Treatment of distal tibial fracture

PREOPERATIVE DIAGNOSIS: Triplane fracture right distal tibia.

POSTOPERATIVE DIAGNOSIS: Triplane fracture right distal tibia.

OPERATIVE PROCEDURE: Closed reduction and screw fixation of right distal tibia fracture.

INDICATIONS: 11 years old and injured her right ankle in a bicycle accident earlier this week. She was found to have fracture involving the distal right tibial epiphysis, which was initially felt to be a Salter-Harris III fracture, Tillaux fracture. Further review of the x-rays demonstrate a metaphyseal fracture of the distal lateral tibia epiphysis, making this a Salter-Harris IV fracture, a triplane variant. She has widening of the ankle mortise medially. The fibula is intact. She is taken to surgery at this time for closed reduction and screw stabilization across the epiphyseal fracture site.

DESCRIPTION OF PROCEDURE: The patient was given a general anesthetic. Tourniquet was not used. I placed a bump under the patient's buttock and the fluoroscope was moved into position. I did initial closed reduction, which restored anatomic ankle mortise. I then had the lower extremity prepared with a Betadine gel scrub and it was draped out freely.

Maintaining the reduction with the ankle in neutral dorsiflexion, I placed a 4.5 cannulated guide pin across the epiphysis, from anterolateral to posteromedial, checking position of the pin to make sure it did not penetrate the joint. I measured the pin and then overdrilled the outer cortex and placed a 46 mm, 4.5 cannulated screw across the fracture, compressing it nicely with the screw. Final x-rays demonstrated anatomic ankle mortise on mortise and lateral views. I felt no further fixation was necessary. I closed the small incision site with two 4-0 nylon sutures, dressed the incision with Bacitracin ointment, 4x4 gauze, followed by sterile Webril and placement of a well-molded short leg plaster and synthetic cast.

The patient tolerated the procedure well. There were no complications. She was taken to the recovery room in good condition postoperatively.

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