Medial Malleolus Fracture Fixation in the Setting of Concomitant Tibial Shaft Fractures
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1 Medial Malleolus Fracture Fixation in the Setting of Concomitant Tibial Shaft Fractures Stephen R. Barchick 1, BA Andrew P. Matson 2, MD Samuel B. Adams 2, MD 1. Duke University School of Medicine, Durham, NC 2. Duke University Health System, Durham, NC
2 Disclosure The authors have no relevant conflicts of interest to disclose.
3 Tibial Shaft Fracture with Concomitant Medial Malleolus Fracture The association between posterior malleolus fractures and concomitant tibial shaft (TS) fractures is well-studied, however less is known about medial malleolus (MM) fracture management in setting of concomitant TS fractures. Treatment of TS fractures with plate or intramedullary nail in setting of MM fractures may pose obstacles to standard MM fixation due to hardware that can impede optimal screw placement for fixation. Aim: 1. Report the presentation and management strategies used to treat MM fractures in the setting of concomitant TS fracture
4 Methods Retrospective Review 7 patients with TS fracture and concomitant MM fractures identified.
5 Patients Age (y) Height (cm) Weight (kg) Sex Tobacco Use Medical History Mechanism of Injury 1 DM, CAD, Fall From F No Tobacco standing (FFS) 2 Motor vehicle M No accident (MVA) M No MVA 4 Tobacco Pedestrian vs M Yes vehicle F No Tobacco FFS M Yes MVA na na F Yes MVA Mean
6 Fracture Characteristics TS fracture MM fracture Open / Closed Fracture Pattern Fragment Size (mm) Fracture Pattern Displacement (mm) 1 Closed Segmental 29.4 Oblique 0 2 Open Transverse 21.9 Oblique Open Transverse 14.4 Transverse, Comminuted Open Transverse 18 Vertical Shear Closed Distal Spiral 14.3 Transverse Open Transverse 17.4 Oblique Closed Transverse 19.1 Transverse 1.4 Mean
7 Simultaneous treatment of TS and MM fractures in 7/7 patients MM Fractures anatomically reduced
8 Technique: Screw Fixation
9 Technique: Plate Fixation
10 Tibial Fixation 1 IMN, distal 2 interlocks, 3 proximal 2 IMN, 1 interlock at each end Medial Malleolus Fixation Method Medial Malleolus # of Screws Screw position relative to nail Complications Screws 1 Anterior none Plate 1 Anterior +posterior none 3 IMN, distal, 2 Screws 2 Medial none interlocks 4 IMN, 1 interlock dis Plate 0 Anterior + Posterior chronic pain 5 Blade plate (previous TKA) Screws 2 n/a superficial wound dehiscence, delayed union of tibia (5.9mos) 6 IMN, 1 interlock Screws 2 Medial none 7 IMN 1 interlock Screws 2 Medial none
11 Average time to union: 3.12 mos. ( mos) Complications in 2 patients 1) Superficial wound dehiscence and delayed union 2) Chronic pain
12 Discussion: MM fixation screws for screw-only or plate fixation can be redirected to accommodate an intramedullary rod in setting of concomitant treatment of MM and TS fractures MM Plate and screw position Distal to nail Screws angled anteriorly, posteriorly, or medially relative to TS hardware
13 Limitations Selection bias Heterogeneous sample Patients Fracture characteristics Incomplete follow-up Future directions Long term outcomes, Comparative studies, Hybrid implants to address both fractures
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