As the medial fracture is an intra-articular injury, and the ankle is likely to be unstable, it should be fixed anatomically.
Order of fixation
The choice of fixing the medial or lateral side first may be dictated by the surgeon's preference.
Choice of implant – Lateral fixation
If the distal fibular fragment is large enough, it may be held with a plate and screws from the lateral side.
If the fragment is large enough, it may be held with a plate and screws from the lateral side,
In osteoporotic bone the fixation may be more secure if locking plates are used.
Anatomic plates are available, and their lower profile may reduce postoperative discomfort due to prominent hardware.
If the fragment is too small, or there is concern about the quality of the bone, it may be better to fix it with K-wires and a tension band wire.
Choice of implant – Medial fixation
Medial malleolar fractures are usually fixed with lag screws. Oblique fractures may benefit from additional support with a buttress plate.
Note on approaches
The two following approaches are used: