Rockwood Adults CH64

2854

SECTION FOUR • Lower Extremity

B

A

Figure 64-22.  The technique of tension band wiring of the medial malleolus. A: An SER 4 (AO/OTA B2.2) fracture in an 85-year-old woman with osteoporosis. The medial malleolar fragment is small and fragile. B: A long axial intramedullary screw has been placed in the distal fibula to provide stability. The distal end of the plate has been bent to facilitate the placement of this screw. The medial malleolus has been reduced and initially secured with two K-wires placed orthogonally across the fracture. A malleable tension band wire has been placed through the deltoid ligament immediately deep to the K-wires, with the aid of an intravenous cannula, and looped over a proximal screw and washer which was then tight- ened to bone. C: An AP follow-up radiograph at 3 months. Note how the fibular fixation was completed with a triangular construct of distal screws in the metaphysis to maximize pull-out strength. The construct has been strengthened further by passing one screw across the syndesmosis into the tibia. On the medial side the bone fragment was compressed with the TBW and the K-wires were then bent over and hammered into bone.

C