University Center of Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany.
Orthopedic Department of First Faculty of Medicine, Charles University and Central Military Hospital, Prague, Czech Republic.
Oper Orthop Traumatol. 2021 Apr;33(2):125-138. doi: 10.1007/s00064-021-00703-0. Epub 2021 Mar 22.
The anterior tibial rim with the anterolateral tibial tubercle provides attachment to the anterior tibiofibular syndesmosis. It may be considered an anterior or "fourth" malleolus. Fixation of a displaced anterior tibial fragment in the treatment of malleolar fractures aims at providing a bone-to-bone fixation of the anterior tibiofibular ligament and restoring the integrity of the tibial incisura.
Displaced intra-articular fragments of the anterior tibia; fractures involving the tibial incisura; fractures with intercalary fragments; impaction of the anterior tibial plafond; syndesmotic avulsions producing instability or preventing reduction of the distal fibula into the tibial incisura.
Critical local soft tissues preventing an anterolateral approach; missing consent to surgery by the patient; overall critical general condition preventing surgery to the extremities.
Anterolateral approach over the tibial tubercle. Identification and mobilization of the anterior tibial fragment without dissecting the anterior syndesmosis. Reduction of the anterior tibial fragment with a pointed reduction clamp. Fixation of extra-articular avulsion fractures (type 1) with suture anchor. Screw fixation of larger fragments involving the joint surface and incisura (type 2). Disimpaction, realignment of the joint surface, bone grafting as needed and plate fixation of impaction fractures of the anterolateral tibial plafond (type 3).
Mobilization with partial weight bearing (15-20 kg) in a special boot (ankle foot orthosis) or cast for 6-8 weeks depending on the overall malleolar fracture pattern, bone quality and patient compliance.
Few studies report the results of anterior tibial fractures in adults. Failure to fix displaced fragments frequently leads to nonunions. Overlooked Chaput fractures have been reported to result in malpositioning of the distal fibula in the tibial incisura leading to incongruity of the ankle mortise requiring revision surgery. Secondary avascular necrosis of the anterolateral tibial plafond may develop after joint impaction.
胫骨前嵴和前外胫骨结节为前胫腓联合提供附着点。它可以被认为是前踝或“第四踝”。治疗踝部骨折时固定移位的胫骨前骨块，旨在实现前胫腓韧带的骨对骨固定，并恢复胫骨切迹的完整性。
胫骨前关节内骨折块移位；累及胫骨切迹的骨折；伴有中间骨块的骨折；胫骨前嵴压缩；导致不稳定或妨碍腓骨远端嵌入胫骨切迹的联合撕脱。
局部严重软组织条件妨碍前外侧入路；患者不同意手术；全身严重状况不允许进行四肢手术。
胫骨结节前外侧入路。在不解剖前联合的情况下识别和移动胫骨前骨块。使用尖复位钳复位胫骨前骨块。关节外撕脱骨折（1 型）用缝线锚钉固定。较大的关节面和切迹内骨折（2 型）用螺钉固定。关节面复位、需要时骨移植和胫骨前嵴前外侧压缩骨折的钢板固定（3 型）。
根据总体踝部骨折模式、骨质量和患者依从性，使用特殊靴（踝足矫形器）或石膏部分负重（15-20kg）进行早期活动，固定 6-8 周。
少数研究报告了成人胫骨前骨折的结果。未能固定移位的骨折块常导致骨折不愈合。Chaput 骨折漏诊可导致腓骨远端在胫骨切迹中的错位，导致踝关节腔不匹配，需要进行翻修手术。关节撞击后可能会发生胫骨前嵴前外侧骨坏死。
