Step-by-Step Procedure for Lateral Malleolar Fracture Fixation with Plating
The standard treatment for lateral malleolar fractures is open reduction and internal fixation (ORIF) using plate fixation, which provides optimal anatomic reconstruction with good outcomes for most fracture patterns. 1
Pre-operative Considerations
Imaging Assessment
- Obtain standing (weight-bearing) radiographs including:
- Anteroposterior (AP) view
- Medial oblique view
- Lateral projection
- Consider CT scan for complex injuries or preoperative planning 2
- MRI may be useful if radiographs are negative but clinical suspicion remains high 1
Patient Positioning
- Place patient in supine position
- Apply tourniquet to the proximal thigh
- Prep and drape the affected limb in sterile fashion
- Elevate the ipsilateral hip with a bump to facilitate access to the lateral malleolus
Surgical Procedure
Step 1: Approach
- Make a longitudinal incision (approximately 8-10 cm) over the distal fibula
- The incision should be slightly posterior to the fibula to avoid injury to the superficial peroneal nerve
- Carry the dissection down to the periosteum
- Identify and protect the superficial peroneal nerve branches
Step 2: Fracture Exposure
- Develop full-thickness skin flaps
- Incise the periosteum longitudinally
- Elevate the periosteum to expose the fracture site
- Remove any hematoma or interposed soft tissue from the fracture site
Step 3: Fracture Reduction
- Reduce the fracture anatomically using reduction clamps or forceps
- Confirm reduction under fluoroscopy
- Ensure proper length, rotation, and alignment of the fibula
- Verify the integrity of the syndesmosis if applicable
Step 4: Temporary Fixation
- Apply pointed reduction forceps to maintain the reduction
- Insert K-wires temporarily if needed to hold the reduction
Step 5: Plate Application
- Select appropriate plate (typically one-third tubular plate for simple fractures or locking plate for comminuted/osteoporotic bone)
- Contour the plate to match the anatomy of the lateral fibula
- Position the plate on the lateral or posterolateral aspect of the fibula
- Ensure proper plate positioning under fluoroscopy
Step 6: Screw Fixation
- Drill the first screw hole proximal to the fracture site
- Measure and insert the appropriate length screw
- Drill the first screw hole distal to the fracture site
- Measure and insert the appropriate length screw
- Complete fixation with additional screws (typically 3 screws proximal and 3 screws distal to the fracture)
- Ensure all screws have adequate purchase in the bone
Step 7: Final Assessment
- Obtain final fluoroscopic images in multiple planes
- Confirm anatomic reduction and proper hardware placement
- Check ankle stability and range of motion
- Irrigate the wound thoroughly
Step 8: Closure
- Close the periosteum if possible
- Close the subcutaneous tissue with absorbable sutures
- Close the skin with non-absorbable sutures or staples
- Apply sterile dressing and splint or cast as appropriate
Post-operative Management
Immediate Post-operative Care
- Elevate the limb to reduce swelling
- Administer pain control medications (NSAIDs recommended as first-line) 1
- Monitor for neurovascular compromise
Follow-up Protocol
- Clinical and radiographic follow-up at 2 weeks and 4-6 weeks 1
- Remove sutures at 10-14 days
- Progress weight-bearing based on fracture pattern and stability:
- Traditional protocol: 4 weeks immobilization with progressive weight-bearing, return to activity at 18-19 weeks
- Accelerated protocol: Early mobilization and weight-bearing, return to activity at 13-14 weeks 1
Potential Complications
- Wound complications (more common with plate fixation compared to intramedullary fixation) 3, 4
- Hardware irritation requiring removal (occurs in approximately 20% of cases) 5
- Infection
- Delayed union or non-union
- Post-traumatic arthritis
- Persistent pain or instability 1
Special Considerations
- For patients with soft tissue concerns, consider minimally invasive techniques 5
- In elderly or osteoporotic patients, locking plates may provide better fixation
- For diabetic patients or those with peripheral vascular disease, careful soft tissue handling is critical to prevent wound complications
While intramedullary fixation has shown promising results with lower complication rates in recent studies 6, 3, 5, 4, plate fixation remains the gold standard for lateral malleolar fractures due to its ability to provide optimal anatomic reconstruction and stable fixation.