The crux of treatment is the correct reduction of the lateral malleolus and fibula. Length alignment and rotation must be restored otherwise it will not be possible to reduce the talus, the syndesmosis or the Volkmann's fragment (if present).


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Multifragmentary diaphyseal fibular fracture with rupture of the deltoid ligament

  1. The fibular shaft is brought out to length and fixed
  2. The integrity of the syndesmosis is restored

The deltoid ligament is not normally fixed as it heals well spontaneously. Occasionally, the ligament is interposed between the talus and medial malleolus, blocking reduction. In these cases, the medial side must be opened to reposition the ligament and it may then be surgically reattached.


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Multifragmentary diaphyseal fibular fracture with fracture of the medial malleolus

The choice of fixing the medial or lateral side first may be guided by the surgeon's preference, but the ankle joint in these fractures is often very unstable. The stability is dramatically improved once the medial fracture is fixed (if present), so we would suggest the following sequence:

  1. The medial fracture is fixed
  2. The fibular shaft is brought out to length and fixed
  3. The integrity of the syndesmosis is restored

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Multifragmentary diaphyseal fibular fracture with fracture of the medial and posterior malleolus

The choice of fixing the medial or lateral side first may be guided by the surgeon's preference, but the ankle joint in these fractures is often very unstable. The stability is dramatically improved once the medial fracture is fixed (if present), so we would suggest the following sequence:

  1. The medial fracture is fixed
  2. The fibular shaft is brought out to length and fixed
  3. The integrity of the syndesmosis is restored
  4. The Volkmann's fragment is reduced and fixed