Abstract
Percutaneous plating of the distal tibia via a limited incision is an accepted technique of osteosynthesis for extra-articular and simple intra-articular distal tibia fractures. In this study we identify structures are risk during this approach.
Method
Thirteen unpaired adult lower limbs were used for this study. Thirteen, 16-hole synthes®LCP anterolateral distal tibial plates were percutaneously inserted according to the manufacturer instructions and confirmed by xray. Dissection was performed around the plate to examine the relation of nerves and soft tissue.
Results
The neurovascular bundle was under the plate in one case. Over the horizontal limb of the plate, typically the superficial peroneal nerve had a variable course over all four screw holes. The anterior tibial artery coursed over hole number 3 and the Extensor hallucis longistendon was positioned over hole 3 or 4. The Anterior tibialis tendon skirted hole 4 in 12 cases. Over the vertical limb of the plate, the neurovascular bundle coursed over holes, 5 to 7, the superficial peroneal nerve over holes 5 to 7.
Discussion
Meticulous attention is required when placing an anterolateral distal tibia plate using a MIPO technique. We recommend a larger initial incision to avoid entanglement of the superficial peroneal nerve under the plate. Over the anterior aspect of the tibia, an open technique with adequate neurovascular structure and tendon protection is necessary due to the variability of structure coursing over the plate. A bridging technique for placement of proximal locking screw should be made through a mini open incision and this is safe to do so proximally over holes 12 to 16. Caution is advised during placement of screws percutaneously from holes 1 to 12 however the neurovascular bundle courses commonly over holes 5 to 7. These landmarks also apply to the use of shorter anterolateral distal tibial plates.
