Executive Editor: Steve Krikler

Authors: Paulo Barbosa, Felix Bonnaire, Kodi Kojima

Malleoli Infrasyndesmotic, medial fracture with LCL rupture

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Glossary

General considerations

As these injuries compromise articular congruity and are usually unstable, fixation is usually preferred.

Circular cast
Indication summary Skill Equipment
Patient not fit for surgery, soft-tissue compromise, nonambulant patient Some specialized surgical experience Basic equipment only

Indications

  • Undisplaced, stable fractures 
  • Patient not fit for surgery
  • Poor soft-tissue condition (excessive swelling, diabetes, neurovascular diseases)

Contraindications

  • Dislocated or unstable joint
  • Severe soft-tissue injury 
  • Very displaced fracture with soft-tissue irritation

Advantages

  • Full weight bearing possible
  • Good stability

Disadvantages

  • Risks of cast complications (eg, pressure ulcer, nerve compression) 
  • Risks of immobilization (joint stiffness, muscle wasting)
  • Longer rehabilitation period
Lag screws (oblique or vertical fractures)
Indication summary Skill Equipment
Large medial fragment, good bone quality Some specialized surgical experience Simple surgical and imaging resources

Indications

  • Large medial malleolar fragment
  • Good bone quality
  • Displaced, unstable fractures of the medial malleolus
  • Open fractures 
  • Severe soft-tissue injury
  • Loss of reduction after nonoperative treatment

Contraindications

  • Comminution
  • Severely osteoporotic bone
  • Poor general condition of the patient (high anesthetic risk) 
  • Low demand patient 
  • Poor quality of soft tissues
  • Peripheral vascular diseases

Advantages

  • Absolute stability
  • Interfragmentary compression
  • Straightforward technique
  • Anatomical reduction of the joint 
  • Early functional recovery 
  • Good long-term results

Disadvantages

  • Risk of fragmentation of the malleolar fragment
  • Risk of wound infection 
  • Risk of soft-tissue breakdown 
  • Cosmetic appearance
Lag screws (transverse fracture)
Indication summary Skill Equipment
Large medial fragment, good bone quality Some specialized surgical experience Simple surgical and imaging resources

Indications

  • Large medial malleolar fragment
  • Good bone quality
  • Displaced, unstable fractures of the medial malleolus
  • Open fractures 
  • Severe soft-tissue injury

Contraindications

  • Comminution
  • Severely osteoporotic bone
  • Poor general condition of the patient (high anesthetic risk) 
  • Low demand patient 
  • Poor quality of soft tissues
  • Peripheral vascular diseases

Advantages

  • Absolute stability
  • Interfragmentary compression
  • Straightforward technique
  • Anatomical reduction of the joint 
  • Early functional recovery 
  • Good long-term results

Disadvantages

  • Risk of fragmentation of the malleolar fragment
  • Risk of wound infection 
  • Risk of soft-tissue breakdown 
  • Cosmetic appearance
Lag screw and buttress plate
Indication summary Skill Equipment
Vertical fracture line, large medial fragment, surgeon's preference Some specialized surgical experience Simple surgical and imaging resources

Indications

  • Vertical fracture line
  • Displaced, unstable fractures of the medial malleolus
  • Open fractures 
  • Severe soft-tissue injury 
  • Surgeon's preference

Contraindications

  • Poor general condition of the patient (high anesthetic risk) 
  • Low demand patient 
  • Poor quality of soft tissues
  • Peripheral vascular diseases 

Advantages

  • Buttressing effect against displacement of the fragment by a shearing force, particularly where it is felt that simple screw fixation may give inadequate hold
  • Absolute stability
  • Anatomical reduction of the joint
  • Early functional recovery 
  • Good long-term results 

Disadvantages

  • Longer incision because of the plate
  • More dissection needed
  • Risk of skin irritation caused by the plate
  • Risk of wound infection 
  • Risk of soft-tissue breakdown 
  • Cosmetic appearance
Lag screw through buttress plate
Indication summary Skill Equipment
Vertical fracture line, large medial fragment, surgeon's preference Some specialized surgical experience Simple surgical and imaging resources

Indications

  • Vertical fracture line
  • Displaced, unstable fractures of the medial malleolus
  • Open fractures 
  • Severe soft-tissue injury 
  • Surgeon's preference

Contraindications

  • Patient not fit for surgery
  • Low demand patient 
  • Peripheral vascular disease
  • Poor state of soft-tissues 

Advantages

  • Buttressing effect against displacement of the fragment by a shearing force
  • Anatomical reduction of the joint 
  • Early functional recovery 
  • Good long-term results 

Disadvantages

  • Longer incision because of the plate
  • More dissection needed
  • Risk of skin irritation caused by the plate
  • Technically more demanding
  • Risk of wound infection 
  • Risk of soft-tissue breakdown 
  • Cosmetic appearance 
  • Surgical risks
*Skill
Basic surgical experience, no specialized skills Basic surgical experience, no specialized skills
Some specialized surgical experience Some specialized surgical experience
Highly experienced and skilled surgeon Highly experienced and skilled surgeon
*Equipment
Basic equipment only Basic equipment only
Simple surgical and imaging resources Simple surgical and imaging resources
Full specialized surgical and imaging resources Full specialized surgical and imaging resources

v1.0 2015-12-04