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37 yo male fell during bad snow storm. Fibula was badly fractured with large butterfly fragment due to double spiral. Medial and posterior malleoli fractured as well but not comminuted.
We typically dissect out posterior mall, then move to fibula, restore length and fixate, then back to post mall to reduce and fixate. Always avoid over dissecting posterior malleolus. Only make small incision at top of fracture line to avoid compromising PITFL and blood flow to posterior tibia. To make the large fragment at the posterior fibula sturdy before we could restore length, we used a small cannulated screw. Once 3 pieces became 2, we then used a huge Inge lamina spreader (in neuro sets). Our typical spreaders would not span the fragment. Once we used this to restore length, we plated underneath/in front of PB muscle belly, sliding plate under perforators. Used ball spike pusher, and Hintermann for Post mall.
Nothing really that remarkable about this case except the fact that the anterior colliculus fracture was the hardest part of this tri-mall to reduce. Getting the posterior mall, and the fibula out to length were simple with a Hintermann, despite the comminution at the lat malleolus. However, once we flipped the patient supine, it took the same time supine as it did prone. When we started to reduce the colliculus it would want to rotate. Maybe in hindsight a small hook plate would be helpful? If you look closely at the lateral you can see the posterior aspect of the colliculus fracture is not perfectly reduced. We elected to use a single 3.0 screw as that’s all we could squeeze in....
41 yo male with unremarkable pmhx aside from smoking 1/2 PPD. Is 6 wks out from Nanoscope, deltoid and ATF/CF ligament repair with Internal Brace x 2, and Fibertaks x 2.
Patient jumped off tall trailer at work ~10 months ago causing distal tib contusion, small non-displaced OLT, and severe sprains to deltoid, and lateral collaterals. We treated the patient with cast immobilization due to severe tenderness. He was then in a walking boot until 10 weeks, a lace-up brace, and PT. At ~7.5months patient was still having what he figured was unacceptable pain. Tricky because this was Workman’s comp. We repeated MRI; contusion gone, & chondral defect hardly noticeable, but ligaments both medial & lateral still edematous, & showed chronic attenuation/disruption.
At this point arthroscopy, direct deltoid & lateral collateral repair was recommended.
At this 6 week follow up he’s doing very well. He is getting transitioned to shoe with lace-up brace, and PT at 8th week. He is swollen & a little weak, but pain free medially, and laterally, for first time in a long time to him.
Many Modified Bröstrum’s get performed everyday across the country, and account for the lion’s share of ankle ligament repairs. Inversion ankle sprains are #1 most common orthopedic injury seen in the ED, yet the amount of times the deltoid component is even considered I think maybe under addressed? This is the 4th deltoid I’ve repaired as sequelae from a bad sprain in 2.5 months. Each patient had different story. 1 pt’s initial trauma was over 3 years old (with previous scope & Bröstrum from another provider), but each had chronic residual medial ankle pain that never improved. Each patient including my own was told it’ll eventually resolve on its own....
Story as old as time.... 30 yo male falls off ladder from 9ft.
1 ppd smoker.
Fortunately lumbar and hip imaging negative.
Half of the posterior facet was incarcerated in the calcaneal body. Following the schanz pin shake we used elevators to hoist and rotate superior, and posterior, the facet back to alignment.
(Böhler’s angle was 10 degrees. Radio called it minimally displaced)
Sinus tarsi approach in lateral decubitus position is the way we do it. Minimal skin healing issues and to date have not met a fracture that deserved lat extensile. If its truly that comminuted then its an arthrodesis for us. Patient doing well so far...All get arthritis, but how much can we minimize it?
Early active ROM NWB to prevent excessive stiffness is important, we think....