Drilling for the first proximal screw
Position the plate firmly by hand and plan the position of the first proximal screw near the fracture.
Drill a 2.5 mm hole through both fibular cortices at the planned screw site.
After measuring the length of the drill hole through the plate, tap with the 3.5 mm cortical tap and protection sleeve and then insert the corresponding cortex screw.
The screw should just penetrate the opposite cortex but not come into contact with the tibia.
First distal screw
Next insert a screw into the first distal plate hole.
All malleolar screws are aimed towards the articular surface of the lateral malleolus. Ensure that their tips do not protrude into the joint by drilling very cautiously once the lateral fibular cortex is pierced. Alternatively, the drill can be angled slightly posteriorly, but this still requires great caution in advancing the drill. Measure the depth to the subchondral bone and select a 3.5 mm cortex screw approximately 2 mm shorter. Tap threads only into the near fibular cortex and then insert the screw.
Above the level of the ankle joint, the screws should obtain a good hold in both cortices.
Insert remaining screws
Insert the remaining proximal screws as described above.
Insert the remaining distal screws slightly obliquely from distal to proximal. Again, choose the screws 2 mm shorter than measured and tap the threads only in the near cortical bone.
- In osteopenic bone, fully threaded cancellous screws should be used in the malleolus.
- In some transsyndesmotic fractures, the fibular fracture line is more distal and can conflict with the third hole from the distal end of the plate. When this is the case, that hole has to be left empty and only the lower 2 plate holes can be used for the lateral malleolar screws.
Gently tighten all screws.
The final fixation should be checked with image intensifier or x-rays before closing.