Abstract
INTRODUCTION: Trifocal, non-contiguous, ipsilateral tibial fractures involving the plateau, diaphysis and ankle are extremely rare, with limited literature to guide their optimal surgical management. These complex injuries demand a strategic approach to achieve stable reduction and fixation, maintain implant compatibility and enable early rehabilitation. CASE REPORT: We report a case of a 60-year-old male who sustained a high energy trifocal fracture of the left tibia following blunt trauma from a falling gate. Imaging revealed a tibial plateau fracture (AO 41C2.2), a long spiral diaphyseal fracture (AO 43C1.3) and a comminuted bimalleolar fracture (AO 44B3.3). Surgical management involved open reduction and internal fixation (ORIF) of the tibial plateau via a posteromedial approach, intramedullary nailing (IMN) of the tibial diaphysis via a suprapatellar approach and ORIF of the bimalleolar fracture using a lateral fibular locking plate and tension band wiring for the medial malleolus. Meticulous preoperative planning and precise implant placement prevented hardware conflict between fixation zones. Post-operatively, a structured rehabilitation protocol was followed. At the final follow-up of 18 months, the patient demonstrated excellent functional outcomes, with near-complete restoration of knee and ankle range of motion, evidenced by a Tegner Lysholm knee score of 96 % and an American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score of 95 %. CONCLUSION: This case illustrates a successful approach to managing a rare, complex trifocal tibial fracture using combined plating and nailing techniques. Careful preoperative planning, fixation sequencing and early mobilization are key to achieving optimal outcomes in such injuries.