planned fixation device
For extraarticular tibial fractures (A3-type fractures) the large or femoral distractor may be used during the fixation of the medial or lateral side depending on where the fixation device will be placed. Eg, the distractor is placed on the medial side if the fixation device will be applied onto the lateral side.
3 Fixation topenlarge
Medial Column Fixation
Reduction and fixation of the medial column is obtained by a one-third tubular plate through a separate posteromedial approach.
Lateral column fixation
The lateral side is reduced through a standard lateral approach. Reduction and fixation was obtained with a lateral L-plate 4.5 which functions here as a bridge plate.
The medially applied disctactor may interfere with screw insertion, but the distractor should be kept until both sides are stabilized to prevent loss of reduction.
Removal of medial distractor
The medial distractor should be kept as long as possible and be removed only after application of both plates.