Cleaning of the fracture site
Remove any small, loose fragments which may prevent anatomic reduction and free the periosteum from the bone edges.
It is important to visualize and inspect the joint, searching for bone and cartilage fragments detached from the medial malleolus or from the talus, and any impaction of the articular surface at the margin of the fracture. If the articular surface has been impacted, this must carefully disimpacted before the medial fragment is reduced.
Reduce the fracture anatomically with the use of small pointed reduction forceps, taking care with the soft tissues.
Depending on fracture configuration and size of the fragment you may need to use large pointed reduction forceps through a lateral stab incision.
Do not strip the periosteum more than necessary.
In the presence of an impacted medial corner fragment, gently open the main vertical fracture plane by retraction of the medial malleolus medially (opening the book). The impacted “corner” fragment, usually identifiable by its articular cartilage, after irrigation if necessary, can then be seen.
Disimpact and carefully tease back the fragment into its anatomical position.
Then close the book by careful reduction of the medial malleolus.
Insert a 1.6 mm K-wire as perpendicularly as possible to the fracture plane, about 1 cm proximal to the level of the horizontal tibiotalar joint line.
Check the reduction and position under image intensification.