ORIF

As the medial fracture is an intra-articular injury, and the ankle is likely to be unstable, it should be fixed anatomically.

The choice of fixing the medial or lateral side first may be dictated by the surgeon's preference.

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 cerclage compression wiring.

Note: “Cerclage compression wiring” was referred to as “Tension band wiring”. We now prefer the term “Cerclage compression wiring” because the tension band mechanism cannot be applied consistently to each component of the fracture fixation. An explanation of the limits of the Tension band mechanism/principle can be found here.

Medial malleolar fractures are usually fixed with lag screws. Oblique fractures may benefit from additional support with a buttress plate.

Depending on the approach, the patient may be placed in the following positions:

• Supine position
• Supine position, figure-of-four

The two following approaches are used:

• Medial approach
• Lateral approach

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

In simple transverse fractures, or in patients with good quality bone and fracture morphology in which stable reduction can be achieved, lag screw fixation is usually sufficient.

• Lag screw transverse fracture

Oblique fractures are fixed with lag screws perpendicular to the plane of the fracture.

In a vertical fracture, provided the fragment is large enough and the bone quality is good enough, two or even three lag screws on their own may be sufficient.

• Lag screw oblique/vertical fracture

In vertical fractures, with a tendency to displace due to shearing forces, or if there is any concern about the strength of fixation, further support may be achieved with a buttress plate.

This may be a short plate over the apex of the fracture, with the lag screw(s) inserted inferior to the plate.

• Lag screw and buttress plate

Alternatively, a longer plate may be used, with the lag screw(s) inserted through the distal end of the plate.

• Lag screw through buttress plate

In fractures when the quality of the bone and the size of the bone are large enough for good fixation to be obtained with plate and screws, this is the preferred method of fixation.

• Fixation of lateral malleolus with a compression plate

If the fragment is too small, cerclage compression wiring can be considered.

• Fixation of lateral malleolus with cerclage compression wiring

Check the completed osteosynthesis by image intensification.

Make sure the intra articular components of the fracture have been anatomically reduced.

Make sure none of the screws are entering the joint. This needs to be confirmed in multiple planes.

A bulky compression dressing and a lower leg backslab, or a splint, are applied, and the limb is kept elevated for the first 24 hours or so, in order to avoid swelling and to decrease pain.

In anatomically reconstructed, stable malleolar fractures, early active exercises and light partial weight bearing are encouraged after day one. In osteoporotic bone, weight bearing should be postponed.

X-ray evaluation is made after 1 week and then monthly until full healing has occurred. Progressive weight bearing is recommended as tolerated.