Executive Editor: Steve Krikler

Authors: Paulo Barbosa, Felix Bonnaire, Kodi Kojima

Malleoli 44-C3 Open reduction internal fination

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Glossary

1 Principles top

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General considerations

In C3 fractures, there is a rupture of the interosseus ligament between the distal tibia and fibula (syndesmosis), with a very proximal fracture of the fibula through the neck or head. 

The medial side fails first in tension, either through the deltoid ligament or through a transverse avulsion fracture of the medial malleolus.

The talus then rotates externally, twisting the fibula. If the interosseous membrane is not completely ruptured, there is little shortening of the fibula (C3.1), but if the interosseous membrane is ruptured, the fibular shaft is no longer attached to the fibula, and there may be significant shortening (C3.2).

These are unstable injuries and the integrity of the syndesmosis must be restored. This necessitates bringing the fibula out to length and then securing the syndesmosis with two positioning screws. The fibular fracture is not normally fixed.

Very rarely, there may also be a fracture of the Volkmann's triangle (C3.3).

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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C3.1 fractures

  1. The medial malleolus is fixed (if fractured)
  2. The integrity of the syndesmosis is restored


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C3.2 fractures

  1. The medial malleolus is fixed (if fractured)
  2. The fibula is brought down to length and the integrity of the syndesmosis is restored


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C3.3 fractures

  1. The medial malleolus is fixed (if fractured)
  2. The fibula is brought down to length if necessary and the integrity of the syndesmosis is restored 
  3. 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 syndesmosis (C3.1 and C3.2)

A direct lateral approach is used for insertion of positioning screws.


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Approaches to the Volkmann's triangle (C3.3)

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 integrity of the syndesmosis may be restored through a standard lateral approach, and 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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Syndesmosis

The integrity of the syndesmosis is restored and stabilized with one or two positioning screws.


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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