Insertion of first proximal screw
Drill a 2.5 mm hole through both fibular cortices at the planned screw site, 3 mm proximal to the fracture.
Measure the length through the plate, tap with the cortical tap and tap sleeve.
Carefully apply the plate. Insert the first proximal screw.
The screw should just penetrate the far cortex.
Insertion of first distal screw
Next, insert a screw into the first distal plate hole. All distal screws are aimed towards the articular surface of the lateral malleolus. Ensure that their tips do not protrude into the joint by aiming the drill slightly posteriorly.
Predrill carefully until just reaching the far cortex. Measure the length and select a 3.5 mm cortex screw approximately 2 mm shorter. Tap threads only in the near fibular cortex, and insert the selected screw.
In osteopenic bone, fully threaded cancellous screws can be used.
Completing screw insertion
Insert the remaining screws as described above in the sequence determined by the preoperative plan.
The most distal screw is inserted slightly obliquely from distal to proximal in a posterior direction.
Again, choose a screw 2 mm shorter than was measured and tap the threads only in the near cortex.
Gently tighten all screws.
Check under image intensification in both planes and ensure that no screw protrudes into the ankle joint or the syndesmosis.
Pearl: Small distal fragment or osteoporotic bone
Consider using a locking screw in case of a small distal fragment or in severe osteoporotic bone.