Wiki TRIMALLEOLAR FX - HELP!

Kaitbohrer

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AM I RIGHT ON THIS? 27823 MOD 22 + 27829 ?

We started by exsanguinating the limb with an Esmarch bandage and inflating a tourniquet. We made a longitudinal incision over the posterior border of the fibula. We dissected down through subcutaneous tissues, taking care to coagulate any crossing vessels. We identified the peroneal tendon sheath and longitudinally incised this and retracted this posteriorly. We then identified the fracture, which was a higher fibula fracture as this was a Weber C pattern. We then reduced the fracture with a combination of longitudinal traction and lobster claws. Given that this is a higher fibula fracture, the deforming forces on the fracture made this more difficult to reduce unusual, hence the modifier 22 due to the increased time taken to reduce the fracture. Once we were able to get the fracture out to length, this was provisionally held in place with a clamp. We then took biplanar fluoroscopic films, which showed that the length, alignment and rotation of the fibula were well restored. We then applied a 10-hole Synthes 1/3 tubular plate over the lateral aspect of the fibula. We placed three 3.5 mm cortical screws proximal to the fracture with the first being just proximal to the apex of the fracture. We then placed a 2.7 cortical lag screw through the plate and across the fracture, fracture compression across the fracture. We then placed an additional two 3.5 mm cortical screws distally to the fracture. We again confirmed on biplanar fluoroscopy that the length, alignment and rotation of the fracture were well reduced. We also confirmed that the posterior malleolus fragment was a small fragment that had reduced nicely with restoration of the fibular length. The decision was made to treat the posterior malleolus closed.

We then turned our attention to the medial side. We made a longitudinal incision over the medial malleolus. We dissected down through subcutaneous tissues, taking care to coagulate any crossing vessels. The saphenous nerve and vein were protected. We dissected down to the fracture site itself. We then thoroughly cleaned the fracture site with a combination of suction irrigation as well as a pituitary rongeur. Once this was thoroughly cleaned, we reduced the fracture with a dental pick. We confirmed on biplanar fluoroscopy that the fracture was well reduced on the medial side. We then placed 2 guidewires into the medial malleolus, 1 in the anterior colliculus and 1 in the posterior colliculus. Care was taken to ensure that these were extraarticular. We then made an incision over the wire and bluntly spread down to bone. We then drilled over the wire and placed two 4.0 partially threaded cannulated screws. This achieved excellent compression across the fracture. This was confirmed on biplanar fluoroscopy. We then performed a cotton test and there was some residual Taylor instability with a cotton test and so decision was made to fix the syndesmosis. The syndesmosis was reduced under direct visualization with a 2 thumbs technique. This was provisionally held in place with a K-wire. We then placed two 3.5 mm cortical screws tricortically through the plate to hold the syndesmosis reduced. We then took final fluoroscopic images, which showed that the fractures had all been well reduced. We also performed a cotton test, which now showed no residual instability to the syndesmosis. We then thoroughly irrigated the wounds. We closed the fascial layer laterally using 2-0 Vicryl, the subcutaneous layer using 3-0 Vicryl and the skin using 3-0 nylon. We then applied a sterile dressing to the wound including Xeroform gauze, Webril, and placed the patient into a well-padded short-leg splint. The patient was awoken from anesthesia and brought back to PACU in stable condition. All sponge and needle counts were correct at the end of the case.
 
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