The patient has a two year old non-infected non-union of the distal tibia after an open fracture. Factors to consider when planning treatment include systemic and local conditions.
Systemic conditions that should be considered include the patients age, smoking status, nutritional status, medical problems, and patient expectations. Local conditions to consider include skin condition, infection status and history, bone density, limb alignment, vascular status of the limb, vascular status of the nonunion, limb function, and distal fragment size. This patient was a non-smoker, had no additional medical problems, had reasonable expectations, and good nutritional status. The skin and local tissues were in good condition ankle motion was near normal. There was no history of infection. The limb was in varus and the distal fragment was small.
A radiograph of the contralateral extremity was obtained. A tracing of this radiograph was made and used as a template for correction of the varus deformity.
Transarticular fixation methods (external and internal fixation) would have resulted in loss of the ankle and subtalar motion. This was not acceptable in a patient with near normal pre-operative function. The small distal fragment precluded antegrade nailing. Small wire fixation of such a small distal fragment would have necessitated transarticular extension of the frame and loss of joint motion. ORIF would include take down of the nonunion, deformity correction, and bone grafting. ORIF would preserve ankle and subtalar motion and had few risks in this patient. ORIF with a lag screw and plate after take down of the nonunion, deformity correction, and bone grafting was chosen as the optimum treatment method in this particular patient.
But which plate? The main problem is fixation in the distal fragment. Adequate fixation with the narrow or broad 4.5mm DCP in a small osteopenic distal fragment is very difficult. A cannulated blade plate was chosen to increase the fixation in the distal fragment. While designed for the proximal humerus it can be bent to fit the distal tibia without much difficulty.
The deformity was corrected on the pre-operative plan and fixation with a blade plate was drawn in. The pre-operative plan determined that in order to obtain a long enough plate the blade would have to be shortened.