This is another example of a distal tibia fracture.
These were the injury xrays:
Clearly shortened leg, some translation, but alignment really wasn't that terrible. With many closed tibia shaft fractures, treatment with a cast is often all that is needed.
However, this was not simply a closed well-aligned tibia fracture.
In addition to the shortening, if you look carefully at the lateral malleolus, you can see that the fracture reaches the distal articular surface. Casting might have been OK, but not ideal. In addition, her entire leg skin was damaged and thin from burns she had sustained earlier in the year. A cast sometimes can be problematic over fragile skin.
To top it off, she was in too much pain and she developed compartment syndrome.
Last but not least, as of early 2012, I had already treated quite a few of these very distal fibula and tibia fractures, very similar to this one, with the same implant choice: nail on the tibia and plate on the fibula. All did well, with excellent outcomes and rather speedy recovery. I feel very comfortable with the treatment method.
For all the above reasons, she was treated surgically.
The appearance in the oblique xray projection above suggested extension of the tibia fracture into the ankle, and insertion of a nail could displace the pilon fracture. A CT scan was done while still in the emergency room. Here are the slices at the level of the ankle:
The CT shows indeed extension into the pilon. In addition, the lateral malleolus comminution and displacement at the articular level is confirmed.
In addition to the fasciotomies, the decision was made to perform a lateral approach to the ankle, reduce anatomically the articular surface of the fibula, and bridge-plate the metaphyseal comminution. It turned out that reduction of the main lateral malleolar fragment to the anterior smaller piece resulted in anatomical and stable syndesmosis. The tibia was treated with closed reduction and nail after stabilization of the distal articular surface with two separate screws inserted from the lateral incision.
Plating the tibia would have been an option, but plating would have been more invasive and the plate is a bit more prominent than the nail and can be felt under the skin.
She was treated with a VAC sponge and by the end of the week the fasciotomy wounds were closed. A splint was not placed, and range of motion was started early. She healed all the wounds well. Weight bearing was allowed at the 2 month point.
The following xrays were done 3 months after the injury. The fracture has already healed, with the patient walking without pain, without limp, and happy as can be.
Here is a brief video done at the 3 month appointment: