What is the step-by-step procedure for treating a medial malleolus fracture with ORIF (Open Reduction Internal Fixation) 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. 1

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 aid in preoperative planning 1
   • Bilateral foot and ankle X-rays may be helpful for comparison 1

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

Surgical Procedure

Step 1: Preparation and Approach

• Administer appropriate anesthesia (general or regional)
• Apply tourniquet to the proximal thigh and inflate after limb exsanguination
• Prepare and drape the surgical field using sterile technique
• Make a curved anteromedial incision over the medial malleolus, centered over the fracture site

Step 2: Exposure and Fracture Identification

• Carefully dissect through subcutaneous tissue
• Identify and protect the saphenous vein and nerve
• Expose the fracture site by elevating periosteum
• Identify and remove any interposed soft tissue or hematoma from the fracture site

Step 3: Fracture Reduction

• Manually reduce the fracture under direct visualization
• Confirm anatomic reduction of the articular surface
• Temporarily hold the reduction with K-wires or a reduction clamp

Step 4: Plate Selection and Application

• Select an appropriately sized plate (contoured medial malleolar plate or fibular locking plate can be used for vertical shear fractures) 2
• Position the plate on the medial aspect of the malleolus
• Ensure proper plate positioning to provide adequate support and fixation

Step 5: Plate Fixation

• Drill pilot holes for screws through the plate
• Insert appropriate length screws
• For vertical shear fractures, consider using a fibular locking plate as a neutralization plate 2
• For comminuted fractures, add additional fixation as needed (e.g., lag screws, tension band wiring) 3

Step 6: Verification of Fixation

• Confirm stable fixation by manual testing
• Verify anatomic reduction and proper hardware placement with intraoperative fluoroscopy
• Check ankle stability and range of motion

Step 7: Wound Closure

• Irrigate the wound thoroughly
• Close the deep fascia with absorbable sutures
• Close subcutaneous tissue and skin with appropriate sutures
• Apply sterile dressing and splint

Postoperative Management

1. Immediate Postoperative Care

   • Elevate the extremity to reduce swelling
   • Apply ice following the PRICE protocol (protection, rest, ice, compression, elevation) 1
   • Administer appropriate pain management

2. Immobilization and Weight-Bearing Protocol

   • Initial immobilization with a cast or boot walker for 4-6 weeks 1
   • Non-weight bearing for 4-6 weeks
   • Progress to partial weight bearing based on radiographic evidence of healing
   • Transition to a removable boot walker as healing progresses 1

3. Rehabilitation

   • Begin early range of motion exercises once fracture stability is confirmed
   • Initiate strengthening exercises when fracture healing is evident
   • Incorporate balance training and fall prevention exercises 1
   • Full return to activities typically occurs at 13-19 weeks depending on rehabilitation protocol 1

Follow-up Care

• Regular radiographic assessment to monitor healing
• Clinical evaluation for swelling, pain, and function
• Assess for complications such as infection, malunion, nonunion, or hardware irritation

Potential Complications to Monitor

• Infection (higher risk in diabetic patients) 4
• Delayed union or nonunion
• Malreduction requiring reoperation 4
• Hardware-related discomfort requiring removal
• Post-traumatic arthritis

Special Considerations

• For complex fracture patterns involving multiple malleoli, address the fibular fracture first, followed by the posterior malleolus (if present), and finally the medial malleolus 5
• In patients with good bone quality and stable fixation, consider early functional treatment and weightbearing which has shown good outcomes 6