Executive Editor: Steve Krikler

Authors: Paulo Barbosa, Felix Bonnaire, Kodi Kojima, Paul Demmer

Malleoli

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Glossary

Basic treatment techniques

Malleoli fracture management with minimal resources
Reduction and casting techniques with limited facilities
Medial, transverse fracture: tension band wiring
Medial, transverse fracture: lag screws
Medial, oblique or vertical fracture: lag screw
Medial, vertical fracture: lag screw and buttress plate
Medial, vertical fracture: lag screw through buttress plate
Posteromedial extension fracture: lag screw
Fibula, transverse fracture: tension band wiring
Fibula, transverse fracture: tension band plate
Fibula, transverse or oblique fracture: compression plate
Fibula, oblique fracture: antiglide plate
Fibula, oblique B fracture: lag screw and neutralization plate
Fibula, oblique C1 fracture: lag screw and neutralization plate
Fibula, multifragmentary fracture: lateral bridging plate
Volkmann fracture: posterior lag screw
Volkmann fracture: anterior lag screw
Syndesmosis injury: Fibulo-tibial positioning screw
Basic technique: Modular external fixation

Surgical procedures sorted by fracture type

Use this menu to jump directly into a specific classification (optional):
A1.1/2 A1.3 A2.1 A2.2/3 A3.1 A3.2/3 B1.1/2 B1.3 B2.1 B2.2 B2.3 B3.1 B3.2 B3.3 C1 C2 C3
A1.1/2

Infrasyndesmotic lesion, isolated; rupture of lateral collateral ligaments, or avulsion of the tip of the lateral malleolus

Please select a treatment option:
Treatment Indication summary Skill Equipment
Functional treatment All A1.1 and A1.2 injuries Basic surgical experience, no specialized skills Basic equipment only
Circular cast All A1.1 and A1.2 injuries Basic surgical experience, no specialized skills Basic equipment only
A1.3

Infrasyndesmotic lesion, isolated; Transverse fracture of the lateral malleolus

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 Basic surgical experience, no specialized skills Basic equipment only
Circular cast Minimally displaced fractures, patients not fit for surgery, soft-tissue compromise, nonambulant patient Basic surgical experience, no specialized skills Basic equipment only
Tension band wiring Higher demand patient, small distal fragment Some specialized surgical experience Simple surgical and imaging resources
Tension band plate Higher demand patient; large distal fragment Some specialized surgical experience Simple surgical and imaging resources
A2.1

Infrasyndesmotic lateral lesion, with fracture of the medial malleolus; Rupture of the lateral collateral ligaments

Please select a treatment option:
Treatment Indication summary Skill Equipment
Circular cast Patient not fit for surgery, soft-tissue compromise, nonambulant patient Some specialized surgical experience Basic equipment only
Open reduction; lag screw (oblique or vertical fractures) Large medial fragment, good bone quality Some specialized surgical experience Simple surgical and imaging resources
Open reduction; lag screw (transverse fracture) Large medial fragment, good bone quality Some specialized surgical experience Simple surgical and imaging resources
Open reduction; lag screw and buttress plate (vertical fracture) Vertical fracture line, large medial fragment, surgeon's preference Some specialized surgical experience Simple surgical and imaging resources
Open reduction; lag screw through buttress plate (vertical fracture) Vertical fracture line, large medial fragment, surgeon's preference Some specialized surgical experience Simple surgical and imaging resources
A2.2/3

Infrasyndesmotic lateral lesion, avulsion of the tip of the lateral malleolus or transverse fracture of the lateral malleolus, with fracture of the medial malleolus

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 Basic surgical experience, no specialized skills Basic equipment only
Joint-bridging modular external fixation Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF) Some specialized surgical experience Simple surgical and imaging resources
Joint-bridging triangular external fixation Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF) Some specialized surgical experience Simple surgical and imaging resources
Open reduction internal fixation Most fractures when the patient is fit and soft tissues do not preclude surgery Highly experienced and skilled surgeon Full specialized surgical and imaging resources
A3.1

Infrasyndesmotic lateral lesion, with posteromedial fracture; Rupture of the lateral collateral ligaments

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. Basic surgical experience, no specialized skills Basic equipment only
Joint-bridging modular external fixation Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF) Some specialized surgical experience Simple surgical and imaging resources
Joint-bridging triangular external fixation Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF) Some specialized surgical experience Simple surgical and imaging resources
Lag screw (Posteriomedial extension) Large posteromedial fragment, good bone quality Highly experienced and skilled surgeon Simple surgical and imaging resources
A3.2/3

Infrasyndesmotic lateral lesion, with posteromedial fracture; Avulsion of the tip, or transverse fracture, of the lateral malleolus

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 Some specialized surgical experience Basic equipment only
Joint-bridging modular external fixation Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF) Some specialized surgical experience Simple surgical and imaging resources
Joint-bridging triangular external fixation Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF) Some specialized surgical experience Simple surgical and imaging resources
Open reduction internal fixation Most fractures when the patient is fit and soft tissues do not preclude surgery Highly experienced and skilled surgeon Full specialized surgical and imaging resources
B1.1/2

Isolated transsyndesmotic fibular fracture; Simple, without or with rupture of the anterior syndesmosis

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 Some specialized surgical experience Basic equipment only
Lag screw and neutralization plate Displaced fractures, loss of initial reduction, good bone qualtiy, anterior tibial tubercle avulsion (fixed with independent lag screw) Some specialized surgical experience Simple surgical and imaging resources
Antiglide plate Displaced fractures, osteoporotic bone, small distal fibular fragment, Le Fort fibular avulsion (fixed independently) Highly experienced and skilled surgeon Simple surgical and imaging resources
B1.3

Isolated transsyndesmotic fibular fracture; Multifragmentary

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 Basic surgical experience, no specialized skills Basic equipment only
Joint-bridging modular external fixation Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF) Some specialized surgical experience Simple surgical and imaging resources
Joint-bridging triangular external fixation Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF) Some specialized surgical experience Simple surgical and imaging resources
Bridging plate B1.3 fracture with significant comminution Highly experienced and skilled surgeon Simple surgical and imaging resources
Antiglide plate Displaced fractures, osteoporotic bone, small distal fibular fragment, Le Fort fibular avulsion (fixed independently) Highly experienced and skilled surgeon Simple surgical and imaging resources
B2.1

Transsyndesmotic fibular fracture: medial lesion; ruptured medial collateral ligament

Please select a treatment option:
Treatment Indication summary Skill Equipment
Circular cast Marked soft-tissue swelling, medical compromise, vascular disease, nonambulant patient Basic surgical experience, no specialized skills Basic equipment only
Joint-bridging modular external fixation Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF) Some specialized surgical experience Simple surgical and imaging resources
Joint-bridging triangular external fixation Damage control in polytrauma, excessive soft-tissue swelling Some specialized surgical experience Simple surgical and imaging resources
B2.2

Transsyndesmotic fibular fracture: medial lesion; simple fracture of the medial malleolus

Please select a treatment option:
Treatment Indication summary Skill Equipment
Circular cast Marked soft-tissue swelling, medical compromise, vascular disease, nonambulant patient Basic surgical experience, no specialized skills Basic equipment only
Joint-bridging modular external fixation Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF) Some specialized surgical experience Simple surgical and imaging resources
Joint-bridging triangular external fixation Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF) Some specialized surgical experience Simple surgical and imaging resources
Open reduction internal fixation Most B2.2 fractures when the patient is fit and soft tissues do not preclude surgery Highly experienced and skilled surgeon Full specialized surgical and imaging resources
B2.3

Transsyndesmotic multifragmentary fibular fracture, with medial lesion

Please select a treatment option:
Treatment Indication summary Skill Equipment
Circular cast Marked soft-tissue swelling, medical compromise, vascular disease, nonambulant patient Basic surgical experience, no specialized skills Basic equipment only
Joint-bridging modular external fixation Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF) Some specialized surgical experience Simple surgical and imaging resources
Joint-bridging triangular external fixation Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF) Some specialized surgical experience Simple surgical and imaging resources
Open reduction internal fixation Most B2.3 fractures when the patient is fit and soft tissues do not preclude surgery Highly experienced and skilled surgeon Full specialized surgical and imaging resources
B3.1

Transsyndesmotic fibular fracture, with medial lesion and fracture of the posterolateral rim (Volkmann); Simple, with ruptured medial collateral ligament

Please select a treatment option:
Treatment Indication summary Skill Equipment
Circular cast Marked soft-tissue swelling, medical compromise, vascular disease, nonambulant patient Basic surgical experience, no specialized skills Basic equipment only
Joint-bridging modular external fixation Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF) Some specialized surgical experience Simple surgical and imaging resources
Joint-bridging triangular external fixation Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF) Some specialized surgical experience Simple surgical and imaging resources
Open reduction internal fixation Most B3.1 fractures when the patient is fit and soft tissues do not preclude surgery Highly experienced and skilled surgeon Full specialized surgical and imaging resources
B3.2

Transsyndesmotic simple fibular fracture, fracture of the posterolateral rim (Volkmann); with fracture of the medial malleolus

Please select a treatment option:
Treatment Indication summary Skill Equipment
Circular cast Marked soft-tissue swelling, medical compromise, vascular disease, nonambulant patient Basic surgical experience, no specialized skills Basic equipment only
Joint-bridging modular external fixation Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF) Some specialized surgical experience Simple surgical and imaging resources
Joint-bridging triangular external fixation Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF) Some specialized surgical experience Simple surgical and imaging resources
Open reduction internal fixation Most B3.2 fractures when the patient is fit and soft tissues do not preclude surgery Highly experienced and skilled surgeon Full specialized surgical and imaging resources
B3.3

Transsyndesmotic multifragmentary fibular fracture, fracture of the posterolateral rim (Volkmann); medial malleolus fractured

Please select a treatment option:
Treatment Indication summary Skill Equipment
Circular cast Marked soft-tissue swelling, medical compromise, vascular disease, nonambulant patient Basic surgical experience, no specialized skills Basic equipment only
Joint-bridging modular external fixation Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF) Some specialized surgical experience Simple surgical and imaging resources
Joint-bridging triangular external fixation Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF) Some specialized surgical experience Simple surgical and imaging resources
Open reduction internal fixation Most B3.3 fractures when the patient is fit and soft tissues do not preclude surgery Highly experienced and skilled surgeon Full specialized surgical and imaging resources
C1

Suprasyndesmotic simple diaphyseal fibular fracture, with medial lesion, without or with Volkmann injury

Please select a treatment option:
Treatment Indication summary Skill Equipment
Long-leg circular cast Marked soft-tissue swelling, medical compromise, vascular disease, nonambulant patient Basic surgical experience, no specialized skills Basic equipment only
Joint-bridging modular external fixation Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF) Some specialized surgical experience Simple surgical and imaging resources
Joint-bridging triangular external fixation Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF) Some specialized surgical experience Simple surgical and imaging resources
Open reduction internal fixation Most C1 fractures when the patient is fit and soft tissues do not preclude surgery Highly experienced and skilled surgeon Full specialized surgical and imaging resources
C2

Suprasyndesmotic multifragmentary fracture of the fibula; with medial lesion: without or with Volkmann injury

Please select a treatment option:
Treatment Indication summary Skill Equipment
Long-leg circular cast Marked soft-tissue swelling, medical compromise, vascular disease, nonambulant patient Basic surgical experience, no specialized skills Basic equipment only
Joint-bridging modular external fixation Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF) Some specialized surgical experience Simple surgical and imaging resources
Joint-bridging triangular external fixation Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF) Some specialized surgical experience Simple surgical and imaging resources
Open reduction internal fixation Most C2 fractures when the patient is fit and soft tissues do not preclude surgery Highly experienced and skilled surgeon Full specialized surgical and imaging resources
C3

Suprasyndesmotic, proximal fibular fracture (Maisonneuve); without or with shortening, with medial lesion, without or with Volkmann injury

Please select a treatment option:
Treatment Indication summary Skill Equipment
Long-leg circular cast Marked soft-tissue swelling, medical compromise, vascular disease, nonambulant patient Basic surgical experience, no specialized skills Basic equipment only
Joint-bridging modular external fixation Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF) Some specialized surgical experience Simple surgical and imaging resources
Joint-bridging triangular external fixation Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF) Some specialized surgical experience Simple surgical and imaging resources
Open reduction internal fixation Most C3 fractures when the patient is fit and soft tissues do not preclude surgery Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Special considerations

Principles of management of open fractures
Complications
Infection
Compartment syndrome
*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 2016-11-15