Plates and Respect for the Soft Tissues: when to use the Ex Fix vs when the fibula is the answer William T. Obremskey MD MPH MMHC Vanderbilt Orthopedic Trauma
• A Pilon fx is a SEVERE soft tissue injury… • The Bones just happen to be broken!!
When to Ex Fix? • You are not Defintive Surgeon!! • Ex Fix and Phone a Friend!
• 55 year old man PMH: neg • engineer Non smoker • fall from ladder • isolated L ankle injury O/E
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Staged Treatment • Blood flow and soft tissue oxygenation are impaired after high-energy plafond fx • When NOT to operate! “UNSAFE” CT angiogram post-injury day 2
When to Ex Fix? • Severe Soft tissue injury
Red Blisters Clear Blisters Open Fracture
When to Ex Fix? • Severe Contamination
When to Ex Fix? • Fibula Fx is distal!
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When the Fibula is the Answer • When Shaft fx and SHORT!
Is Routine Plating of the Fibula Necessary? Retrospective review with two groups – one with fibular plating, the other without • Plating 5/22 fibular wound infections (23%), no tibial infections and 1/22 malunion (5%) – MORE FIBULAR PROBLEMS! • No plate –1/31 tibial infections, 6/31 malunions (19%) • Fix fibula – A few wound problems (none needed an operation) is better than Malunions
When to Ex Fix (only)? • You are not Defintive Surgeon!! – Ex Fix and Phone a Friend! • Severe Soft Tissue Injury • Bad Contamination • Fibula is distal • Fibula not fractured
When to Fix Fibula? • Shaft fx and SHORT • You are definitive surgeon
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