Surgical Discussion

This case was done supine on a radio translucent operating table. I addressed the lateral side initially and focused on dissection anteriorly to demonstrate the avulsion. Reduction of the tubercle was unremarkable following evacuation of haematoma and extrication of folded periosteal tissue. This was then secured with the 4.0 mm cannulated screw. Following reduction of the tubercle the distal fibula spontaneously reduced and required minimal secondary manipulation. Consequently reduction and fixation of the fibula fracture was relatively straightforward. The placement of the syndesmosis transfixation screw was a perhaps redundant belt and braces approach to maintaining stabilisation of the syndemosis although no injury to the PITFL was identified. A second incision medially to address the transverse avulsion fracture of the medial malleolus was relatively straightforward and again fixed with the 4.0 mm cannulated screw. In our department we have the benefit of intraoperative 3D imaging. This was performed at the end of fixation to assess reduction of both the tubercle avulsion and ultimately the reduction of the fibula and syndesmosis.