Executive Editor: Steve Krikler

Authors: Paulo Barbosa, Felix Bonnaire, Kodi Kojima

Malleoli Suprasyndesmotic multifragmentary fibula, medial injury, +/- posterior fracture

back to skeleton

Glossary

1 Principles top

enlarge

General considerations

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 fragment (if present).


enlarge

Multifragmentary diaphyseal fibular fracture with rupture of the deltoid ligament

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

The deltoid ligament is not normally fixed as it heals well spontaneously. Occasionally, the ligament is interposed between the talus and medial malleolus, blocking reduction. In these cases, the medial side must be opened to reposition the ligament and it may then be surgically reattached.


enlarge

Multifragmentary diaphyseal fibular fracture with fracture of the medial malleolus

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

enlarge

Multifragmentary diaphyseal fibular fracture with fracture of the medial and posterior malleolus

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

enlarge

Approach to the medial fracture

A medial fracture is addressed through the medial approach.


enlarge

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.


enlarge

Approaches tothe Volkmann's fragment

If direct reduction and fixation of the Volkmann's fragment 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.


enlarge

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

4 Fixation top

enlarge

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.


enlarge

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


enlarge

Fibula

The multifragmentary fibular fracture must be brought out to length and is then best fixed with a bridging plate.


enlarge

Syndesmosis

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.


enlarge

Volkmann's fragment (if fractured)

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


enlarge

If indirect reduction of the Volkmann's fragment 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 2015-12-04