From the Research
The best treatment for a comminuted fracture of the medial malleolus extending into the tibiotalar joint is open reduction and internal fixation (ORIF) surgery, as it provides the most effective means of achieving anatomical reduction and stable fixation, thereby minimizing the risk of post-traumatic arthritis and restoring normal ankle biomechanics. This procedure involves surgically exposing the fracture site, anatomically reducing the fracture fragments, and securing them with hardware such as screws, plates, or tension band wiring. For comminuted medial malleolus fractures with intra-articular extension, cancellous lag screws (typically 4.0mm) are often used in combination with buttress or neutralization plates to provide stability, as seen in the study by 1.
The importance of anatomical reduction and stable fixation in medial malleolus fractures is highlighted by the study by 2, which demonstrated that restoration of anatomical alignment and stability through fixation significantly improves contact characteristics in the tibiotalar joint. Furthermore, the study by 3 showed that both ORIF and closed reduction and percutaneous fixation (CRPF) resulted in acceptable radiographic outcomes and low complication rates for the treatment of medial malleolus fractures, but ORIF is generally preferred for comminuted fractures with intra-articular extension.
Post-operatively, the patient should be immobilized in a below-knee cast or removable boot for 6-8 weeks, with weight-bearing restrictions for the first 4-6 weeks depending on fracture stability and fixation quality. Physical therapy should begin after immobilization to restore range of motion, strength, and proprioception. The use of mini-screws only for fixation of small fragments in medial malleolus fractures, as described in the study by 1, is a novel and effective technique that can provide safe and stable fixation for young adult patients.
In cases where ORIF is not possible due to severe comminution or poor bone quality, alternative approaches such as external fixation or primary arthrodesis may be considered, but these are generally reserved for salvage procedures. The study by 4 demonstrated the importance of understanding the local anatomy and restoring the distorted anatomy to optimize patient function, and the study by 5 highlighted the need for thorough exploration of the zone of injury to identify and address any surrounding pathologic features.
Key points to consider in the treatment of comminuted medial malleolus fractures include:
- Anatomical reduction and stable fixation are crucial to prevent post-traumatic arthritis and restore normal ankle biomechanics
- ORIF is generally preferred for comminuted fractures with intra-articular extension
- Cancellous lag screws and buttress or neutralization plates can be used to provide stability
- Mini-screws only can be used for fixation of small fragments in medial malleolus fractures
- Post-operative immobilization and physical therapy are essential to restore range of motion, strength, and proprioception.