Mason and Molloy 2B Posterior Malleolar Fracture with Posteromedial die punch
Score and Comment on this Case
Clinical Details
Clinical and radiological findings: Fracture Type - Lauge Hansen – SER 4 Mason and Molloy – 2B AO – 44B3.3 Soft -Tissue - Closed fracture Tscherne – C1 Specific Problems - Oblique fibular fracture. Type 2B PM fracture, with large 2B and small 2A fractures.
Preoperative Plan
Planning remarks: The 2B fracture pattern needs medial access to allow PM reduction first. Additionally, there was a small die punch fragment posteromedially. The fibular could be approached through posterolateral or direct lateral position.
Surgical Discussion
Patient positioning: Recovery position.
Anatomical surgical approach: Lateral and medial posteromedial
Operative remarks:My approaches were planned to allow easy reduction and fixation of the fibular through a direct lateral approach. Needing access to the PM and PL fragments the interval between tibialis posterior and FDL was most sensible. This also allowed access to the die punch fragment.
The MPM approach allowed me to open the fracture planes and attempt reduction of the die punch fragment. The PM fragment was then reduced which was initially K wired in position. The PL fragment was then reduced and K wired in position. The 2B plate was applied to provide lateral and anterior compression ensuring the tibialis posterior was not impinged. X2 screws were used to fix the PL fragment to give compression and stop rotation
The fibular was reduced and I was able to lag before plate application. The syndesmosis was screened and was stable.
Postoperative protocol: 2 weeks NWB in a back slab. Conversion to Vacuum cast boot at 2 weeks to allow full weightbearing. Wean out of boot at 6 weeks.
Orthopaedic implants used: Volition (Orthosolutions)
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User Discussion (1)
Dr Ed Oates
Impeccable fixation. The posteromedial plate looks like it was poured on.