Surgical Discussion

Patient positioning:  Supine

Anatomical surgical approach:  Limited anteromedial longitudinal approach over the fracture curving slightly posteriorly over pes. Incision ~7cm

Location of the fracture was immediately distal to the pes insertion suggesting the external valgus forced had loaded against an adduction / varus constraint provided by both the MCL and hamstrings. Both the distal aspect of the superficial MCL together with distal fibres of pes and periosteum were incarcerated in the fracture preventing reduction. Removal of interposition facilitated correction of the slight rotational deformity, together with correction of valgus. The fracture was lagged ML with 2 3.5mm cortical screws, then neutralised with a 3.5mm LCP locking plate. The plate was pre contoured to not actively influence the now anatomically restored native long axis. The plate was placed anterior to pes as posterior placement under the hamstrings would have been off-axis to counter any valgus collapse. The most proximal screw was kept monocortical below the level of the physis. The MCL was considered clinically stable. No adjuvant fixation of MCL was done

Postoperative protocol:   No splint during the day, and TWB for 4 weeks. PWB from week 5 progressing to FWB by week 6 post.

Orthopaedic implants used:   3.5mm Synthes LCP locking plate