What is the step-by-step procedure for treating a lateral malleolus fracture with plating?

Lateral Malleolus Fracture Fixation with Plating: Step-by-Step Procedure

Open reduction and internal fixation with plating is the standard of care for managing lateral malleolus fractures, providing optimal anatomic reconstruction with excellent outcomes. 1, 2

Preoperative Assessment

• Obtain standing (weight-bearing) radiographs including:
  • Anteroposterior (AP)
  • Medial oblique
  • Lateral projections
• Consider MRI if radiographs are negative but clinical suspicion remains high
• CT may be useful for complex injuries with posterior involvement

Surgical Procedure

Step 1: Patient Positioning and Preparation

• Position patient supine with a bump under the ipsilateral hip
• Prepare and drape the affected limb in sterile fashion
• Apply tourniquet to the proximal thigh and inflate after limb exsanguination

Step 2: Surgical Approach

• Make a longitudinal incision (8-10 cm) along the posterior border of the fibula
• Carefully dissect through subcutaneous tissue, identifying and protecting the superficial peroneal nerve
• Develop the interval between the peroneus tertius and peroneus brevis muscles
• Expose the fracture site with minimal periosteal stripping

Step 3: Fracture Reduction

• Remove hematoma and debris from the fracture site
• Reduce the fracture anatomically using pointed reduction clamps
• Confirm reduction with fluoroscopy in multiple planes
• Maintain reduction with temporary K-wires if necessary

Step 4: Fixation with Plate

• Select appropriate plate (one-third tubular, neutralization, or locking plate depending on fracture pattern)
• Contour the plate to match the anatomy of the lateral malleolus
• Position the plate on the lateral or posterolateral aspect of the fibula
• For Weber B fractures (most common):
  • Insert a lag screw through the plate or separately to achieve interfragmentary compression
  • Place the lag screw perpendicular to the fracture line
  • Secure the plate with appropriate screws above and below the fracture

Step 5: Fixation Verification

• Confirm adequate reduction and fixation with fluoroscopy
• Check ankle stability through range of motion
• Irrigate the wound thoroughly

Step 6: Wound Closure

• Close the periosteum if possible
• Approximate the subcutaneous tissue with absorbable sutures
• Close the skin with non-absorbable sutures or staples
• Apply sterile dressing and a well-padded splint

Postoperative Management

• Elevate the limb to minimize swelling
• Keep the wound dry until suture removal (10-14 days)
• Clinical and radiographic follow-up at 2 weeks and 4-6 weeks to ensure maintained alignment and assess healing 1
• Begin early mobilization with protected weight-bearing in a removable walking boot
• Progress to full weight-bearing based on clinical and radiographic evidence of healing (typically 6-8 weeks)
• Consider NSAIDs for pain control 1

Rehabilitation Protocol

• Traditional Protocol:

  • Immobilization: 4 weeks
  • Progressive weight bearing
  • Return to activity: 18-19 weeks

• Accelerated Protocol:

  • Early mobilization
  • Early weight bearing
  • Return to activity: 13-14 weeks 1

Technical Considerations and Pitfalls

• Plate Positioning: The plate should be positioned on the tension side of the fibula (typically lateral or posterolateral)
• Screw Length: Avoid over-penetration of the medial cortex to prevent soft tissue irritation
• Fracture Pattern Assessment: Properly classify the fracture (Weber A, B, or C) to determine optimal fixation strategy
• Syndesmosis Evaluation: Always assess the syndesmosis intraoperatively after fixation
• Soft Tissue Handling: Minimize soft tissue stripping to preserve blood supply

Alternative Techniques

While plating is the standard approach, alternative techniques may be considered in specific situations:

• Intramedullary fixation with screws or nails may be viable for certain fracture patterns 3, 4, 5
• Antiglide plating (posterior) may provide comparable outcomes to lateral plating 2
• Minimally invasive techniques with percutaneous screws may be suitable for simple oblique fractures 6

Potential Complications

• Wound dehiscence (higher risk with lateral plating)
• Hardware irritation requiring removal
• Infection
• Malunion or nonunion
• Chronic pain (approximately 20% of patients) 1

Early mobilization and appropriate fixation technique are crucial to minimize these complications and achieve optimal outcomes.