Surgical Discussion

Patient positioning:  The patient was positioned supine on the operating table, with the affected leg prepped and draped in a sterile fashion. A tourniquet was not applied due to the open nature of the injury.

Anatomical surgical approach:  A direct medial approach to the tibia was utilized for debridement and fracture management. The fibular fractures were accessed through separate lateral incisions to allow for direct reduction and fixation. The syndesmosis was addressed through an anterolateral approach to the ankle.

Intraoperatively, after debridement, the stripped tibial fragments were cleaned on the back table and used temporarily for reduction before removal. The distal fibula remained short after clamping, and a positive Cotton test confirmed syndesmotic instability, necessitating fixation of both fibular fractures followed by syndesmotic stabilization. Implant choice was considered carefully, with options including dual plating or a combination of plate and nail constructs. A fine wire frame was deemed suitable for external fixation. Coordination with plastic surgery was planned for soft tissue coverage within 48 hours.

Postoperative protocol:   Postoperatively, the patient was placed in a fine wire frame for stabilization. Weight-bearing was restricted initially, with gradual progression based on clinical and radiographic healing. Early range of motion exercises were encouraged to prevent joint stiffness.

Follow up:   Not specified.

Orthopaedic implants used:   Dual plating for fibular fractures, external fixator (fine wire frame), syndesmotic screw fixation.