Updated: 10/9/2017

Ankle Simple Bimalleolar Fracture ORIF with 1/3 Tubular Plate and Cannulated Screw of Medial Malleolus

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Preoperative Patient Care

A

Outpatient Evaluation and Management

1

Obtain focused history and performs focused exam

  • recognize implications of soft tissue injury
  • check neurovascular status

2

Interpret basic imaging studies

  • interpret triplanar radiographs of the ankle

3

Makes informed decision to proceed with operative treatment

  • describes accepted indications and contraindications for surgical intervention

4

Modifies and adjusts post-operative treatment plan as needed

  • postop: 2-3 week postoperative visit
  • remove sutures
  • wound check
  • remove splint and place in short-leg cast boot, non-weight bearing
  • can allow ROM if soft tissue is appropriate
  • postop: 6 weeks
  • advance weight-bearing status in CAM boot
  • advance rehabilitation
  • if syndesmotic screw(s) placed, need to be non-weightbearing
  • postop: 12 Weeks postoperative visit
  • advance weight-bearing if diabetic, insensate, or syndesmotic screws present
  • syndesmotic screws to stay in for at least 12 weeks
B

Advanced Evaluation and Management

1

Recognizes indications for and provides non-operative treatment of an unstable fracture

  • diabetes
  • medical comorbidities
  • noncompliance

2

Capable of treating complications both intraoperatively and post-operatively

  • wound breakdown following malleolar fixation

3

Appropriately orders and interprets advanced imaging studies

  • stress views
  • CT scan

4

Provides a comprehensive assessment of most fractures on imaging studies

C

Preoperative History and Physical

1

Obtain history and perform basic physical exam

  • document neurovascular status

2

Order basic imaging studies

  • order weight bearing triplanar radiographs of the ankle

3

Splint fracture appropriately

  • place in posterior splint with stirrups

4

Perform operative consent

  • describe complications of surgery including
  • wound breakdown (4-5%)
  • superficial and deep infections (1-2%, up to 20% in diabetics, peripheral neuropathy)
  • hardware loosening and/or failure (highest incidence in neuropathic patients)
  • post-traumatic arthritis

Operative Techniques

E

Preoperative Plan

1

Radiographic templating of fracture

  • identify ankle fracture pattern (Lauge-Hansen SA, SER, PA, PER) based on mechanism and pre/post-reduction xrays
  • systematically make list of damaged structures that need to be repaired

2

Execute surgical walkthrough

  • resident can describe the key steps of the procedure verbally to the attending prior to the start of the case
  • describe potential complications and steps to avoid them
F

Room Preparation

1

Surgical instrumentation

  • small fragment set (2.0/2.5/2.7/3.5mm drill bits, 2.7/3.5mm cortical screws, 4.0mm cancellous screws, 1/3 tubular plates)
  • 4.0mm cannulated screws (guidewires, 2.5mm cannulated drill, 4.0mm cannulated partially threaded screws, washers)

2

Room setup and equipment

  • radiolucent table
  • c-arm from contralateral side, perpendicular to table, monitor at foot of bed

3

Patient positioning

  • supine with feet at the end of the bed, bump under hip to get limb into neutral rotation (patella pointed towards ceiling)
  • thigh tourniquet optional
  • can elevate distal limb with bump or foam to minimize overlap from other ankle during lateral radiograph
G

Lateral Malleolus Approach

1

Mark fibula anatomy and fracture site

  • mark out lateral malleolus and anterior and posterior borders of fibula
  • mark estimated location of fracture site
  • check with C-arm if unsure

2

Make incision

  • perform a straight longitudinal incision 4-6cm in length centered on fracture
  • make incision along posterior fibula if access to the posterior malleolus is needed
  • create full thickness flaps over distal fibula
  • ensure hemostatsis with cautery

3

Dissect through subcutaneous tissue

  • proximally, use tenotomy scissors to spread subcutaneous tissue in vertical direction with minimal soft tissue stripping
  • identify superficial peroneal nerve with more proximal fractures

4

Perform 2-3mm subperiosteal dissection at fracture edges with scalpel

  • extraperiosteal dissection more proximal and distal to fracture site with knife and/or wood handled elevator
H

Lateral Malleolus Reduction

1

Prepare the fracture

  • open fracture site with Freer elevator
  • remove hematoma and interposed soft tissue with curettes, small rongeur and right angle snap

2

Reduction

  • use reduction tenaculums to reduce fracture using hand rotation and contralateral thumb to help guide fragments together
  • lobster clamp has good hold on bone but damages more periosteum
  • pointed clamps have a more fine-tuned feel for reduction
  • need to be perpendicular to vector of fracture line
  • apply pressure, then pronate hand to bring fibula out to length for right sided fractures, supinate for left sided fractures (SER patterns)
  • use another clamp to hold reduction once achieved
I

Lateral Malleolus Lag Screw and Plate Fixation

1

Drill holes

  • mark out perpendicular line to fracture and place 2.7/3.5mm drill bit with sleeve on superior ridge of fibula in same perpendicular line
  • drill first cortex only with 2.7mm drill (for 2.7mm screw) or 3.5mm drill (for 3.5mm screw)
  • insert 2.0mm sleeve into hole (2.7mm screw) or 2.5mm sleeve (3.5mm screw)
  • drill far cortex with 2.0 bit (2.7mm screw) or 2.5mm bit (3.5mm screw)
  • can countersink first cortex to increase surface area distribution for screw
  • use depth gauge to measure length

2

Insert screw

  • keep depth gauge in drill hole to maintain orientation for screw placement
  • insert lag screw and hand tighten carefully to not break bone
  • watch for compression across fracture site

3

Place Fixation with 1/3 tubular plate

  • determine length of plate
  • check placement on C-arm
  • plan out 2 vs. 3 bicortical 3.5mm screws above and below fracture site
  • plan hole placement for possible syndesmotic screw placement
  • screw fixation will contour plate in non-osteopenic bone
  • contour distal aspect of plate if poor bone or very distal screw placement
  • contouring is done by by bending against screw driver tip or using handheld plate benders
  • distal fibula typically flares out laterally and then in more distally
  • insert screws
  • drill bicortically with 2.5mm drill bit, then use depth gauge
  • insert appropriate length 3.5mm screw, alternating proximal to fracture then distal
  • 4.0mm cancellous screw used in this instance
  • alternatively, can drill and place a unicortical locking screw
  • antiglide plate technique
  • determine length of 1/3 tubular plate needed ( typically 6-8holes)
  • prepare fracture
  • identify apex of fracture spike posteriorly
  • plate fixation
  • place plate posteriorly over spike, ensuring appropriate proximal-distal placement
  • clamp plate to bone proximally and drill/place non-locking screw in proximal hole in plate
  • drill and place another non-locking screw in the hole just proximal to the fracture line to obtain a reduction
  • place another screw proximally
  • distally, you can place a lag screw if desired, or place 1-2 screws to stabilize distal fragment
  • confirm Plate & Screw Position
  • check with C-arm on mortise and lateral views
J

Medial Malleolus Approach

1

Superficial Dissection

  • Make 10cm longitudinal, curved incision on medial ankle
  • begin 5cm proximal to medial malleolus over subcutaneous tibia
  • continue incision across anterior third of medial mallelous
  • this can be curved apex anteriorly for improved visualization of the ankle joint
  • finish 5cm distal and 5cm anterior to tip of medial malleolus
  • mobilize skin flaps
  • identify and protect long saphenous vein just anterior to medial malleolus
  • identify and protect long saphenous nerve, if possible, next to vein
  • clear remaining tissues down to periosteum

2

Deep dissection

  • expose fracture site
  • incise the anterior joint capsule to visualize joint and dome of talus
  • split fibers of deltoid ligament to allow hardware to seat directly on bone
  • posterior tibial tendon should be visualized to ensure that it remains intact
K

Medial Malleolus Reduction and Fixation

1

Prepare fracture site

  • evert the foot to increase exposure of the fracture site
  • remove any loose bodies or osteochondral defects
  • visualize posterior tibial tendon for potential tears

2

Reduce fracture

  • use 2.0-2.5 mm drill bit to drill a unicortical hole 2 cm proximal to fracture site
  • place a pointed reduction clamp and compress across fracture
  • place additional clamp over distal fragment to control position of distal fragment

3

Confirm reduction with mortise view

4

Obtain screw fixation

  • for cortical (solid) screws
  • use 2.5mm drill bit to drill from tip of malleolus proximally
  • can drill unicortically or bicortically
  • bicortical screws more biomechanically sound
  • place cortical screws (70-100mm) if bicortical
  • place partially threaded cancellous screw (typically ~45mm) if unicortical
  • drill and place second screw
  • screw placement should not be posterior in malleolus
  • posterior placement increases posterior tibial tendon irritation
  • for cannulated screws
  • insert 2 parallel k-wires from 4.0mm cannulated screw set across fracture site
  • k-wires to be overlapping on AP view and directed ~60 degrees up through fracture avoiding articular surface
  • on lateral view, K-wires need to be parallel and evenly spaced apart
  • use cannulated drill over first k-wire
  • can use unicortical or bicortical technique
  • place screw across fracture and drill/place second screw
L

Syndesmosis Exam & ORIF

1

Syndesmosis Exams

  • Cotton Test
  • reduction tenaculum is placed ~2cm above joint and lateral pull applied
  • opening of the syndesmosis is indicative of a positive stress test
  • External Rotation Stress Test
  • firmly hold proximal tibia
  • contralateral hand dorsiflexes and externally rotates foot
  • if increased opening of tibia-fibular overlap on mortise view syndesmosis is injured
  • anterior-posterior instability exam is most sensitive for syndesmosis injury

2

Syndesmosis Reduction

  • formally open the anterior aspect of the syndesmosis (anterior to fibula)
  • remove interposing tissue if preventing reduction
  • place Weber pointed clamp or large periarticular clamp across syndesmosis
  • one tine on medial tibia and other in screw head or empty screw hole on fibula
  • hold foot in neutral dorsiflexion and inspect syndesmosis from lateral incision
  • make sure no bump under heel (will translate talus and cause malreduction)
  • tighten clamp to maintain reduction
  • inspect syndesmosis from lateral incision to ensure anatomic reduction

3

Cortical Screw Fixation

  • use 2.5mm (or 3.5mm) long drill bit to drill across fibula into tibia
  • drill bit orientation parallel to joint 2-4cm above joint
  • drill bit is angled ~20-30° posterior to anterior due to fibular position in syndesmosis
  • can drill either 3 or 4 cortices
  • can use either 3.5/4.5mm screws
  • remove large clamp

4

Confirm reduction and implant placement

  • obtain final AP, mortise, and lateral radiographs

5

Treat intraoperative and postoperative complications

  • wound breakdown following malleolar fixation
N

Wound Closure

1

Irrigation and hemostasis

  • irrigate wounds thoroughly and deflate tourniquet if used
  • cauterize any bleeding vessels
  • watching out for saphenous vein medially and SPN laterally

2

Deep closure

  • Use 0-vicryl to close deep fascia over plate
  • ensure no entrapment of the SPN

3

Superficial closure

  • 2-0 vicryl for subcutaneous tissue
  • 3-0 nylon for skin with horizontal mattress stitches
  • in diabetics or patients with high risk for skin breakdown use modified Allgower-Donati stitch to reduce tension on skin

4

Dressing and immediate immobilization

  • soft incision dressing followed by AO splint with extra padding under heel for immobilization
  • crutches or walker for ambulation

Postoperative Patient Care

O

Perioperative Inpatient Management

1

Discharge patient appropriately

  • take xrays of the ankle in postop to verify reduction
  • oral pain meds
  • schedule follow up
  • wound care instructions
  • outpatient PT
R

Complex Patient Management

1

Develops unique, complex post-operative management plans

 

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