Malleoli

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Infrasyndesmotic, lateral isolated ligament rupture/avulsion fracture Please select a treatment option:
Treatment	Indication summary	Skill	Equipment
Functional treatment	All infrasyndesmotic lateral ligament ruptures and avulsion fractures
Circular cast	All infrasyndesmotic lateral ligament ruptures and avulsion fractures

Infrasyndesmotic, lateral isolated fracture Please select a treatment option:
Treatment	Indication summary	Skill	Equipment
Functional treatment	Minimally displaced fractures, patients not fit for surgery, soft-tissue compromise, nonambulant patient
Circular cast	Minimally displaced fractures, patients not fit for surgery, soft-tissue compromise, nonambulant patient
Tension band wiring	Higher demand patient, small distal fragment
Tension band plate	Higher demand patient; large distal fragment

Infrasyndesmotic, medial fracture with LCL rupture Please select a treatment option:
Treatment	Indication summary	Skill	Equipment
Circular cast	Patient not fit for surgery, soft-tissue compromise, nonambulant patient
Lag screws (oblique or vertical fractures)	Large medial fragment, good bone quality
Lag screws (transverse fracture)	Large medial fragment, good bone quality
Lag screw and buttress plate	Vertical fracture line, large medial fragment, surgeon's preference
Lag screw through buttress plate	Vertical fracture line, large medial fragment, surgeon's preference

Infrasyndesmotic, medial fracture with lateral fracture/avulsion Please select a treatment option:
Treatment	Indication summary	Skill	Equipment
Circular cast	Undisplaced or reduced fractures, marked soft-tissue swelling, patient not fit for surgery, vascular disease, nonambulant patient
External fixation	Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF)
Triangular external fixation	Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF)
ORIF	Most fractures when the patient is fit and soft tissues do not preclude surgery

Infrasyndesmotic, posteromedial fracture with LCL rupture Please select a treatment option:
Treatment	Indication summary	Skill	Equipment
Circular cast	Undisplaced or reduced fractures, marked soft-tissue swelling, patient not fit for surgery, vascular disease, nonambulant patient
External fixation	Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF)
Triangular external fixation	Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF)
Lag screw	Large posteromedial fragment, good bone quality

Infrasyndesmotic, posteromedial fracture with lateral fracture/avulsion Please select a treatment option:
Treatment	Indication summary	Skill	Equipment
Circular cast	Undisplaced or reduced fractures, marked soft-tissue swelling, patient not fit for surgery, vascular disease, nonambulant patient
External fixation	Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF)
Triangular external fixation	Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF)
ORIF	Most fractures when the patient is fit and soft tissues do not preclude surgery

Transsyndesmotic, lateral isolated simple fracture Please select a treatment option:
Treatment	Indication summary	Skill	Equipment
Circular cast	Undisplaced or reduced fractures, marked soft-tissue swelling, medical compromise, vascular disease, nonambulant patient
Lag screw and neutralization plate	Displaced fractures, loss of initial reduction, good bone qualtiy, anterior tibial tubercle avulsion (fixed with independent lag screw)
Antiglide plate	Displaced fractures, osteoporotic bone, small distal fibular fragment, Le Fort fibular avulsion (fixed independently)

Transsyndesmotic, lateral isolated multifragmentary fracture Please select a treatment option:
Treatment	Indication summary	Skill	Equipment
Circular cast	Undisplaced or reduced fractures, marked soft-tissue swelling, medical compromise, vascular disease, nonambulant patient
External fixation	Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF)
Triangular external fixation	Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF)
Bridging plate	Significant comminution
Antiglide plate	Displaced fractures, osteoporotic bone, small distal fibular fragment, Le Fort fibular avulsion (fixed independently)

Transsyndesmotic, lateral simple fracture with deltoid rupture Please select a treatment option:
Treatment	Indication summary	Skill	Equipment
Circular cast	Marked soft-tissue swelling, medical compromise, vascular disease, nonambulant patient
External fixation	Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF)
Triangular external fixation	Damage control in polytrauma, excessive soft-tissue swelling

Transsyndesmotic, lateral simple fracture with medial fracture Please select a treatment option:
Treatment	Indication summary	Skill	Equipment
Circular cast	Marked soft-tissue swelling, medical compromise, vascular disease, nonambulant patient
External fixation	Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF)
Triangular external fixation	Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF)
ORIF	Most fractures when the patient is fit and soft tissues do not preclude surgery

Transsyndesmotic, lateral multifragmentary fracture with medial injury Please select a treatment option:
Treatment	Indication summary	Skill	Equipment
Circular cast	Marked soft-tissue swelling, medical compromise, vascular disease, nonambulant patient
External fixation	Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF)
Triangular external fixation	Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF)
ORIF	Most fractures when the patient is fit and soft tissues do not preclude surgery

Transsyndesmotic, posterior, lateral simple fractures, and deltoid rupture Please select a treatment option:
Treatment	Indication summary	Skill	Equipment
Circular cast	Marked soft-tissue swelling, medical compromise, vascular disease, nonambulant patient
External fixation	Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF)
Triangular external fixation	Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF)
ORIF	Most fractures when the patient is fit and soft tissues do not preclude surgery

Transsyndesmotic, posterior, lateral simple, and medial fractures Please select a treatment option:
Treatment	Indication summary	Skill	Equipment
Circular cast	Marked soft-tissue swelling, medical compromise, vascular disease, nonambulant patient
External fixation	Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF)
Triangular external fixation	Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF)
ORIF	Most fractures when the patient is fit and soft tissues do not preclude surgery

Transsyndesmotic, posterior, lateral multifragmentary, and medial fractures Please select a treatment option:
Treatment	Indication summary	Skill	Equipment
Circular cast	Marked soft-tissue swelling, medical compromise, vascular disease, nonambulant patient
External fixation	Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF)
Triangular external fixation	Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF)
ORIF	Most fractures when the patient is fit and soft tissues do not preclude surgery

Suprasyndesmotic, simple fibular fracture, medial injury, +/- posterior fracture Please select a treatment option:
Treatment	Indication summary	Skill	Equipment
Long-leg circular cast	Marked soft-tissue swelling, medical compromise, vascular disease, nonambulant patient
External fixation	Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF)
Triangular external fixation	Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF)
ORIF	Most fractures when the patient is fit and soft tissues do not preclude surgery

Suprasyndesmotic multifragmentary fibula, medial injury, +/- posterior fracture Please select a treatment option:
Treatment	Indication summary	Skill	Equipment
Long-leg circular cast	Marked soft-tissue swelling, medical compromise, vascular disease, nonambulant patient
External fixation	Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF)
Triangular external fixation	Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF)
ORIF	Most fractures when the patient is fit and soft tissues do not preclude surgery

Suprasyndesmotic, proximal fibular fracture, medial injury, +/- posterior fracture Please select a treatment option:
Treatment	Indication summary	Skill	Equipment
Long-leg circular cast	Marked soft-tissue swelling, medical compromise, vascular disease, nonambulant patient
External fixation	Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF)
Triangular external fixation	Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF)
ORIF	Most fractures when the patient is fit and soft tissues do not preclude surgery

Special considerations
Principles of management of open fractures Infection Compartment syndrome

*Skill
	Basic surgical experience, no specialized skills
	Some specialized surgical experience
	Highly experienced and skilled surgeon

*Equipment
	Basic equipment only
	Simple surgical and imaging resources
	Full specialized surgical and imaging resources

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v1.0 2015-12-04