1 Principles topenlarge
As the medial fracture is an intra-articular injury, it should be fixed anatomically.
Order of fixation
The choice of fixing the medial or lateral side first may be dictated by the surgeon's preference. If there is significant comminution on the lateral side, the fibula must be brought out to length and the lateral malleolus returned to its anatomic position.For this reason, some surgeons prefer to fix this side first. As the medial fracture is the simpler, some surgeons prefer to fix this first.
Choice of implant – Lateral fixation
As this is a multifragmentary fracture a bridging plate is the most appropriate method of fixation.
Anatomic plates are available, and their lower profile may reduce postoperative discomfort due to prominent hardware. As these plates use locking screws, they may provide more secure fixation in osteoporotic bone.
Choice of implant – Medial fixation
Medial malleolar fractures are usually fixed with lag screws. If the fragment is too small or in poor quality bone, K-wires and tension band wiring may be better.
2 Patient preparation and approaches top
Depending on the approach, the patient may be placed in the following positions:
Note on approaches
The two following approaches are used:
3 Fixation topenlarge
Most medial fractures are fixed with lag screws, which should be inserted perpendicular to the plane of the fracture.
If the fragment is too small or in poor quality bone, K-wires and tension band wiring may be better.
If the lateral side is comminuted, these fractures are best fixed with a bridging plate and relative stability.
4 Check of osteosynthesis top
Check the completed osteosynthesis by image intensification.
Make sure the intra articular components of the fracture have been anatomically reduced.
Make sure none of the screws are entering the joint as shown in the X-ray. This needs to be confirmed in multiple planes.