Ankle Fracture ORIF - Weber B/C Fibula with Medial Malleolus

Patient Position: Supine with radiolucent table. Small bump under ipsilateral hip to internally rotate leg 15-20° (brings fibula anterior for exposure). Knee flexed 30-45° over triangle or end of table - allows gravity to assist fibular reduction and provides access to posterior structures if needed.

Surgical Approach: Lateral approach for fibula (posterolateral border), medial approach for medial malleolus (anterior to posterior tibial tendon). May need posterolateral approach for posterior malleolus if >25% tibial plafond involved or significantly displaced.

Incision Planning:

• Lateral: 8-12cm incision centered 1cm posterior to posterolateral border of fibula extending from mid-shaft to tip
• Medial: 6-8cm curvilinear incision 1cm posterior to medial malleolar tip extending proximally along posterior border of tibia
• Posterior (if needed): Between peroneal tendons and Achilles tendon or posteromedial between FHL and neurovascular bundle

Tourniquet: Thigh tourniquet optional - improves visualization but increases risk if prolonged. Consider tourniquet-free technique if soft tissue concerns.

Imaging Setup: C-arm positioned on contralateral side for AP, mortise (15-20° internal rotation), and lateral views of ankle. Ensure all views obtainable before draping. Have contralateral ankle X-rays available for comparison.

Step 1: Patient Positioning and Pre-operative Planning

Patient Positioning and Pre-operative Planning: Position patient supine with bump under ipsilateral hip achieving 15-20° internal rotation. Knee flexed 30-45° over triangle or end of table. Thigh tourniquet applied but consider tourniquet-free if soft tissue concerns. Prep and drape circumferentially from mid-calf to toes. C-arm positioned on contralateral side. Systematic pre-operative imaging review: (1) Weber classification (A/B/C based on fracture level relative to syndesmosis), (2) Medial injury pattern (malleolar fracture vs deltoid rupture - medial clear space >4mm suggests deltoid), (3) Syndesmotic injury indicators (tibiofibular clear space >6mm, decreased overlap <6mm, medial clear space widening), (4) Posterior malleolar involvement (measure % on lateral view - fix if >25% or >2mm step-off). CT scan invaluable for surgical planning especially if posterior malleolus involved - assess fragment size, rotation, comminution.

Step 2: Lateral Fibular Approach and Exposure

Lateral Fibular Approach and Exposure: Longitudinal 8-12cm incision centered 1cm posterior to posterolateral border of fibula from mid-shaft to lateral malleolar tip. Incise skin and subcutaneous tissues. Identify and protect superficial peroneal nerve if visible (emerges ~10cm proximal, runs subcutaneously) and sural nerve (runs along lateral Achilles border). Deepen to fibular periosteum. Elevate periosteum anteriorly and posteriorly as continuous sleeve using periosteal elevator - preserve periosteal blood supply to fracture fragments. Expose fracture site and adequate length proximal (4-6cm) and distal (2-3cm) for plate application. Protect peroneal tendons posteriorly. Place Hohmann retractors anterior and posterior. Clean fracture site of hematoma and debris using pulsatile lavage and curette. Assess fracture pattern - simple oblique (most Weber B SER), comminuted (Weber C or high-energy Weber B).

Step 3: Fibular Fracture Reduction and Provisional Fixation

Fibular Fracture Reduction and Provisional Fixation: Anatomic fibular reduction is paramount - determines entire mortise alignment. Three-dimensional reduction required: (1) LENGTH: Use intact contralateral fibula as template - measure from lateral malleolar tip to joint line (typically ~1cm) and compare both sides. Even 2mm shortening unacceptable. Use Weber clamp or distraction if shortened. (2) ROTATION: Lateral malleolus must point anteriorly toward 1st toe - external rotation malreduction common error. Assess rotational profile of distal fragment. (3) SAGITTAL ALIGNMENT: Restore normal anteroposterior bow of fibula. Reduce fracture using pointed reduction clamps or Weber clamp applying longitudinal traction if shortened. Provisional hold with small pointed reduction clamp across fracture or 2.0mm K-wire. Check reduction with fluoroscopy: AP view (fibular length, alignment), mortise view (medial clear space should be <4mm if medial structures intact), lateral view (sagittal alignment). If medial clear space >4mm despite anatomic fibular reduction, indicates syndesmotic or deltoid injury requiring additional fixation.

Step 4: Fibular Plate Application and Fixation

Fibular Plate Application and Fixation: One-third tubular plate (3.5mm system) applied to posterolateral fibula (preferred) or lateral fibula. Posterolateral position biomechanically optimal - resists external rotation forces and avoids peroneal tendons. Plate length: 6-8 holes for simple Weber B, longer (8-10 holes) for Weber C or comminuted fractures. Contour plate to match fibular anatomy using bending irons. For simple oblique fracture (SER mechanism): Place lag screw perpendicular to fracture line through plate - drill 3.5mm glide hole in near cortex, 2.5mm thread hole in far cortex, measure depth, insert 3.5mm cortical lag screw achieving interfragmentary compression. Then apply plate screws as neutralization - minimum 3 bicortical screws (6 cortices) proximal and 2 bicortical screws (4 cortices) distal to fracture. For comminuted fracture: Bridge plate technique - do not compress comminuted zone. Use unicortical or locking screws in comminuted area, bicortical screws in intact bone proximal and distal. Maintain fibular length with plate acting as buttress. Confirm final reduction on fluoroscopy: AP (fibular length, alignment), mortise (medial clear space <4mm, symmetric joint), lateral (sagittal alignment).

Step 5: Syndesmotic Stability Assessment

Syndesmotic Stability Assessment: CRITICAL STEP after anatomic fibular fixation. Systematic stress testing under fluoroscopy to assess syndesmotic competence. Cotton test (external rotation stress): Externally rotate foot while watching mortise view - observe medial clear space and tibiofibular clear space. STABLE: no widening. UNSTABLE: medial clear space widens >4mm or tibiofibular clear space widens >6mm. Hook test (lateral stress): Use bone hook or clamp to laterally stress fibula - observe tibiofibular relationship. If >2mm lateral translation or increased tibiofibular clear space, syndesmosis incompetent. Indications for syndesmotic fixation: (1) Weber C fracture - syndesmosis typically disrupted; (2) Weber B with positive stress test; (3) Medial clear space remains >4mm after anatomic fibular fixation despite intact medial malleolus; (4) Fracture >4.5cm proximal to plafond; (5) Posterior malleolus fracture with PITFL avulsion. When in doubt, fix - consequences of missed syndesmotic instability (chronic pain, instability, arthritis) worse than over-treatment.

Step 6: Syndesmotic Reduction and Fixation (if unstable)

Syndesmotic Reduction and Fixation (if unstable): Anatomic syndesmotic reduction paramount - malreduction worse than no fixation. Reduction technique: (1) Ensure fibula reduced anatomically in fibular incisura of tibia; (2) Apply pointed reduction clamp from medial tibia to lateral fibula 2-3cm proximal to joint line - clamp should be parallel to joint, slightly anterior to posterior (if clamp too posterior will externally rotate fibula); (3) Dorsiflex ankle to neutral position - locks wider anterior talus in mortise and reduces syndesmosis; (4) Confirm reduction on AP and mortise fluoroscopy - tibiofibular clear space <6mm, tibiofibular overlap >6mm (or >42% fibular width). Fixation options: (1) Screw fixation - two 3.5mm cortical screws 2-3cm and 3.5cm proximal to plafond, inserted 25-30° from lateral to posteromedial (parallel to joint line), engage tricortical (preferred - allows micro-motion, may not need removal) or quadricortical (traditional but requires removal 10-12 weeks to prevent breakage); (2) Suture button device (TightRope) - flexible construct allowing physiologic motion, no routine removal needed, equivalent outcomes to screws in RCTs. Remove clamp after screw or button placement. Confirm mortise restoration and syndesmotic reduction on fluoroscopy all views.

Step 7: Medial Malleolar Approach and Exposure

Medial Malleolar Approach and Exposure: Medial curvilinear incision 6-8cm long starting 1cm posterior to medial malleolar tip extending proximally along posterior border of tibia. Incise skin and subcutaneous tissues. Identify and protect greater saphenous vein (large superficial vein) and saphenous nerve (runs with vein) anteriorly - visualize and retract gently. Deepen to periosteum over medial malleolus and medial tibial metaphysis. Stay anterior to posterior tibial tendon - tendon marks posterior extent of safe dissection. Expose medial malleolar fracture site. Use periosteal elevator to expose fracture and proximal tibia for screw placement. Clean fracture hematoma and debris. Assess fracture pattern: transverse/oblique (most common - avulsion from deltoid tension), vertical shear (SA mechanism - unstable pattern), or comminuted. If vertical shear pattern identified, plan for anti-glide plate fixation as screws alone insufficient.

Step 8: Medial Malleolar Reduction and Fixation

Medial Malleolar Reduction and Fixation: Medial malleolus is articular surface - anatomic reduction mandatory with zero tolerance for articular step-off. Reduce fracture using pointed clamps - usually reduces easily with direct pressure. Hold reduction provisionally with 1.6-2.0mm K-wire. Confirm reduction on AP, mortise, and lateral fluoroscopy - articular surface must be flush. Fixation technique for transverse/oblique fracture (most common): Two 3.5mm or 4.0mm partially threaded cancellous screws. Insert from distal (malleolar tip) to proximal (tibial metaphysis). If oblique fracture, aim screws perpendicular to fracture line for maximum compression. If vertical fracture, slightly divergent trajectory. Critical: screws must be parallel to tibial plafond to avoid penetrating ankle joint. Technique: Drill 2.5mm guidewire from tip aimed at proximal tibial metaphysis staying parallel to plafond. Measure depth. Drill over wire with 3.5mm drill bit. Insert 3.5mm partially threaded cancellous screw engaging both cortices. Place second screw parallel to first. Vertical shear pattern: Requires medial anti-glide plate (one-third tubular) on medial tibial surface acting as buttress - screws alone will fail. Confirm final reduction and hardware position on all fluoroscopic views - ensure mortise restored with medial clear space <4mm and congruent joint space 360°.

Step 9: Posterior Malleolar Assessment and Fixation (if indicated)

Posterior Malleolar Assessment and Fixation (if indicated): Assess posterior malleolus on lateral fluoroscopy. Measure fragment size as percentage of tibial plafond - draw lines from anterior and posterior tibial lips to center of talar dome, measure fragment size. Fixation indications: (1) Fragment >25% of tibial plafond on lateral view; (2) Articular step-off >2mm; (3) Syndesmotic instability (PITFL attached to fragment). Small fragments (<25%, <2mm step) often reduce indirectly with anatomic fibular fixation and syndesmosis - verify on lateral fluoroscopy after fibular and syndesmotic fixation. Fixation options: (1) Percutaneous anterior-to-posterior lag screws if minimally displaced - patient remains supine. Insert 2.7mm or 3.5mm screws from anterior tibia 3-4cm proximal to joint, 1-2cm medial to tibial crest, aim posterolaterally into posterior malleolar fragment. Palpate anterior tibial pulse to avoid neurovascular bundle. One or two screws. (2) Posterolateral approach with direct reduction and plate fixation if large displaced fragment - approach between peroneal tendons and Achilles, buttress plate on posterior tibia. (3) Posteromedial approach if medial extension (Haraguchi Type II). Goal: restore posterior plafond articular congruity, improve syndesmotic stability, prevent posterior talar subluxation.

Step 10: Final Reduction Confirmation and Stability Testing

Final Reduction Confirmation and Stability Testing: Systematic final fluoroscopic assessment of ankle mortise restoration. AP view: (1) Tibiotalar joint space symmetric; (2) Tibiofibular overlap >6mm and <10mm (or >42% fibular width); (3) Tibiofibular clear space <6mm; (4) Medial clear space <4mm and should equal superior clear space within 1mm. Mortise view (15-20° IR): (1) Symmetric medial and lateral clear space (both <4mm); (2) Congruent tibiotalar joint space 360° around talar dome; (3) No talar shift - medial clear space critical measurement. Lateral view: (1) Posterior malleolar reduction if fixed (step-off <2mm); (2) No anterior or posterior talar subluxation; (3) Hardware position - screws parallel to plafond. If any asymmetry identified: reassess fibular length and rotation, syndesmotic reduction, medial malleolar reduction. Perform stress views if concern about residual instability. Range of motion testing: Gently dorsiflex and plantarflex ankle - should have smooth motion without crepitus or mechanical block. Ensure no hardware impingement. Remove all provisional K-wires. Irrigate all wounds thoroughly with 3L pulsatile lavage.

Step 11: Deltoid Ligament Assessment and Management

Deltoid Ligament Assessment and Management: After medial malleolar fixation complete (or if no malleolar fracture but suspected deltoid rupture - "bimalleolar equivalent" injury), assess deltoid integrity. On mortise fluoroscopy with anatomic fibular and syndesmotic fixation, medial clear space should be <4mm and equal to superior clear space. If medial clear space remains >4mm despite anatomic fibular and syndesmotic fixation, indicates deep deltoid ligament incompetence. Options: (1) Direct repair if deltoid tear identified on exploration - use non-absorbable sutures to repair torn deltoid to medial malleolus or tibial attachment; (2) Suture anchor repair - place suture anchors in medial malleolar footprint and repair deep deltoid; (3) Accept widening if mortise otherwise stable - some literature suggests anatomic fibular fixation alone sufficient with good outcomes. Current consensus: if medial clear space persistently >4mm, repair deltoid to ensure mortise stability and prevent chronic talar shift. Technique: If exploring deltoid, incise between superficial and deep layers, identify tear (usually at tibial or malleolar insertion), repair with suture anchors or transosseous sutures.

Step 12: Soft Tissue Assessment and Surgical Timing Considerations

Soft Tissue Assessment and Surgical Timing Considerations: Critical in ankle fracture management - soft tissue envelope dictates surgical timing and outcomes. Pre-operative assessment: Examine for severe swelling, fracture blisters (serous vs hemorrhagic), skin compromise, compartment syndrome. If compromised soft tissues: DELAY surgery until soft tissues recover - typically 7-14 days until "wrinkle sign" appears (skin wrinkles indicate edema resolved). Immediate management: (1) Closed reduction and well-padded posterior splint in reduced position; (2) Strict elevation above heart level; (3) Ice therapy; (4) Monitor compartments if high-energy mechanism; (5) Serial examinations every 2-3 days assessing swinkle sign. Exceptions requiring urgent surgery: (1) Open fracture (immediate irrigation and debridement, temporary stabilization, delayed definitive fixation); (2) Compartment syndrome (urgent fasciotomy); (3) Skin tenting/compromise (urgent reduction and temporary fixation); (4) Vascular injury. Operating through compromised soft tissues dramatically increases wound complications (dehiscence, infection, skin necrosis) especially medial malleolus in diabetics/PVD patients. Lower leg has four compartments: anterior (deep peroneal nerve), lateral (superficial peroneal nerve), deep posterior (tibial nerve and posterior tibial vessels), superficial posterior (sural nerve).

Step 13: Wound Irrigation and Hemostasis

Wound Irrigation and Hemostasis: Thorough irrigation all surgical wounds critical for infection prevention. Use minimum 3 liters pulsatile lavage normal saline per wound (fibular, medial malleolar, posterior if applicable). Irrigate deep and superficial layers. Remove all debris, bone fragments without soft tissue attachments, and clot. Release tourniquet if used and achieve meticulous hemostasis - identify bleeding vessels and cauterize with bipolar electrocautery. Avoid monopolar cautery near nerves (saphenous, sural). Pack wounds temporarily with lap sponges while achieving hemostasis. Ensure hemostasis complete - hematoma formation increases infection risk and wound complications. Reassess hardware position ensuring no prominent edges or corners causing soft tissue irritation. Bury all screw heads where possible. Ensure adequate soft tissue coverage over all hardware - if questionable coverage consider hardware position adjustment.

Step 14: Layered Wound Closure and Dressing Application

Layered Wound Closure and Dressing Application: Close wounds in layers ensuring tension-free closure. If deep fascia opened, close with interrupted 2-0 absorbable suture (vicryl) - avoid tight closure causing compartment syndrome. Subcutaneous layer closed with 3-0 absorbable suture in interrupted or running fashion to eliminate dead space and reduce skin tension. Skin closure options: (1) Non-absorbable sutures 3-0 or 4-0 nylon with interrupted vertical mattress or simple interrupted - provides excellent wound edge eversion and strength, remove at 14 days; (2) Skin staples - faster closure, equivalent outcomes, remove at 14 days; (3) Absorbable subcuticular - 4-0 monocryl running subcuticular if excellent soft tissue quality and low tension, no suture removal needed. I prefer non-absorbable interrupted sutures for ankle fractures given soft tissue concerns. Apply sterile absorbent dressing (telfa, 4x4 gauze). Apply well-padded below-knee posterior splint: multiple layers cast padding, plaster or fiberglass slab from toes to fibular head, secure with elastic bandage (not circumferential cast). Ankle in neutral dorsiflexion (90° to leg) - avoid equinus which causes Achilles contracture. Elevate limb on pillows with foot above heart level. Strict elevation instructions and written post-operative orders.

Step 15: Post-operative Protocol and Follow-up Plan

Post-operative Protocol and Follow-up Plan: Immediate post-op (0-2 weeks): Strict non-weight-bearing (NWB), strict elevation above heart level, posterior splint, ice therapy. DVT prophylaxis per institutional protocol - consider LMWH or aspirin 100mg daily for high-risk patients (age >60, obesity, prior VTE, cancer, prolonged immobilization). Early ankle pumping exercises within splint to reduce DVT risk. Pain management with multimodal approach. 2 weeks: First follow-up, wound check, suture/staple removal if healing well. X-rays (AP, mortise, lateral) assess fracture position and hardware. If wounds healed, transition to removable CAM boot or well-padded short leg cast. Continue NWB. Begin ankle ROM exercises out of boot. 6 weeks: X-rays assess healing. If early callus formation and clinical healing, begin weight-bearing as tolerated (WBAT) in CAM boot with progressive weight-bearing protocol guided by symptoms. Continue physiotherapy. 10-12 weeks: Remove quadricortical syndesmotic screws if used (prevent breakage). Tricortical screws and suture buttons do not need routine removal. Progress to full weight-bearing in supportive shoe. Wean from boot based on comfort. 3-4 months: Full weight-bearing, return to normal shoes, continue strengthening and proprioception exercises. 4-6 months: Return to impact activities and sport if strength and ROM adequate. Long-term: Annual X-rays first 2-3 years monitoring for arthritis development. Hardware removal 10-20% if symptomatic prominence (typically 12-24 months after fracture union).

References

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   • Classic cadaveric study demonstrating 1mm lateral talar shift decreases tibiotalar contact area 42%

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   • Systematic review showing 75-85% good-excellent outcomes with anatomic reduction, 15-30% post-traumatic arthritis at 10-20 years

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   • RCT demonstrating tricortical syndesmotic screws equivalent outcomes to quadricortical with lower hardware complications

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   • Biomechanical study demonstrating posterior malleolar fixation improves syndesmotic stability

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    • Australian eTG guidelines for perioperative antibiotic prophylaxis: cefazolin 2g IV for closed fracture ORIF, cefazolin + gentamicin for open fractures