For a patient with an ankle fracture, should fixation of the fibula or the medial malleolus be prioritized first in a young to middle-aged adult with a history of trauma and possible comorbidities such as osteoporosis?

Surgical Sequence for Ankle Fracture Fixation

Fix the fibula first to restore the lateral column and ankle mortise stability, which serves as the anatomical template for subsequent medial malleolus reduction. This sequence is the established surgical principle for unstable ankle fractures requiring operative intervention.

Rationale for Fibula-First Fixation

The fibula serves as the primary anatomical reference for ankle mortise reconstruction and must be addressed first:

• Restoration of fibular length and rotation is the critical first step because the fibula determines the width and alignment of the ankle mortise 1
• Lateral mortise widening confirms instability and indicates that fibular displacement has disrupted the normal ankle architecture 1
• Fibular shortening of even 3-5mm is associated with long-term degenerative changes and poor outcomes, making anatomic fibular restoration paramount 2

Surgical Algorithm

Step 1: Fibular Fixation

• Achieve anatomic reduction of the fibula first using either plate fixation (traditional standard) or intramedullary nail fixation 3, 4
• Restore fibular length, rotation, and alignment as this establishes the lateral column reference 2
• Intramedullary nail fixation reduces complications by 14 per 100 patients compared to plate fixation, with equivalent functional outcomes and union rates 4

Step 2: Assess Medial Malleolus After Fibular Fixation

• After fibular stabilization, obtain intraoperative imaging to assess medial malleolus reduction 5
• If medial malleolus displacement is ≤2mm after fibular fixation alone, selective nonfixation may be considered, though this results in radiographic nonunion in 20% of cases 5
• If displacement remains >2mm or medial clear space >4mm, proceed with medial malleolus fixation using buttress/hook plate with lag screws 1, 6

Step 3: Posterior Malleolus (If Trimalleolar)

• Address posterior malleolar fragments after lateral and medial fixation if they involve significant articular surface or contribute to instability 1
• CT imaging preoperatively helps evaluate posterior fragment size and comminution 1

Critical Technical Points

For patients with comorbidities (diabetes, neuropathy, osteoporosis):

• Use enhanced fixation techniques including locking plates for fibula, medial buttress plates, and multiple syndesmotic screws even without obvious syndesmotic injury 6
• Consider temporary transfixation pins from calcaneus to tibia for additional stability 6
• The presence of comorbidities should not preclude operative intervention, as nonoperative treatment yields poor results in unstable fractures 6

Common Pitfalls to Avoid

• Never accept fibular shortening or malrotation, as this leads to persistent mortise widening and post-traumatic arthritis in 37% of cases despite otherwise anatomic reduction 2
• Do not assume medial malleolus will reduce with fibular fixation alone without intraoperative confirmation—displacement >2mm mandates fixation 1, 5
• Failure to repair the medial collateral ligament complex (when disrupted) is associated with long-term degenerative changes and reduced mobility 2
• Inadequate assessment of syndesmotic stability after fibular fixation can lead to chronic instability 6