Malleoli Suprasyndesmotic proximal fibular fracture, medial injury, +/- posterior fracture

1 Principles top

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General considerations

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.

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).

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Proximal fibular fracture without shortening

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

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Proximal fibular fracture with shortening

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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Proximal fibular fracture with medial and posterior fracture

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 Patient preparation top

Depending on the approach, the patient may be placed in the following positions:

• Supine position
• Lateral position
• Supine position, figure-of-four
• Prone position (preferred for posterior fractures)

4 Approaches top

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Approach to the medial fracture

A medial fracture is addressed through the medial approach.

• Medial approach

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Approach to the syndesmosis

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

• Lateral fibular approach

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Approaches to the Volkmann's fragment

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

• Posterolateral approach

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.

• Safe zones for anterior screw insertion

5 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.

• Lag screw transverse 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.

• Medial K-wires and tension band wiring

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Syndesmosis

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

• Positioning screws

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Volkmann's fragment (if fractured)

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

• Posterolateral fixation of Volkmann's fragment

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

• Anterior lag screw fixation of Volkmann's fragment

6 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.