ORIF

In B3.3 fractures there is a multifragmentary fracture on the lateral side, associated with a fracture of the posterolateral tibia, and a transverse fracture on the medial side.

As the tibial fractures are intra-articular injuries, they should be fixed anatomically.

It is possible to obtain good access to the posterolateral fracture and fibular fracture through a single posterolateral approach. Direct reduction of the Volkmann's fragment is possible, facilitating anatomic reduction and fixation. This requires the patient to be positioned prone.

Alternatively, the fibular fracture can be fixed through a standard lateral approach and the Volkmann's fragment can be indirectly reduced by dorsiflexing the ankle and then secured with screws inserted through anterior stab incisions.

In these factures the talus is often unstable within the ankle mortise, so it may be preferable to fix the Volkmann's fragment and fibular fracture through one incision first, then fix the medial side through a medial approach.

If the surgeon prefers to fix the Volkmann's fragment with screws inserted from the anterior surface, this is usually performed after the medial and lateral side has been fixed through two separate approaches. The choice of fixing the medial or lateral side first may be dictated by the surgeon's preference.

As this is a multifragmentary fracture, a bridging plate is the most appropriate method of fixation.

Anatomic plates are available and their lower profile may reduce postoperative discomfort due to prominent hardware. As these plates use locking screws, they may provide more secure fixation in osteoporotic bone.

Medial malleolar fractures are usually fixed with lag screws. If the fragment is too small, K-wires and cerclage compression wiring may be better.

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.

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

• Supine position
• Lateral position
• Supine position, figure-of-four
• Prone position (preferred for posterior fractures)

If the direct reduction and fixation of the Volkmann's fragment is chosen, a posterolateral approach is used, both for this fragment and the fibular fracture.

• Posterolateral approach

Alternatively, the fibular fracture may be approached directly through a standard lateral approach with additional anterior stab incisions.

• Lateral approach

• Safe zones for anterior screw insertion

The medial fragment is addressed through a medial approach.

• Medial approach

As the lateral side in B3.3 fractures is comminuted, these fractures are best fixed with a bridging plate and relative stability.

• Lateral bridging plate

This may be fixed through direct reduction via a posterolateral approach with lag screws.

• Posterolateral fixation of Volkmann's fragment

If indirect reduction is chosen, sagittal lag screws are inserted through separate stab incisions.

• Anterior lag screw fixation of Volkmann's fragment

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

• Lag screw transverse fracture

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

• 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.