Executive Editor: Steve Krikler

Authors: Paulo Barbosa, Felix Bonnaire, Kodi Kojima

Malleoli 44-B3.1 Open reduction internal fination

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Glossary

1 Principles top

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General considerations

In B3.1 fractures there is a simple oblique fracture on the lateral side, associated with a fracture of the Volkmann's triangle, and a rupture of the deltoid ligament on the medial side.

As the Volkmann's fracture is an intra-articular injury, it should be fixed anatomically.

It is possible to obtain good access to the posterolateral fracture and fibular fracture through a single posterolateral approach. Direct reduction of the Volkmann's triangle is possible, facilitating anatomic reduction and fixation. This requires the patient to be positioned prone.

Alternatively, the fibular fracture can be fixed through a standard lateral approach and the Volkmann's triangle can be indirectly reduced by dorsiflexing the ankle and then secured with screws inserted through anterior stab incisions.


Order of fixation

In these factures the talus is often unstable within the ankle mortise. Stability is restored when the fibular fracture is stabilized. The Volkmann's fragment can then be reduced and fixed.


Choice of implant – Lateral fixation

As this is a simple fracture a lag screw and neutralization 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.


Medial injury

There is a rupture of the deltoid ligament. Once the talus is stabilized within the ankle mortise, the ruptured deltoid ligament usually heals without the need for surgical repair.

Occasionally the ligament may lie between the talus and the medial malleolus blocking reduction, in which case the medial side will need to be opened to remove ligament. Once the medial side is open the surgeon may choose to repair the ligament.


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Note on approaches

If the direct reduction and fixation of the Volkmann's triangle is chosen, a posterolateral approach is used, both for this fragment and the fibular fracture. 


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Alternatively the fibular fracture may be approached directly through a standard lateral approach with additional anterior stab incisions.


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2 Fixation top

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Lateral fixation

As the lateral side in B3.2 fractures is a simple oblique fracture, this is usually fixed with a lag screw and neutralization plate. 


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Alternatively, and in particular if there is poor bone or a small fragment, an antiglide plate may be used.


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Fixation of Volkmann's triangle

This may be fixed through direct reduction via a posterolateral approach with lag screws. 


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If indirect reduction is chosen, sagittal lag screws are inserted through separate stab incisions.

3 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. This needs to be confirmed in multiple planes.

v1.0 2016-11-15