What is the step-by-step procedure for treating a fracture of the medial malleolus?

Step-by-Step Procedure for Medial Malleolar Fracture Fixation Using Tension Band Wiring (TBW)

The optimal surgical technique for medial malleolar fracture fixation using tension band wiring involves careful preoperative planning, proper patient positioning, meticulous surgical exposure, and precise reduction and fixation to ensure anatomic alignment and stable fixation for optimal healing and functional outcomes.

Preoperative Assessment and Planning

1. Imaging Studies

   • Obtain standing (weight-bearing) radiographs including anteroposterior (AP), medial oblique, and lateral projections 1
   • Consider CT scan for complex injuries or preoperative planning 1
   • MRI may be indicated if radiographs are negative but clinical suspicion remains high 2, 1

2. Patient Positioning

   • Position patient supine on operating table
   • Place a bump under the ipsilateral hip for better exposure
   • Prep and drape the affected ankle in sterile fashion

Surgical Procedure

Step 1: Surgical Approach

• Make a longitudinal incision over the medial malleolus, approximately 5-6 cm in length
• Carry dissection down to the periosteum
• Identify and protect any branches of the saphenous nerve and vein
• Expose the fracture site by careful soft tissue dissection

Step 2: Fracture Preparation

• Clean the fracture site of hematoma and debris
• Irrigate thoroughly
• Assess the fracture pattern and quality of bone
• Identify the deltoid ligament attachment (important to preserve)

Step 3: Fracture Reduction

• Reduce the fracture anatomically using pointed reduction forceps
• Confirm reduction visually and with fluoroscopy
• Temporarily hold reduction with K-wires

Step 4: Tension Band Wiring Technique

1. K-wire Placement

   • Insert two parallel 1.6 mm K-wires from the fracture site proximally into the tibia
   • Place K-wires approximately 2 cm apart
   • Ensure K-wires are parallel to each other and perpendicular to the fracture line
   • Drive K-wires through the opposite cortex for stability

2. Drill Holes for Wire Passage

   • Drill two transverse holes in the tibial shaft approximately 3-4 cm proximal to the fracture site
   • Ensure holes are perpendicular to the K-wires

3. Wire Configuration

   • Use 1.25 mm stainless steel wire
   • Pass the wire through the drill holes in a figure-of-eight configuration
   • Loop the wire around the protruding ends of the K-wires
   • Tighten the wire using wire tighteners to create compression across the fracture site

4. Final Tightening and Cutting

   • Twist the wire ends together to secure the construct
   • Cut and bend the K-wires to prevent soft tissue irritation
   • Bury the twisted wire ends to prevent soft tissue irritation

Step 5: Fixation Verification

• Confirm stable fixation by stressing the construct
• Verify anatomic reduction with fluoroscopy in multiple planes
• Ensure no intra-articular hardware placement

Step 6: Wound Closure

• Irrigate the wound thoroughly
• Close the periosteum if possible
• Close subcutaneous tissue with absorbable sutures
• Close skin with non-absorbable sutures or staples
• Apply sterile dressing and splint

Alternative Fixation Methods

For small or comminuted fragments where TBW may not be optimal:

• Consider mini-screw fixation for small fragments, which has shown good outcomes with no incidental bone breakage during the procedure 3
• Hook plates may provide advantages in medial malleolus fractures with small or fragmented fragments 4
• For simple fractures, cannulated screws may be used with comparable outcomes to hook plates 4

Postoperative Care and Rehabilitation

1. Immediate Postoperative Care

   • Elevate the extremity to reduce swelling
   • Ice application for the first 48-72 hours
   • Pain management with NSAIDs as first-line treatment 1

2. Follow-up Protocol

   • Clinical and radiographic follow-up at 2 weeks and 4-6 weeks 1
   • Monitor for maintained alignment and assess healing
   • Watch for complications such as delayed union, non-union, or infection

3. Rehabilitation Timeline

   • Early mobilization to prevent stiffness and promote healing 1
   • Progressive weight-bearing based on fracture stability and healing
   • Return to activity typically between 13-19 weeks depending on protocol 1

Potential Complications and Monitoring

• Hardware irritation requiring removal
• Infection
• Delayed union or non-union (1.7% after surgical treatment) 5
• Post-traumatic arthritis
• Chronic pain (affects approximately 20% of patients) 1

Special Considerations

• For stress fractures of the medial malleolus, surgical fixation is recommended for athletes desiring early return to activity 6
• For isolated medial malleolar fractures displaced ≤2 mm, conservative treatment may be appropriate 5
• In cases with deltoid ligament avulsion, arthroscopically assisted reduction and fixation may be considered 7

Remember that proper anatomic reduction and stable fixation are crucial to prevent post-traumatic arthritis and ensure optimal functional outcomes.