Executive Editor: Steve Krikler

Authors: Paulo Barbosa, Felix Bonnaire, Kodi Kojima

Malleoli 44-C1 Open reduction internal fixation

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Glossary

1 Principles top

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General considerations

In C1 fractures, there is fracture of the fibula above the level of the syndesmosis. It is usually a simple fracture.  This is associated with
a rupture of the interosseus ligament between the distal tibia and fibula (syndesmosis), and the interosseous membrane up to the level of the fracture. 

The medial side fails first in tension, either through the deltoid ligament (C1.1) or through a transverse avulsion fracture of the medial malleolus (C1.2). Very rarely, there may also be a fracture of the Volkmann's triangle (C1.3).

These are unstable injuries and the integrity of the syndesmosis must be restored.

2 Order of fixation top

The crux of treatment is the correct reduction of the lateral malleolus and fibula. Length alignment and rotation must be restored otherwise it will not be possible to reduce the talus, the syndesmosis or the Volkmann’s triangle (if present).


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C1.1 fractures

  1. The fibular shaft is brought out to length and fixed
  2. The integrity of the syndesmosis is restored


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C1.2 fractures

The choice of fixing the medial or lateral side first may be guided by the surgeon's preference, but the ankle joint in these fractures is often very unstable. The stability is dramatically improved once the medial fracture is fixed (if present), so we would suggest the following sequence:

  1. The medial fracture is fixed
  2. The fibular shaft is brought out to length and fixed
  3. The integrity of the syndesmosis is restored

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C1.3 fractures

The choice of fixing the medial or lateral side first may be guided by the surgeon's preference, but the ankle joint in these fractures is often very unstable. The stability is dramatically improved once the medial fracture is fixed (if present), so we would suggest the following sequence:

  1. The medial fracture is fixed
  2. The fibular shaft is brought out to length and fixed
  3. The integrity of the syndesmosis is restored
  4. The Volkmann's fragment is reduced and fixed

3 Approaches top

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Approach to the medial fracture

A medial fracture is addressed through the medial approach.


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Approach to the fibular shaft fracture and syndesmosis

A direct lateral approach is used for the fibular shaft fracture. The level of the fracture dictates the level of the incision required. The distal end of the incision may need to be extended for insertion of positioning screws, or a small separate incision may be used.


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Approaches to the Volkmann's triangle

If direct reduction and fixation of the Volkmann's triangle is chosen, a posterior lateral approach is used. 

This incision may be extended proximally to allow access and fixation of the fibular fracture if it is relatively low. Alternatively, and more commonly, the fibular fracture is relatively high, and is approached through a separate lateral incision placed more proximally.


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Alternatively, the Volkmann's fragment may be addressed with indirect reduction and anterior screw fixation through additional anterior stab incisions.

4 Fixation top

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Medial malleolar fracture (if present)

The ankle joint in these fractures is often very unstable. The stability is dramatically improved once the medial fracture is fixed (if present).

Most medial fractures are fixed with lag screws, which should be inserted perpendicular to the plane of the fracture.


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If the fragment is too small or in poor quality bone, K-wires and tension band wiring may be better.


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Fibula

The fibular fracture is often oblique or spiral so it may be reduced anatomically and fixed with a lag screw(s) and neutralization plate.


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If it is a transverse fracture it may be best fixed with a compression plate


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Syndesmosis

After the fibula has been fixed, the stability of the syndesmosis is tested with a hook. In C-type fractures, the syndesmosis is usually disrupted, and must be stabilized. This may be achieved The integrity of the syndesmosis is restored and stabilized with one or two positioning screws. These may be inserted through the distal holes in the plate or separately from the plate.


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Volkmann's triangle (if fractured)

The Volkmann's triangle may be addressed under direct vision through a posterolateral approach. 


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If indirect reduction of the Volkmann's triangle is chosen, sagittal lag screws are inserted through separate stab incisions.

5 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 2006-12-04