What is the step-by-step procedure for treating a left-sided medial malleolus fracture with plating?

Step-by-Step Procedure for Left-Sided Medial Malleolus Fracture Fixation 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 2, 1
   • Consider CT scan for complex fracture patterns to aid in preoperative planning 1
   • Assess fracture displacement, comminution, and associated injuries

2. Patient Positioning

   • Position patient supine on the operating table
   • Place a bump under the ipsilateral hip to internally rotate the leg
   • Apply a tourniquet to the proximal thigh
   • Prep and drape the left lower extremity in standard sterile fashion

Surgical Procedure

Step 1: Approach and Exposure

1. Make a curved anteromedial incision (approximately 8-10 cm) centered over the medial malleolus
2. Carefully dissect through subcutaneous tissue, identifying and protecting the saphenous vein and nerve
3. Develop full-thickness flaps to expose the fracture site
4. Identify and protect the posterior tibial tendon located posteriorly

Step 2: Fracture Site Preparation

1. Irrigate the fracture site to remove hematoma and debris
2. Remove any interposed soft tissue or periosteum from the fracture site
3. Debride any devitalized bone fragments while preserving viable fragments
4. Reduce the fracture anatomically using pointed reduction clamps or K-wires for temporary fixation

Step 3: Fracture Reduction and Fixation

1. Achieve and verify anatomic reduction of the fracture
2. Apply a pre-contoured medial malleolar plate to the medial surface
   • Position the plate to provide optimal support to the fracture fragments
   • For small fragments, consider mini-screws for fixation 3
3. Secure the plate with appropriate screws:
   • Place at least 2-3 screws proximal to the fracture site
   • Place 1-2 screws distal to the fracture site
4. For comminuted fractures, consider supplemental fixation with:
   • K-wires for small fragments
   • Tension band wiring for additional stability 4

Step 4: Intraoperative Assessment

1. Verify reduction and fixation with fluoroscopy:
   • Anteroposterior view
   • Lateral view
   • Mortise view
2. Assess ankle stability through range of motion
3. Confirm proper hardware placement and length

Step 5: Wound Closure

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

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 and antibiotic prophylaxis 2

2. Immobilization and Weight-Bearing Protocol

   • Non-weight bearing for 4-6 weeks with cast or boot walker
   • Transition to a removable boot walker after initial immobilization
   • Progressive weight bearing based on fracture healing 1

3. Follow-up and Rehabilitation

   • First follow-up at 2 weeks for wound check and suture removal
   • Radiographic assessment at 6 weeks to evaluate healing
   • Begin physical therapy for range of motion exercises once adequate healing is evident
   • Progress to strengthening exercises and balance training 1

Special Considerations

1. For Comminuted Fractures

   • Consider mini-screw fixation for small fragments 3
   • Hook plates may provide advantages over cannulated screws for small or fragmented fragments 5

2. For Associated Fibular Fractures

   • Address fibular fractures according to pattern and stability requirements
   • Consider intramedullary fixation as an alternative to plating for the fibula in appropriate cases 6

3. Potential Complications

   • Monitor for wound complications, infection, and hardware irritation
   • Assess for nonunion or malunion during follow-up visits
   • Consider hardware removal if symptomatic after fracture healing 7

By following this systematic approach to medial malleolus fracture fixation, optimal anatomic reduction and stable fixation can be achieved, allowing for early functional rehabilitation and improved outcomes.