4. The lateral radiograph demonstrated significant impaction
of the anterior articular surface (arrows).
5. The CT scan identifies the major posteriomedial fragment
as well as the displaced anterolateral fragment and the void from
where the impacted articular segment was displaced.
6. ANTEROLATERAL
FRACTURE
ARTICULAR VOID
FROM IMPACTION
The CT scan identifies the major posteriomedial fragment
as well as the displaced anterolateral fragment and the void from
where the impacted articular segment was displaced.
7. Surgery for the plafond fracture is always deferred until the soft
tissue injury appears to be resolving. In this case, a standard
anteromedial incision is chosen, which is placed medial
to the palpable tibialis anterior tendon.
8. Surgery for the plafond fracture is always deferred until the soft
tissue injury appears to be resolving. In this case, a standard
anterolateral medial incision is chosen, which is placed medial
to the palpable tibialis anterior tendon.
JOINT LINE
MEDIAL
MALLEOLUS
TIBIALIS
ANTERIOR
9. It is important when performing this approach that the tendon
sheath not be violated and that the incision is medial enough
to the sheath to protect it in its entirety.
JOINT LINE
MEDIAL
MALLEOLUS
TIBIALIS
ANTERIOR
10. The incision is brought down directly to bone medial to the tibialis
anterior tendon sheath, which is within the soft tissue sleeve. The
impaction of the anterior articular surface leaves a large void
adjacent to the talar articular surface.
11. The incision is brought down directly to bone lateral to the tibialis
anterior tendon sheath, which is within the soft tissue sleeve. The
impaction of the anterior articular surface leaves a large void
adjacent to the tail of the articular surface.
IMPACTED
FRAGMENT
TIBIALIS ANTERIOR
WITHIN SOFT TISSUE
VOID ABOVE
JOINT
12. A no-touch technique is utilized with self-retaining retractors,
allowing access to the intraarticular displacement. The two
articular fragments, including the impacted articular fragment,
are visible with medial retraction of the plafond.
13. A no-touch technique is utilized with self-retaining retractors,
allowing access to the intraarticular displacement. The two
articular fragments, including the impacted articular fragment,
are visible with medial retraction of the plafond.
ARTICULAR
FRAGMENT
IMPACTED
FRAGMENT
14. A no-touch technique is utilized with self-retaining retractors,
allowing access to the intraarticular displacement. The two
articular fragments, including the impacted articular fragment,
are visible with medial retraction of the plafond.
15. A no-touch technique is utilized with self-retaining retractors,
allowing access to the intraarticular displacement. The two
articular fragments, including the impacted articular fragment,
are visible with medial retraction of the plafond.
16.
17. The impacted articular surface, which is easily visualized on
the lateral radiograph must be reduced down to the normal
position of the joint.
18. This is normally performed by placing a curved
osteotome above the attached cancellous bone of the
articular segment and forcefully manipulating the
fragment distally against the talus as a template.
19. The curved osteotome is reducing the impacted
articular fragment down against the talus
IMPACTED FRAGMENT
CURVED
OSTEOTOME
20. BONE
TAMP
A bone tamp can be used to support the articular surface against
the talus while fixation is performed, typically with a lag screw
or push plate.
21. The joint is now well reconstructed anteriorly and medially.
A lag screw has been used to fix the anterior impacted
fragment and a medial push plate has been used to support
the anteromedial cortical rim.
22. The joint is now well reconstructed anteriorly and medially.
A lag screw has been used to fix the anterior impacted
segment and a medial push plate has been used to support
the anteromedial cortical rim.
PLAFOND
TALUS
MEDIAL
PUSH PLATE
LAG SCREW
23. The joint is now well reconstructed anteriorly and medially.
A lag screw has been used to fix the anterior impacted
segment and a medial push plate has been used to support
the anteromedial cortical rim.
24. The joint is now well reconstructed anteriorly and medially.
A lag screw has been used to fix the anterior impacted
segment and a medial push plate has been used to support
the anteromedial cortical rim.
PLAFOND
TALUS
MEDIAL
PUSH PLATE
LAG SCREW
25. After reduction of the impacted articular segment, several small
fragments of bone, including cortical fragments and another articular
segment, were removed from between the impacted articular surface
and the anterolateral fragment.
26. A pointed reduction clamp will then be used to reduce the
anterolateral fragment to the reconsrtructed anteromedial
portion of the joint, which has been reconstructed. A
percutaneous screw and an anterolateral push plate is
then used to support the reduction.
27. The reduction is anatomic and supported with two low
profile plates, one medially and one anterolaterally.
TALUS
TIBIA
AL FRAGMENT
28. The reduction is anatomic and supported with two low
profile plates, one medially and one anterolaterally.
30. Closure is performed in layers, being careful to protect the
tibialis anterior paratenon and soft tissue sleeve. The closure
should be performed with vertical mattress sutures of Danati
without tension. If any tension is present, relaxing incisions or
pie-crusting technique should be utilized.
31. AP and lateral radiographs demonstrating good
alignment and fixation of the plafond fracture.
