What is the step-by-step procedure for treating a medial malleolus fracture with Open Reduction Internal Fixation (ORIF) and plating?

Step-by-Step Procedure for Medial Malleolus Fracture ORIF with Plating

Open reduction and internal fixation (ORIF) with plating is the recommended approach for displaced medial malleolus fractures as it provides superior anatomic reduction and healing compared to percutaneous techniques.

Preoperative Assessment and Planning

1. Imaging Evaluation

   • Obtain standard ankle radiographs: anteroposterior, lateral, and mortise views 1
   • Consider CT scan for complex fracture patterns to help with preoperative planning 1
   • Evaluate for associated injuries including syndesmotic injury or other malleolar fractures 2

2. Patient Positioning

   • Position patient supine on the operating table
   • Place a bump under the ipsilateral hip to internally rotate the leg for better access to the medial malleolus
   • Prepare and drape the leg in sterile fashion from mid-thigh to toes

Surgical Procedure

Step 1: Approach and Exposure

1. Make a curvilinear incision (5-7 cm) over the medial malleolus, centered on the fracture site
2. Carry the incision down through skin and subcutaneous tissue
3. Identify and protect the saphenous vein and nerve
4. Incise the periosteum longitudinally and elevate subperiosteally to expose the fracture site

Step 2: Fracture Preparation

1. Irrigate the fracture site to remove hematoma and debris
2. Remove any interposed soft tissue from the fracture site (critical for proper reduction) 3
3. Debride any devitalized bone fragments while preserving viable fragments

Step 3: Reduction

1. Reduce the fracture anatomically using pointed reduction forceps
2. Confirm reduction with direct visualization and fluoroscopy
3. Temporarily hold the reduction with K-wires placed away from intended plate position

Step 4: Fixation with Plating

1. Select appropriate plate (typically one-third tubular plate or pre-contoured medial malleolar plate)
2. Position the plate on the medial surface of the medial malleolus
3. Secure the plate with appropriate screws:
   • Place at least 2 screws in the distal fragment
   • Place 2-3 screws in the proximal fragment
4. For larger fragments, consider supplemental lag screw fixation prior to plate application:
   • Drill a gliding hole in the near fragment
   • Drill a threaded hole in the far fragment
   • Insert appropriate length partially threaded cancellous screw

Step 5: Final Assessment

1. Obtain final fluoroscopic images in multiple planes to confirm:
   • Anatomic reduction of the fracture
   • Proper hardware placement
   • Restoration of ankle mortise
2. Perform ankle range of motion to ensure stability of fixation
3. Check for any impingement of hardware

Step 6: Wound Closure

1. Irrigate wound thoroughly
2. Close the periosteum if possible
3. Close subcutaneous tissue with absorbable sutures
4. Close skin with nylon sutures or staples
5. Apply sterile dressing and well-padded splint with ankle in neutral position

Postoperative Management

1. Immediate Postoperative Care

   • Elevate the extremity to reduce swelling
   • Apply ice following PRICE protocol (protection, rest, ice, compression, elevation) 2
   • Administer appropriate pain control

2. Weight-Bearing Protocol

   • Non-weight bearing for 4-6 weeks 2
   • Transition to progressive weight bearing based on radiographic evidence of healing

3. Rehabilitation

   • Early range of motion exercises when soft tissues permit
   • Strengthening exercises once fracture healing is evident
   • Balance training and proprioception exercises 2

4. Follow-up Schedule

   • First follow-up at 1-2 weeks for wound check and suture removal
   • Subsequent follow-ups at 6 weeks, 3 months, and 6 months with radiographs to assess healing

Potential Complications and Considerations

• Hardware irritation may necessitate removal after healing (occurs in approximately 20% of cases) 4
• Risk of nonunion is significantly lower with open reduction compared to percutaneous techniques 3
• Patients with ORIF are 5 times more likely to have healed fractures at 8 weeks compared to percutaneous fixation 3
• Consider patient factors such as diabetes, peripheral vascular disease, and smoking status as they may affect healing

Technical Pearls

• Ensure anatomic reduction of the articular surface to prevent post-traumatic arthritis
• Avoid excessive soft tissue stripping to preserve blood supply
• When treating associated fractures (e.g., bimalleolar or trimalleolar), address the fibular fracture first to restore length, followed by the medial malleolus 5
• For comminuted fractures, consider tension band wiring as a supplement to plate fixation 6