Reduce the main fragments and hold with a pointed reduction forceps. Ensure that the third fragment is reduced before tightening the 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.
Tightening the screw will push the plate against the fracture, holding it reduced.
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 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
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 is inserted through the remaining distal plate hole.
Final x-rays should be taken now.
In less oblique fractures, or with a large third fragment, it is not possible to insert a lag screw. In this case you can omit the postero-anterior lag screw.
Fixation of third fragment
The final stage is the fixation of the third fragment to the main lateral malleolar fragment, using an anteroposterior cancellous lag screw, fitted with a washer.