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Medial malleolar fracture (if present)

The ankle joint in these fractures is often very unstable. The stability is dramatically improved once the medial fracture is fixed (if present).

Most medial fractures are fixed with lag screws, which should be inserted perpendicular to the plane of the fracture.


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If the fragment is too small or in poor quality bone, K-wires and tension band wiring may be better.


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Fibula

The fibular fracture is often oblique or spiral so it may be reduced anatomically and fixed with a lag screw(s) and neutralization plate.


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If it is a transverse fracture it may be best fixed with a compression plate


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Syndesmosis

After the fibula has been fixed, the stability of the syndesmosis is tested with a hook. In suprasyndesmotic fractures, the syndesmosis is usually disrupted, and must be stabilized. This may be achieved. The integrity of the syndesmosis is restored and stabilized with one or two positioning screws. These may be inserted through the distal holes in the plate or separately from the plate.


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Volkmann's fragment (if fractured)

The Volkmann's fragment may be addressed under direct vision through a posterolateral approach. 


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If indirect reduction of the Volkmann's fragment is chosen, sagittal lag screws are inserted through separate stab incisions.