Surgical Discussion

Patient positioning:  The patient was positioned supine on the operating table with the affected limb wedged under ipsi and contralteral hemipelvis to allow for access to both posteromedial and lateral aspects of the ankle from a supine position.

Anatomical surgical approach:  A medial approach was utilized to expose the medial malleolus, allowing for direct visualization and management of the multifragmentary fracture. A modified posteromedial window was created for reduction and fixation of the posterior malleolus using a mini fragment plate. The lateral malleolus was approached laterally, with additional exposure posteriorly for anti-glide plate placement.

Intraoperative findings confirmed the complexity of the medial malleolus fracture, with multiple avulsion fragments complicating reduction efforts. Intraoperative 3D Cone Beam imaging facilitated radiologically guided reconstruction of the medial joint mortise. Fragment-specific fixation was achieved using a 2.0 mm mini fragment plate and locking screws, supplemented by transosseous sutures for posterior avulsions and a suture anchor for the anterior collicular fragment. The lateral malleolus required dual plating due to unexpected multifragmentary nature, with a 2.4 mm posterior anti-glide plate and a 2.7 mm lateral plate employed to stabilize the fracture. Syndesmotic stabilization was achieved with two tricortical screws.

Postoperative protocol:   Postoperatively, the patient was placed in a non-weight-bearing status for six weeks, with gradual progression to partial weight-bearing as tolerated. Range of motion exercises were initiated early to prevent stiffness, with emphasis on maintaining joint mobility.

Follow up:   Not specified.

Orthopaedic implants used:   2.0 mm mini fragment plate, 2.4 mm posterior anti-glide plate, 2.7 mm lateral plate, suture anchor, transosseous sutures, two tricortical syndesmotic screws.