Reduce the main fragments and hold with a pointed reduction forceps.
Either make sure the position of the forceps allows the plate to lie in the correct position, or alternatively, place the forceps through the hole in the plate before tightening the forceps.
In the proximal fibular fragment, drill a 2.5 mm hole through both cortices, from posterior to anterior, 3-5 mm proximal to the apex of the fracture.
Carefully position the plate so that two holes overlie each fragment, and hold it in place with a finger.
Insertion of the first proximal screw
Measure the length of the drilled hole through the plate.
Tap with the 3.5 mm cortical tap and insert the first 3.5 mm cortex screw.
Check reduction visually and under image intensification.
Insertion of the second proximal screw
Insert the second screw through the most proximal plate hole, drilling, measuring and tapping through the plate hole.
Prepare insertion of a lag screw
Drill a gliding hole in the near cortex, through the plate hole closest and just distal to the fracture, using a 3.5 mm drill bit. The hole should be drilled as perpendicularly to the fracture line as possible.
Insert a 2.5 mm drill sleeve inside the gliding hole and drill the threaded hole in the far cortex with a 2.5 mm drill bit.
Measure the depth of the hole with the hook of the depth gauge pointing proximally.
Tap the far cortex with the 3.5 mm cortical tap.
Insertion of the lag screw(s)
Insert a 3.5 mm cortical screw, functioning as a lag screw, and tighten carefully.
If the bone is osteoporotic, or if the fragment is large, a second cortical lag screw may be inserted through the remaining distal plate hole.
Final x-rays should be taken now.
NoteIn less oblique fractures, or comminution of the anterior cortex (Le Fort lesion), it may not be possible to insert a lag screw, but the distal fragment may still be held with cortex screws through the plate.