Surgical Discussion

Patient positioning:  Recovery position.

Anatomical surgical approach:  Lateral and medial posteromedial

My approaches were planned to allow confident reduction of the fibular through a direct lateral approach. Needing access to the PM and PL fragments the interval between tibialis posterior and FDL was most sensible. Therefore, a lateral and MPM is easiest in this case. The MPM can be curved anteriorly along the tib post course to allow access the anterior collicular fracture.

The MPM approach allowed me to reduce the PM fragment which was initially K wired in position. The PL fragment was then reduced and K wired in position before application of plate. The type 3 plate fitted best in this ankle with an additional headless PM screw to ensure reduction and rigid fixation of both fragments.

The fibular was redcued and I was able to lag before plate application. The anterior collisular fracture was reduced and fixed with a small headless screw. The syndesmosis was screened and as unstable was fixed with x1 screw. This is important as just fixing the PM fracture doesn't mean the anterior syndesmosis is not still unstable.

Postoperative protocol:   2 weeks NWB in a back slab. Conversion to Vacuum cast boot at 2 weeks to allow full weightbearing. Wean out of boot at 6 weeks.

Orthopaedic implants used:   Volition (Orthosolutions), Accumed Headless 3.5mm screws