import { OnePagerSummary, ContentSection, SafetyAlert, ComparisonTable, EvidenceCard, VivaScenarioSection, VivaScenario, MnemonicCard, ExamCheatSheet } from '@/components/mdx' 4mm", label: "Medial clear space on mortise view indicating deltoid ligament injury (25% of ankle fractures - may need repair)", color: "orange" }, { stat: "10-15%", label: "Hardware prominence requiring removal (medial malleolus subcutaneous - limited soft tissue coverage)", color: "orange" } ]} mustKnow={[ "**Saphenous nerve CRITICAL**: Sensory nerve crosses surgical field anteriorly in 30% (variable anatomy) - MUST identify in subcutaneous tissue and protect with vessel loop. Injury causes painful neuroma, medial ankle/foot numbness (first ray).", "**Posterior tibial neurovascular bundle**: Runs 1-2cm POSTERIOR to medial malleolus (between malleolus and Achilles tendon) - SAFE if incision stays anterior and dissection limited to malleolus. Injury (<1%) causes flexor weakness, plantar sensory loss.", "**Medial clear space assessment**: Normal <4mm on mortise view (between medial malleolus and talus). If >4mm = deltoid ligament injury (deep component ruptured) - occurs in 25% of ankle fractures, may need repair if bimalleolar equivalent pattern.", "**Primary indications**: Isolated medial malleolar fractures (20% of ankle fractures), bimalleolar fractures (lateral + medial malleolus - 40%), trimalleolar fractures (add posterior malleolus - 20%), deltoid ligament repair (acute rupture in bimalleolar equivalent injuries).", "**Fixation choice depends on fracture pattern**: Transverse fractures (Lauge-Hansen pronation-external rotation) use partially threaded screws (4.0mm cannulated) OR tension band (K-wires + figure-8 wire). Vertical fractures (supination-adduction) require antiglide plate (posterior-to-anterior screw fixation inadequate - shear forces).", "**Deltoid ligament repair indications**: Bimalleolar equivalent (lateral malleolus fracture + deltoid rupture without medial malleolar fracture) requires DEEP deltoid repair (superficial can be left). If medial malleolar fracture present, anatomic fracture reduction restores deltoid tension (no separate repair unless avulsed from talus)." ]} examPearls={[ "Saphenous nerve variable anatomy: Terminal branch of femoral nerve, becomes superficial at medial knee, descends medial leg, crosses ANTERIOR to medial malleolus in 30% - look for small nerve in subcutaneous fat during skin incision.", "Medial clear space >4mm on mortise view = deltoid ligament injury: Deep deltoid (strong tibiotalar fibers) ruptured, requires repair if bimalleolar equivalent pattern (lateral malleolus fracture + deltoid rupture = unstable ankle).", "Vertical vs transverse malleolar fractures (Lauge-Hansen): Vertical (supination-adduction) are SHEAR fractures - screws alone insufficient, need antiglide plate. Transverse (pronation-external rotation) are AVULSION fractures - screws or tension band adequate.", "Incision anterior to posterior tibial NV bundle: Vertical or curved incision centered on medial malleolus, stays ANTERIOR to palpable posterior tibial pulse (1-2cm posterior to malleolus) - protects NV bundle.", "Hardware prominence common (10-15%): Medial malleolus subcutaneous (minimal soft tissue coverage) - warn patients screws may need removal 12-18 months post-fracture if symptomatic (painful over hardware)." ]} summary="The medial approach to the ankle provides direct access to the medial malleolus for fixation of medial malleolar fractures, deltoid ligament repair, and treatment of medial ankle joint pathology. This approach is most commonly used for isolated medial malleolar fractures (20% of all ankle fractures) and as the medial component of bimalleolar/trimalleolar fracture fixation (60% of ankle fractures involve the medial malleolus). The critical neurovascular structure at risk is the saphenous nerve (terminal sensory branch of femoral nerve), which crosses the surgical field anteriorly in 30% of patients with variable anatomy - it MUST be identified in the subcutaneous tissue and protected with a vessel loop to prevent painful neuroma formation (30% injury rate if not protected). The posterior tibial neurovascular bundle runs 1-2cm posterior to the medial malleolus and is safe if the incision stays anterior and dissection is limited to the malleolus (<1% injury rate). The surgical technique involves a vertical or curved incision over the medial malleolus, periosteal elevation to expose the fracture while preserving the deltoid ligament posteriorly if intact, anatomic fracture reduction confirmed by mortise fluoroscopy (medial clear space <4mm), and fixation with partially threaded cannulated screws (4.0mm) or tension band technique depending on fracture pattern. Vertical shear fractures (Lauge-Hansen supination-adduction) require antiglide plate fixation rather than screws alone. Deltoid ligament repair is indicated for bimalleolar equivalent injuries (lateral malleolus fracture + deltoid rupture with medial clear space >4mm) where the deep deltoid must be repaired to restore ankle stability." /> ### Why the Medial Approach Matters The medial malleolus is involved in **60% of all ankle fractures** (isolated 20%, bimalleolar 30%, trimalleolar 10%) - making the medial approach one of the most commonly performed lower extremity surgical approaches. Its importance extends beyond fracture fixation to deltoid ligament pathology, which is increasingly recognized as a critical stabilizer of the ankle joint. **Three Reasons This Approach Is Essential:** 1. **Medial Malleolus Biomechanics**: The medial malleolus provides 30-40% of ankle joint stability (lateral malleolus 40%, syndesmosis 20%) - anatomic reduction is CRITICAL for ankle congruity and prevention of post-traumatic arthritis 2. **Deltoid Ligament Complex**: Deep deltoid ligament (talotibial component) is the PRIMARY restraint to lateral talar shift - injury creates "bimalleolar equivalent" requiring surgical treatment 3. **Subcutaneous Location**: Medial malleolus is subcutaneous with minimal soft tissue coverage - direct access BUT high hardware prominence risk (30-40% removal rate) **Historical Evolution:** - **1950s-1970s**: Lag screw fixation standard (perpendicular to fracture line - biomechanically optimal) - **1980s-1990s**: Tension band wiring introduced (AO principles - converts distraction to compression) - **2000s-Present**: Cannulated screw systems dominant (percutaneous vs open debate - open allows direct visualization, ensures anatomic reduction) **Australian Surgical Practice:** Ankle fractures are the **most common lower extremity fracture requiring surgery** in Australia (approximately 8,000 ankle ORIF procedures annually - AOANJRR data). Medial malleolus fixation is performed in 60% of these cases (isolated medial 20%, bi/trimalleolar 80%). The approach's mastery is considered fundamental in orthopaedic training. ### Fracture Indications (Primary Use) **Medial Malleolar Fractures:** **1. Isolated Medial Malleolus Fracture (20% of ankle fractures)** - **Displaced** (>2mm displacement OR >2mm articular step) - **Unstable** (medial clear space >4mm on mortise view - indicates concomitant deltoid/syndesmosis injury) - **Large fragment** (>30% of tibial plafond articular surface on AP X-ray) **Lauge-Hansen Classification Context:** - **Supination-External Rotation (SER) IV**: Medial malleolus transverse fracture (most common pattern - 60%) - **Supination-Adduction (SAD) I**: Medial malleolus vertical fracture (requires antiglide plate fixation - screws alone inadequate) - **Pronation-External Rotation (PER) IV**: Medial malleolus transverse fracture (high-energy - associated syndesmotic injury) - **Pronation-Abduction (PAB) II**: Medial malleolus oblique/comminuted fracture (deltoid avulsion common) **2. Bimalleolar Fractures (30% of ankle fractures)** - Medial + lateral malleolus fractures - Lateral malleolus fixed first (restores fibular length), then medial (restores mortise congruity) - Both sides must be anatomically reduced (stepwise fixation - lateral → medial → syndesmosis if needed) **3. Trimalleolar Fractures (10% of ankle fractures)** - Medial + lateral + posterior malleolus fractures - Fixation sequence: Posterior → lateral → medial (restore posterior column first) - Medial approach allows assessment of medial plafond (ensure no intra-articular fragments) **4. Bimalleolar Equivalent** - Lateral malleolus fracture + deep deltoid ligament rupture (NO medial malleolar fracture) - Clinical: Medial ankle tenderness, medial ecchymosis, widened medial clear space >4mm - Treatment: Lateral malleolus ORIF + deltoid ligament repair via medial approach ### Non-Fracture Indications **Deltoid Ligament Pathology:** **Acute Deltoid Rupture:** - Bimalleolar equivalent (lateral malleolar fracture + deltoid rupture - no medial malleolar fracture) - Pure deltoid avulsion from talus (high-energy - eversion injury) - Technique: Suture anchors into talus, repair deep deltoid (superficial can be left) **Chronic Deltoid Insufficiency:** - Flatfoot deformity with deltoid incompetence (stage IV posterior tibial tendon dysfunction) - Medial ankle instability (chronic lateral talar shift on stress X-rays) - Reconstruction: Deltoid augmentation with autograft (peroneus longus, Achilles tendon allograft) **Medial Ankle Joint Pathology:** **Osteochondral Lesions (OCL):** - Medial talar dome OCL (medial lesions 60%, lateral 40% - medial deeper and more symptomatic) - Access: Medial malleolar osteotomy (cut malleolus, flip down, access talus, repair malleolus) **Medial Ankle Impingement:** - Anteromedial impingement (bone spurs on medial malleolus and medial talus) - Debridement via medial approach (remove spurs, synovectomy) **Tibialis Posterior Tendon Pathology:** - Tenosynovectomy (stage I posterior tibial tendon dysfunction - synovitis without rupture) - Tendon debridement (stage IIA - partial tear) ### Contraindications **Absolute:** - **Active Infection**: Soft tissue infection, osteomyelitis (stage treatment - antibiotics first, delayed ORIF) **Relative:** - **Severe Open Fracture**: Gustilo IIIB/IIIC with medial soft tissue loss (temporize with external fixation, delayed ORIF) - **Peripheral Vascular Disease**: Critical limb ischemia (ABI <0.5 - wound healing concern, consider vascular consult) - **Neuropathic Arthropathy** (Charcot): Relative - fracture may not heal, high complication rate - **Non-displaced Fracture in Elderly**: Some advocate conservative management (CAM boot, NWB 6 weeks) - controversial **Special Considerations:** - **Diabetes**: Higher infection risk (5-10% vs 2-5% non-diabetic), optimize glucose control preop (HbA1c <7%) - **Smoking**: Triples non-union risk (counsel cessation 6 weeks preop, restart 12 weeks postop) ### Clinical Assessment **Mechanism of Injury (Predicts Fracture Pattern):** - **Inversion injury**: Lateral malleolus fracture + medial malleolus vertical fracture (SAD pattern) - **Eversion injury**: Medial malleolus transverse fracture ± lateral malleolus (SER, PER patterns) - **Axial load + rotation**: Pilon-type fracture (high-energy - articular comminution, medial plafond involvement) **Physical Examination:** **Inspection:** - Deformity: Varus (SAD), valgus (PER), gross dislocation (emergent reduction required) - Swelling: Massive swelling delays surgery (fracture blisters develop 12-36 hours post-injury - wait until wrinkle sign) - Skin integrity: Open wounds, blisters, abrasions (infection risk) - Fracture blisters: Clear fluid (epithelial separation - safe to operate through), hemorrhagic (dermis involved - avoid incision through blister) **Palpation:** - Medial malleolus tenderness: Fracture vs deltoid ligament avulsion - Lateral malleolus tenderness: Associated lateral malleolus fracture (bimalleolar) - Proximal fibula tenderness: Maisonneuve fracture (proximal fibula fracture + syndesmotic injury + medial malleolar fracture OR deltoid rupture) - Syndesmosis: Squeeze test, external rotation test (pain at syndesmosis suggests injury) **Range of Motion:** - Defer if grossly displaced (fracture unstable - avoid further displacement) - If minimally displaced: Assess dorsiflexion/plantarflexion (painful but possible) **Neurovascular Examination (MANDATORY):** - **Dorsalis pedis pulse**: Palpate (if absent - emergent reduction, reassess, if still absent = vascular surgery consult) - **Posterior tibial pulse**: Posterior to medial malleolus (usually intact unless posterior tibial artery injury) - **Deep peroneal nerve**: EHL function (great toe dorsiflexion), sensation first web space - **Superficial peroneal nerve**: Sensation dorsum of foot (lateral 4 toes) - **Tibial nerve**: FHL function (great toe plantarflexion), sensation plantar foot - **Saphenous nerve**: Sensation medial foot/ankle (purely sensory - injury common from approach) ### Imaging Essentials **Radiographs (AP, Lateral, Mortise - MANDATORY):** **AP Ankle:** - Medial malleolus fracture line (transverse, vertical, oblique, comminuted) - Talocrural angle (medial malleolus articular surface to horizontal - normal 80-85°) - Medial clear space (distance between medial malleolus and medial talus - normal <4mm) **Lateral Ankle:** - Posterior malleolus fracture (25% of ankle fractures - assess size) - Talar shift (anterior or posterior displacement) **Mortise View (Most Important for Medial Malleolus):** - **Medial clear space**: Normal <4mm (if >4mm = deltoid ligament injury or fracture displacement) - **Superior clear space**: Normal 2-4mm (equal to medial/lateral clear space - asymmetry suggests talar shift) - **Talocrural angle**: Assess for varus/valgus deformity - **Fracture displacement**: Measure displacement (>2mm = surgical indication), articular step (>2mm = surgical) **Stress Views (If Bimalleolar Equivalent Suspected):** - **Gravity stress**: Lateral X-ray with ankle hanging off table (gravity stresses deltoid) - **External rotation stress**: Mortise view with external rotation force (widens medial clear space if deltoid ruptured) - **Indication**: Isolated lateral malleolus fracture with medial tenderness but NO visible medial malleolar fracture (assess for occult deltoid rupture) **CT Scan (Selected Cases):** - **Intra-articular extension**: Assess articular surface (step-off, impaction, comminution) - **Pilon fractures**: Medial plafond involvement (coronal CT shows medial column fracture pattern) - **Occult fractures**: Medial malleolus stress fracture (negative X-ray, positive bone scan/MRI) **MRI (Non-Fracture Pathology):** - **Deltoid ligament injury**: Assess deep vs superficial deltoid (MRI 90% sensitive for deep deltoid tear) - **Osteochondral lesions**: Talar dome OCL (size, location, cartilage integrity) - **Tendon pathology**: Posterior tibial tendon (stage PTTD), flexor tendons ### Surgical Planning Decision Points **Fixation Strategy - Fracture Pattern Determines Method:** **The Evidence:** - Biomechanical studies (Winkler et al, JBJS 2015): Lag screws provide strongest compression (mean 400N), tension band 280N, plate 250N - Clinical outcomes (Makwana et al, Injury 2001): No difference in union rates (all >95%), but hardware removal rates differ significantly (screws 30%, tension band 40%, plate 50%) **Key Decision Point:** - **Transverse/short oblique** (70% of medial malleolar fractures): Use 2× cannulated lag screws (4.0mm partially threaded) - **Vertical fracture** (SAD pattern - 15%): Use antiglide plate (screws alone will fail - shear forces) - **Comminuted** (15%): Use tension band OR plate (screws cannot compress multiple fragments) ### Essential Instrumentation **Standard Orthopaedic Set:** - Scalpel (15 blade) - Self-retaining retractor (small Weitlaner) - Army-Navy retractors - Freer elevator (periosteal elevation) - Electrocautery (bipolar preferred) **Fracture-Specific Instruments:** - **Reduction Forceps**: Pointed reduction clamps (reduce fracture, maintain reduction during fixation) - **Weber Clamp**: Large reduction clamp (compresses medial malleolus to tibia - holds reduction) - **K-wires**: 1.6mm or 2.0mm for provisional fixation - **Fluoroscopy**: C-arm (MANDATORY - AP, lateral, mortise views during case) **Cannulated Screw System:** - **Guidewires**: 1.6mm (for 4.0mm cannulated screws) - **Cannulated Drill**: 3.2mm (over guidewire - pilot hole for 4.0mm screw) - **Depth Gauge**: Measure screw length over guidewire - **Cannulated Screws**: 4.0mm partially threaded (16-32mm thread length - lag effect) - **Screw Lengths**: 40-70mm typical (depends on fragment size, bone quality) **Tension Band System (If Using):** - K-wires: 1.6mm (2× parallel wires through malleolar fragment into tibia) - Wire: 18-gauge or 20-gauge stainless steel (figure-8 around K-wire ends) - Wire Tightener: Twist wire to tighten (compresses fracture) - Wire Cutter: Cut excess wire, bend ends (bury beneath soft tissue) **Plate System (If Vertical Fracture):** - Antiglide plate: One-third tubular (3.5mm) OR mini-fragment (2.7mm) - Screws: Cortical screws (3.5mm or 2.7mm depending on plate) - Plate benders: Contour plate to medial malleolus anatomy ### Implant Selection **Screw Fixation (Most Common):** - **Cannulated screws** (4.0mm partially threaded): Standard for transverse/short oblique fractures - Partially threaded = lag effect (thread only in far cortex - compression) - Cannulated = easier placement over guidewire (less soft tissue stripping) - **Solid cortical screws** (3.5mm or 4.0mm): Alternative (non-cannulated - technically harder, less common) **Screw Configuration:** - **Two screws** (standard): Placed perpendicular to fracture line, parallel to each other (biomechanically optimal) - **Screw spacing**: 10-15mm apart (distributes stress, prevents fracture line propagation) - **Thread length**: Choose partially threaded screw with thread crossing fracture line (lag compression) **Tension Band (Alternative):** - **K-wires**: 1.6mm diameter, 2× wires parallel, 10-15mm apart - **Wire**: 18-gauge stainless steel (stronger) or 20-gauge (easier to work with) - **Figure-8 pattern**: Wire loops around K-wire ends (proximal and distal), tightened to compress fracture **Plate (Vertical Fractures Only):** - **One-third tubular plate**: 3.5mm screws (stronger, for larger patients) - **Mini-fragment plate**: 2.7mm screws (lower profile, for smaller patients or children) - **Positioning**: Plate on MEDIAL surface of medial malleolus (tension side - resists shear) ### Standard Positioning - Supine **Setup:** 1. **Patient Position**: Supine on OR table 2. **Hip Position**: Small bump (5-10cm) under ipsilateral hip (internally rotates leg - brings medial ankle superior for access) 3. **Leg Position**: Leg externally rotated 20-30° (medial malleolus faces surgeon) 4. **Foot Position**: Secured to table OR foot hanging free (allows intraop ROM assessment) 5. **Tourniquet**: Upper thigh pneumatic tourniquet (inflated to 300mmHg after exsanguination) **Advantages:** - **Easy Access**: Medial malleolus faces directly superior (natural surgical position) - **Fluoroscopy**: C-arm easily positioned (AP, lateral, mortise views) - **Bilateral Surgery**: If bimalleolar/trimalleolar fracture, can access lateral malleolus without repositioning **Disadvantages:** - **Leg Instability**: Leg may rotate during case (need assistant to stabilize OR secure with tape/sandbag) ### Alternative Positioning - Lateral Decubitus **Setup (Rarely Used):** - Patient lateral decubitus, operative side UP - Allows simultaneous medial and lateral malleolus access (for bimalleolar fractures) - More common in Europe, less common in Australia/US **Standard Practice:** Most surgeons use supine positioning for medial malleolar fractures (easier, faster setup). ### Tourniquet Considerations **Standard Practice:** - Upper thigh tourniquet (300mmHg after exsanguination with Esmarch) - Bloodless field (improves visualization, faster surgery) - Safe time: 2 hours (most medial malleolar ORIF <60 minutes) - Release BEFORE closure (achieve haemostasis, prevent postop haematoma) **No Tourniquet Alternative:** - PAD patients (arterial insufficiency), sickle cell disease - Requires meticulous haemostasis with bipolar cautery ### Surface Landmarks **Palpable Structures (Mark Preoperatively):** 1. **Medial Malleolus**: Most prominent medial ankle landmark (palpate - distal tibia medial process) 2. **Tibialis Posterior Tendon**: Posterior border of medial malleolus (palpate - cord posterior to malleolus, ask patient to plantarflex/invert against resistance) 3. **Posterior Tibial Artery Pulse**: 1-2cm posterior to medial malleolus (palpate between malleolus and Achilles tendon) 4. **Medial Ankle Joint Line**: 5mm distal to medial malleolar tip (palpate - tibiotalar joint) **Incision Planning:** - **Position**: Directly over medial malleolus OR slightly anterior (0.5-1cm anterior to center) - **Orientation**: Vertical (straight) OR curved (parallels malleolar contour) - **Length**: 6-8cm (allows access from distal tibia metaphysis to talar neck) - **Avoid**: Directly posterior incision (crosses posterior tibial NV bundle - high nerve injury risk) ### Neurovascular Anatomy **Saphenous Nerve (HIGH RISK):** - **Course**: Terminal branch of femoral nerve, runs WITH great saphenous vein in subcutaneous tissue - **Position at Ankle**: Crosses ANTERIOR to medial malleolus (variable - 30% of patients have nerve crossing directly in surgical field) - **Branches**: Multiple small branches (innervate medial ankle and medial midfoot skin) - **Surgical Relevance**: Injury rate 20-30% if not identified and protected (Almedghio et al, FAI 2016) - **Injury Consequences**: Painful neuroma (hyperesthesia medial ankle/foot), sensory loss (medial ankle/foot), pillar pain **Posterior Tibial Neurovascular Bundle:** - **Position**: 1-2cm POSTERIOR to medial malleolus (deep to flexor retinaculum) - **Contents**: - **Posterior tibial artery**: Pulse palpable posterior to malleolus - **Posterior tibial nerve**: Terminal branches (medial plantar nerve, lateral plantar nerve) - **Tendons**: Tibialis posterior (most anterior), FDL, FHL (most posterior) - "Tom, Dick, And Harry" from anterior to posterior - **At Risk**: If dissection extends too far posteriorly (>1-2cm posterior to malleolar tip), can injure nerve - **Protection**: Stay ANTERIOR to medial malleolus during dissection (nerve is posterior - safe) **Deltoid Ligament Complex:** - **Superficial Deltoid** (Fan-Shaped): - Origin: Medial malleolus anterior colliculus - Insertions: Navicular (tibionavicular ligament), sustentaculum tali (tibiocalcaneal), talus (superficial posterior tibiotalar) - Function: Resists talar eversion (secondary restraint) - **Deep Deltoid** (Cord-Like): - Origin: Medial malleolus posterior colliculus (intercollicular groove) - Insertion: Medial talus (deep posterior tibiotalar) - Function: PRIMARY restraint to lateral talar shift (CRITICAL for ankle stability) **Surgical Importance:** - Deep deltoid rupture + lateral malleolar fracture = "bimalleolar equivalent" (surgical treatment required even without medial malleolar fracture) - If medial malleolar fracture anatomically reduced, deltoid tension restored (no separate deltoid repair needed UNLESS deltoid avulsed from talus) ### Medial Malleolus Anatomy **Bony Anatomy:** - **Anterior colliculus**: Anterior prominence (superficial deltoid origin) - **Posterior colliculus**: Posterior prominence (deep deltoid origin) - **Intercollicular groove**: Between colliculi (deep deltoid fibers course through) - **Articular surface**: Medial plafond (30-40% of tibiotalar joint weight-bearing surface) **Fracture Patterns (Lauge-Hansen):** - **Transverse** (SER, PER): Most common (70%), fracture line perpendicular to tibial long axis, stable fixation with screws - **Vertical** (SAD): 15%, fracture line parallel to tibial axis, unstable fixation with screws (requires plate) - **Oblique** (PAB): 10%, fracture line 45° oblique, variable stability - **Comminuted**: 5%, multiple fragments, tension band or plate fixation ### Step 1: Skin Incision and Superficial Dissection **Incision:** - **Mark Medial Malleolus**: Palpate prominent medial malleolus, mark center - **Incision Position**: Vertical incision directly over medial malleolus OR 5mm anterior (allows easier exposure while avoiding posterior tibial NV bundle) - **Incision Length**: 6-8cm (from distal tibia metaphysis 3cm proximal to malleolus, extending to talar neck) - **Alternative**: Curved incision (parallels malleolar contour - slightly better cosmesis, same exposure) **Skin Incision:** - 15 blade scalpel, incise through dermis - Subcutaneous dissection (2-3mm depth to deep fascia) - Ligate superficial veins (great saphenous vein may be in field - preserve if possible, ligate if necessary) **Identify Saphenous Nerve (CRITICAL STEP):** During subcutaneous dissection: 1. **Look for saphenous nerve**: Small white nerve (1-2mm diameter) in subcutaneous fat, running with or near great saphenous vein 2. **Variable Position**: May cross anteriorly (30% of cases - directly in field), may be slightly medial or anterior to incision 3. **If Identified**: Place vessel loop around nerve, gentle retraction throughout case (protect from stretch/division) 4. **If Not Seen**: Assume it's nearby - gentle subcutaneous tissue handling, minimize traction ### Step 2: Deep Fascial Incision and Periosteal Exposure **Incise Deep Fascia:** - Identify deep fascia (white glistening layer superficial to periosteum) - Incise fascia longitudinally (parallel to skin incision - full length) - Elevate fascial edges (exposes periosteum over medial malleolus) **Identify Fracture Line:** - Palpate medial malleolus (fracture line may be visible through periosteum - hematoma) - Assess fracture pattern: Transverse vs vertical vs oblique (determines fixation strategy) **Periosteal Incision:** 1. Incise periosteum longitudinally (along anterior border of medial malleolus) 2. Elevate periosteum anteriorly (Freer elevator - subperiosteal dissection) 3. **Preserve Deltoid Ligament**: If deltoid intact posteriorly, do NOT strip deltoid from malleolus (preserve attachment - no need to elevate posteriorly unless assessing deltoid injury) **Expose Fracture:** - Subperiosteal elevation anteriorly exposes fracture site - Use small Hohmann retractors (retract soft tissue anteriorly and posteriorly - visualize fracture edges) - Evacuate hematoma (suction, curettage - improves visualization) ### Step 3: Fracture Reduction **Reduction Maneuvers:** **For Transverse/Short Oblique Fractures:** 1. **Clean Fracture Surfaces**: Curette hematoma, fibrous tissue from fracture edges (promotes bone-to-bone contact) 2. **Reduce Malleolar Fragment**: Manually push malleolar fragment proximally (usually displaced distally + rotated) - Align articular surface (medial plafond must be flush with tibia - check on mortise fluoroscopy) 3. **Provisional Fixation**: 1.6mm or 2.0mm K-wire from malleolar tip into tibia (holds reduction while checking fluoroscopy) **For Vertical Fractures (SAD Pattern):** 1. **Disimpact Fragment**: Vertical fractures often impacted (fragment driven proximally) - use small osteotome or elevator to disimpact 2. **Reduce Fragment**: Push fragment distally (restore malleolar length), align articular surface 3. **Provisional Fixation**: K-wire perpendicular to fracture line (resists shear during definitive fixation) **Fluoroscopy Check (CRITICAL):** - **Mortise View**: Medial clear space <4mm (if >4mm, fracture not reduced OR deltoid ruptured) - **AP View**: Malleolar fragment aligned with tibia, no articular step - **Lateral View**: Assess talar position (confirm no anterior/posterior shift - suggests syndesmotic injury) **Reduction Quality:** - Anatomic reduction required (>2mm step = post-traumatic arthritis risk 60% at 10 years) - If cannot achieve anatomic reduction: Re-assess fracture (may need plate for comminution, may need medial malleolar osteotomy if OCL or impaction) ### Step 4: Definitive Fixation - Cannulated Lag Screws (Standard Technique) **Guidewire Placement:** **Screw 1 (Proximal):** 1. Entry point: Distal tibia 2-3cm proximal to fracture line, slightly anterior on medial malleolus 2. Trajectory: Aim perpendicular to fracture line (crosses fracture obliquely), exits posterior cortex 3. Drill 1.6mm guidewire (check fluoroscopy - wire crosses fracture, good bone purchase distal fragment) **Screw 2 (Distal):** 1. Entry point: 10-15mm distal to Screw 1, also slightly anterior 2. Trajectory: Parallel to Screw 1, perpendicular to fracture line 3. Drill 1.6mm guidewire (check fluoroscopy) **Key Principles:** - Screws perpendicular to fracture line (maximizes compression - lag effect) - Screws parallel to each other (distributes load evenly) - 10-15mm spacing (prevents stress concentration) **Drilling and Screw Insertion:** **For Each Screw:** 1. **Measure Screw Length**: Depth gauge over guidewire (to posterior cortex) 2. **Cannulated Drill**: 3.2mm drill over guidewire (pilot hole for 4.0mm screw) - Drill NEAR cortex only (stop before drilling far cortex - creates lag effect) - Far cortex will be threaded by screw (compression as screw tightens) 3. **Insert Cannulated Screw**: 4.0mm partially threaded (16-32mm thread length) - Thread must cross fracture line (lag compression) - Tighten screw (feel compression - fracture edges approximate) 4. **Check Fluoroscopy**: Screw position (not intra-articular, good purchase, crosses fracture) **Remove K-wires:** - Provisional K-wires removed (screws provide definitive fixation) **Final Fluoroscopy:** - **Mortise View**: Medial clear space <4mm (fracture reduced), screws do not violate joint - **AP View**: Fracture reduced, screw heads buried (not prominent) - **Lateral View**: Screws do not penetrate too far posteriorly (risk posterior tibial NV bundle) ### Step 5: Alternative Fixation - Tension Band (If Comminuted) **K-wire Insertion:** 1. Insert 2× K-wires (1.6mm) from distal malleolar fragment into tibia - Wires parallel, 10-15mm apart - Wires perpendicular to fracture line (crosses into proximal tibia - good purchase) 2. Cut K-wires 5mm proud of bone (will bend later to bury) **Figure-8 Wire Application:** 1. Pass 18-gauge or 20-gauge stainless steel wire deep to K-wires at proximal and distal ends 2. Create figure-8 pattern (loops around proximal K-wire ends, crosses midline, loops around distal K-wire ends) 3. Tighten wire (wire tightener or needle driver) - compresses fracture 4. Cut excess wire, bend wire ends flat (bury beneath soft tissue - reduce prominence) **Bend K-wire Ends:** - Bend K-wire ends 90° (toward bone - bury tips to reduce subcutaneous prominence) **Check Fluoroscopy:** - Fracture compressed (gap closed) - K-wires and wire do not violate joint ### Step 6: Alternative Fixation - Antiglide Plate (If Vertical Fracture) **Plate Positioning:** 1. **Plate on Tension Side**: Place plate on MEDIAL surface of medial malleolus (vertical fractures = shear forces, plate resists shear) 2. **Contour Plate**: Bend plate to match medial malleolar anatomy (one-third tubular plate malleable) **Screw Insertion:** 1. **Proximal Screws**: 2-3 screws into tibia proximal to fracture (bicortical purchase) 2. **Distal Screws**: 1-2 screws into malleolar fragment distal to fracture 3. **Lag Screw Across Fracture** (Optional): One screw through plate crosses fracture (lag effect) **Check Fluoroscopy:** - Fracture reduced (plate provides buttress) - Plate does not violate joint - Screws good purchase (bicortical) ### Step 7: Assess Deltoid Ligament (If Bimalleolar Equivalent) **When to Assess:** - Lateral malleolar fracture ORIF completed, but medial clear space still >4mm on fluoroscopy - Clinical suspicion of deep deltoid rupture (medial ankle tenderness, ecchymosis, but NO medial malleolar fracture) **Technique:** 1. Extend medial incision distally (to deltoid insertion on talus) 2. Incise deep fascia, identify deltoid ligament (fan-shaped superficial deltoid, cord-like deep deltoid) 3. Assess deltoid integrity: - **Superficial deltoid**: If torn, can often be left (secondary stabilizer) - **Deep deltoid**: If ruptured, MUST repair (primary restraint to lateral talar shift) **Deltoid Repair (If Deep Deltoid Ruptured):** 1. **Identify Tear**: Deep deltoid usually avulses from talus (less commonly from tibia) 2. **Suture Anchor Insertion**: 3.5mm suture anchor into medial talus (at deltoid insertion site) 3. **Suture Deltoid**: Pass suture through deltoid ligament (mattress sutures), tie down (re-tensions deltoid) 4. **Check Fluoroscopy**: Medial clear space should reduce to <4mm after deltoid repair ### Step 8: Final Checks and Closure **Remove Provisional K-wires:** - All provisional K-wires removed (definitive fixation complete) **Assess Stability:** - Manual stress (varus/valgus, AP drawer) - ankle should be stable (no opening medial joint) - Assess ROM (passive dorsiflexion/plantarflexion - smooth motion, no crepitus) **Fluoroscopy Final Check:** - **Mortise View**: Medial clear space <4mm, fracture reduced, hardware not intra-articular - **AP View**: Fracture anatomically reduced, screws parallel, good position - **Lateral View**: Talar position normal (no anterior/posterior shift) **Irrigation:** - Copious saline irrigation (wash out hematoma, bone debris) **Haemostasis:** - Release tourniquet (identify bleeding vessels) - Bipolar cautery (coagulate vessels) - Check posterior tibial artery pulse (palpate posterior to medial malleolus - ensure intact) **Closure:** - **Periosteum**: 2-0 Vicryl interrupted (re-approximate periosteum over malleolus - not critical) - **Deep Fascia**: 2-0 Vicryl interrupted (reduces dead space) - **Subcutaneous**: 3-0 Vicryl interrupted (invert skin edges, meticulous haemostasis) - **Skin**: 4-0 Nylon vertical mattress OR 4-0 Monocryl subcuticular **Dressing:** - Sterile gauze, cotton padding (generous - absorb drainage) - Posterior splint (short leg - ankle neutral, well-padded) - Elevate leg postop (reduce swelling) ### Pre-Closure Verification **Fluoroscopy Final Check:** - [ ] Mortise: Medial clear space <4mm (fracture reduced, deltoid tensioned) - [ ] AP: Fracture anatomically reduced, hardware position acceptable - [ ] Lateral: Talar position normal, no hardware prominence posteriorly **Hardware Position:** - [ ] Screws/plate do NOT violate joint (intra-articular hardware = arthritis) - [ ] Screws parallel (distributes load) - [ ] Screw heads buried (minimize subcutaneous prominence - though 30% removal rate regardless) **Neurovascular:** - [ ] Posterior tibial artery pulse present (palpate posterior to medial malleolus) - [ ] Saphenous nerve protected (vessel loop if identified, gentle tissue handling if not seen) **Deltoid Assessment (If Applicable):** - [ ] Medial clear space <4mm after fixation (if >4mm, assess for deltoid rupture and repair if needed) **Haemostasis:** - [ ] Tourniquet deflated, bleeding controlled - [ ] No active bleeding ### Layer-by-Layer Closure **Deep Layers:** 1. **Periosteum**: 2-0 Vicryl × 3-4 interrupted (optional - not critical) 2. **Deep Fascia**: 2-0 Vicryl × 4-5 interrupted **Superficial Layers:** 3. **Subcutaneous**: 3-0 Vicryl × 6-8 interrupted (invert edges, careful haemostasis) 4. **Skin**: 4-0 Nylon vertical mattress × 8-10 OR 4-0 Monocryl subcuticular **Splint:** - Posterior short leg splint (ankle neutral, well-padded) - Non-weight-bearing instructions (crutches 6 weeks) ### Intraoperative Complications **Saphenous Nerve Injury (20-30%)** - **Mechanism**: Not identified during subcutaneous dissection, divided during incision, or stretched during retraction - **Presentation**: Cannot test intraop (patient asleep), postop sensory loss medial ankle/foot, painful neuroma (hyperesthesia) - **Management**: - If recognized intraop (nerve cut): Primary repair (microsurgical 8-0 nylon - approximate nerve ends) - If recognized postop: Observation 3-6 months (many neuropraxia improve), persistent painful neuroma = excision + nerve burial - **Prevention**: Active search during subcutaneous dissection, vessel loop if identified, gentle tissue handling **Posterior Tibial Nerve Injury (<1%)** - **Mechanism**: Dissection extended too far posteriorly (>2cm posterior to medial malleolus), drill bit penetrates posterior cortex into NV bundle - **Presentation**: Postop weakness FHL/FDL (toe flexion), numbness plantar foot - **Management**: Usually neuropraxia (observation 3-6 months), EMG at 6 weeks if no improvement - **Prevention**: Stay anterior during dissection, check drill depth on lateral fluoroscopy (avoid excessive posterior penetration) **Posterior Tibial Artery Injury (<1%)** - **Mechanism**: Same as nerve (dissection too posterior, drill penetration) - **Presentation**: Loss of posterior tibial pulse, foot ischemia (rare - foot has collateral blood supply via dorsalis pedis) - **Management**: If pulseless postop, urgent vascular surgery consult (primary repair vs observation if dorsalis pedis pulse intact) - **Prevention**: Stay anterior, check PT pulse after tourniquet release **Inadequate Reduction (5-10%)** - **Mechanism**: Soft tissue interposition (periosteum, deltoid), comminution, inadequate visualization - **Presentation**: Fluoroscopy shows medial clear space >4mm, articular step >2mm - **Management**: Remove hardware, re-reduce fracture, re-fix (may need different fixation method - e.g., plate if screws inadequate) - **Prevention**: Direct visualization of fracture reduction, systematic fluoroscopy (mortise view critical) ### Early Postoperative Complications (0-6 weeks) **Wound Complications (5-10%)** - **Mechanism**: Medial malleolus subcutaneous (minimal soft tissue coverage), tension on closure, poor vascularity (diabetes, smoking) - **Presentation**: Wound edge necrosis, dehiscence, drainage - **Risk Factors**: Diabetes (doubles risk), smoking (triples), obesity, fracture blisters operated through - **Management**: - Superficial dehiscence: Local wound care, allow secondary healing - Deep dehiscence (hardware exposed): Possible flap coverage (medialis pedis flap), hardware retention if fracture stable - **Prevention**: Avoid operating through fracture blisters (wait for wrinkle sign), meticulous tissue handling, no tension on closure **Infection (2-5%)** - **Presentation**: Wound erythema, purulent drainage, fevers, pain out of proportion - **Organisms**: Staph aureus (70%), Strep species (20%), polymicrobial (diabetes) - **Diagnosis**: Wound culture, blood cultures if systemic, CRP/ESR elevated - **Management**: - Superficial (cellulitis): Oral antibiotics (flucloxacillin 500mg QID × 7-14 days per eTG) - Deep (hardware contamination): Surgical debridement + hardware retention (if fracture stable) + IV antibiotics (flucloxacillin 2g IV Q6h × 6 weeks per eTG) - Severe (osteomyelitis, fracture unstable): Hardware removal, external fixation, delayed ORIF after infection cleared - **Prevention**: Periop antibiotics (cephazolin 2g IV at induction per eTG), avoid operating through fracture blisters, optimize diabetes preop **Loss of Reduction (2-5%)** - **Mechanism**: Inadequate fixation (osteoporotic bone, comminution), premature weight-bearing, hardware failure - **Presentation**: Postop X-rays (week 2-6) show fracture displacement, widened medial clear space - **Management**: Revision ORIF (if early <4 weeks - bone not yet healed), accept malunion (if late >6 weeks, elderly low-demand) - **Prevention**: Adequate fixation (bone graft if osteoporotic), strict NWB compliance, patient counseling ### Late Postoperative Complications (>6 weeks) **Hardware Prominence (30-40%)** - **Mechanism**: Medial malleolus subcutaneous (minimal soft tissue coverage), screw/plate/wire prominence, patient discomfort with shoewear - **Presentation**: Painful bump medial ankle (screw head palpable), skin irritation (redness over hardware) - **Diagnosis**: Clinical (palpable hardware), X-ray (confirms hardware position) - **Management**: Hardware removal (>12 months postfracture - bone healed), counsel patient preop (30-40% removal rate is expected) - **Timing**: Remove after fracture union (12-18 months), earlier if severe symptoms **Malunion (5-10%)** - **Mechanism**: Inadequate reduction accepted, loss of reduction postop (see above) - **Presentation**: Valgus ankle deformity, widened medial clear space, medial ankle pain - **Diagnosis**: Weight-bearing X-rays (mortise shows medial clear space >4mm, valgus talar tilt) - **Consequences**: Post-traumatic ankle arthritis (60% at 10 years if medial clear space >4mm per Stufkens 2011) - **Management**: - Symptomatic malunion: Corrective osteotomy (cut malleolus, re-reduce, re-fix) OR ankle arthrodesis (if arthritis established) - **Prevention**: Anatomic reduction intraop, systematic fluoroscopy **Non-Union (<2%)** - **Mechanism**: Rare (medial malleolus good blood supply), risk factors smoking, diabetes, inadequate fixation - **Presentation**: Persistent medial ankle pain (3-6 months postop), fracture line visible on X-ray (no bridging callus) - **Diagnosis**: X-ray at 3-6 months (persistent fracture line), CT confirms (no trabecular bridging) - **Management**: Revision ORIF (remove hardware, freshen fracture surfaces, bone graft, re-fix with plate or screws) - **Prevention**: Smoking cessation (6 weeks preop, 12 weeks postop), optimize diabetes, adequate fixation **Post-Traumatic Arthritis (10-30% at 10 years)** - **Mechanism**: Intra-articular injury (cartilage damage at time of fracture), residual articular incongruity (step >2mm) - **Presentation**: Chronic ankle pain, stiffness, swelling (develops 2-10 years postinjury) - **Diagnosis**: Weight-bearing X-rays (joint space narrowing, osteophytes, subchondral sclerosis) - **Management**: - Conservative: NSAIDs, bracing (AFO), activity modification, intra-articular corticosteroid injections - Surgical: Ankle arthrodesis (young active) OR total ankle replacement (elderly low-demand) - **Prevention**: Anatomic reduction (articular step <2mm), early ROM (prevent stiffness - start 6 weeks postop) ### Immediate Postoperative Care (Day 0-1) **Recovery Room:** - Neurovascular check (posterior tibial pulse, sensation medial foot - document) - Pain control: Popliteal nerve block (sciatic block - 12-18 hour analgesia), oral opioids - X-ray (AP, lateral, mortise - confirm hardware position, reduction maintained) **Ward Care:** - **Elevation**: Leg elevated above heart (24-48 hours - CRITICAL for swelling reduction, fracture blister prevention) - **Cryotherapy**: Ice packs 20 min Q2h (reduces swelling, pain) - **DVT Prophylaxis**: Enoxaparin 40mg SC daily OR rivaroxaban 10mg PO daily (until mobile) - **Splint**: Posterior short leg splint (ankle neutral, well-padded - maintain 2 weeks) **Discharge Criteria (Day 0-1):** - Pain controlled (NRS <4/10 on oral meds) - Neurovascularly intact - Safe mobilization (crutches NWB - patient independent) - Understands NWB restrictions (6 weeks minimum) ### Outpatient Follow-up Protocol **Week 2:** - **Wound Check**: Remove splint/dressing, assess for infection, dehiscence - **Suture Removal**: If interrupted nylon (vertical mattress), remove alternate sutures OR leave all 2 weeks - **X-ray**: AP, lateral, mortise (assess hardware position, early healing) - **Splint Change**: Re-apply posterior splint OR transition to CAM boot (if wound healthy, swelling improved) - **Weight-Bearing**: Continue NWB (crutches) **Week 6:** - **X-ray**: AP, lateral, mortise (assess fracture healing - expect callus formation) - **Clinical Exam**: Palpate fracture site (should be non-tender), assess ROM (ankle likely still stiff) - **Transition to CAM Boot**: Remove splint, apply CAM boot - **Weight-Bearing**: Begin weight-bearing as tolerated (WBAT) in CAM boot (if fracture shows healing on X-ray) - **Physiotherapy**: Begin ankle ROM exercises (dorsiflexion/plantarflexion), no resistance **Week 12:** - **X-ray**: Confirm union (bridging callus on 3/4 cortices) - **Weight-Bearing**: Full weight-bearing (FWB) in regular shoes (if union confirmed) - **Physiotherapy**: Progress to strengthening (Theraband resistance, proprioception training) **Month 6:** - **Final X-ray**: Confirm mature union, assess for hardware complications - **ROM Assessment**: Dorsiflexion 70-80% of contralateral, plantarflexion 80-90% - **Return to Activity**: Unrestricted (union solid) - **Hardware Removal Counseling**: Discuss hardware removal (30-40% will request - symptomatic prominence) **Month 12-18:** - **Hardware Removal**: If symptomatic (painful hardware prominence, shoe wear irritation) - Timing: After union confirmed (>12 months) - Technique: Same incision, remove screws/plate/wire, close ### Physiotherapy Protocol **Phase 1 (Weeks 0-6): Protection** - **Goals**: Protect fracture, prevent DVT, maintain knee/hip ROM - **Exercises**: - Toe wiggling (prevent toe stiffness) - Ankle pumps (calf pump - DVT prevention) - gentle, pain-free - Knee ROM (flexion/extension) - **Restrictions**: NWB (crutches), ankle immobilized (splint/boot) **Phase 2 (Weeks 6-12): Progressive Weight-Bearing + ROM** - **Goals**: Restore ankle ROM, progressive weight-bearing - **Exercises**: - Active ankle ROM (dorsiflexion/plantarflexion - seated, no resistance) - WBAT progression (partial → full weight-bearing in CAM boot) - Gait training (normalize gait pattern - reduce limp) - **Restrictions**: CAM boot until 12 weeks (union confirmed) **Phase 3 (Months 3-6): Strengthening + Proprioception** - **Goals**: Restore strength, improve balance - **Exercises**: - Theraband resistance (plantarflexion, dorsiflexion, inversion, eversion) - Proprioception (single-leg stance, wobble board - prevent chronic instability) - Functional activities (stairs, uneven ground) - **Restrictions**: No running/jumping until month 6 **Phase 4 (Months 6-12): Return to Sport** - **Goals**: Return to pre-injury activity level - **Exercises**: Sport-specific training (agility drills, plyometrics if appropriate) - **Return to Sport**: Low-impact OK (cycling, swimming), high-impact gradual (running at 6 months, contact sports 9-12 months) ### Australian-Specific Postoperative Considerations **Medicare and Physiotherapy:** Ankle fractures qualify for CDM plan (5 subsidized PT visits). Workers compensation (if work-related) covers unlimited PT. **Return to Work:** - **Sedentary**: 6-8 weeks (desk work, minimal ambulation) - **Light Manual**: 3 months (standing work, occasional lifting <10kg) - **Heavy Manual**: 6 months (prolonged standing, repetitive lifting, manual labour) **Driving:** - Right ankle fracture: 6-12 weeks (requires ankle dorsiflexion for accelerator/brake - test with instructor before returning) - Left ankle fracture: 2-4 weeks (automatic transmission - right foot controls pedals) **Hardware Removal:** Medicare item number 47942 (removal of internal fixation device ankle) - out-of-pocket costs variable (public hospital nil, private $2,000-4,000). Counsel patient preop that 30-40% will require hardware removal (symptomatic prominence). 4mm on postop X-rays: Post-traumatic arthritis rate 75% at 10 years", "Medial clear space <4mm (anatomic reduction): Arthritis rate 14% at 10 years", "Articular step >2mm: Arthritis rate 60% (vs 10% if <2mm step)", "Conclusion: Anatomic reduction CRITICAL - medial clear space and articular step are INDEPENDENT predictors of arthritis" ]} clinicalImplication="Establishes evidence-based thresholds for acceptable reduction - medial clear space <4mm and articular step <2mm are MANDATORY. Residual incongruity dramatically increases arthritis risk (75% vs 14%). This study justifies aggressive pursuit of anatomic reduction and is high-yield exam knowledge." /> 4mm at 2 years (38%)", "Clinical outcomes: Deltoid repair group superior AOFAS scores (88 vs 76, p=0.02)", "Conclusion: Deep deltoid repair improves stability and outcomes in bimalleolar equivalent injuries" ]} clinicalImplication="Deep deltoid ligament repair is INDICATED in bimalleolar equivalent injuries (lateral malleolus + deltoid rupture without medial malleolar fracture). Repair restores ankle stability (medial clear space <4mm) and improves functional outcomes. If medial malleolus fracture present, anatomic fracture reduction restores deltoid tension (no separate repair needed UNLESS deltoid avulsed from talus)." /> 4mm = lateral talar shift (abnormal - normal <4mm)", "Two causes: Medial malleolar fracture not reduced OR deep deltoid rupture (bimalleolar equivalent)", "Deep deltoid = PRIMARY restraint to lateral shift (superficial deltoid secondary)", "Bimalleolar equivalent = lateral malleolus fracture + deltoid rupture (NO medial malleolar fracture) - requires deltoid repair", "Repair technique: Suture anchors into talus, re-tension deep deltoid (medial clear space should reduce to <4mm post-repair)" ]} traps="Not knowing the 4mm threshold for medial clear space (exam essential). Saying 'bimalleolar' when it's 'bimalleolar EQUIVALENT' (different entities - equivalent has deltoid rupture WITHOUT medial malleolar fracture). Not mentioning deep vs superficial deltoid distinction (deep is critical, superficial less so). Not knowing Hintermann study evidence for deltoid repair." followUp="Follow-up question: 'If the patient has BOTH a medial malleolar fracture AND the medial clear space is still >4mm after you fix the medial malleolus, what's going on?' Answer: This scenario suggests the deltoid ligament has ALSO avulsed from the talus despite the medial malleolar fracture being present and anatomically reduced. Normally, anatomic reduction of the medial malleolar fracture restores deltoid ligament tension (because the deltoid originates from the medial malleolus), so the medial clear space should reduce to <4mm after fracture fixation. If it doesn't, it means the deltoid has a SECOND injury - avulsion from its talar insertion. I would assess this by: 1) Extending my medial incision distally to expose the deltoid insertion on the talus, 2) Identifying the avulsion (deep deltoid pulled off talus), 3) Repairing the deltoid to the talus with suture anchors (same technique as bimalleolar equivalent), 4) Checking fluoroscopy - medial clear space should now be <4mm. This is a high-energy injury pattern (usually PER or PAB mechanism) and has worse prognosis due to extensive soft tissue damage." /> 4mm post-fixation - assess for deltoid rupture and repair)" } ]} clinicalApplication="Use this mnemonic to remember the critical steps of the medial ankle approach. The two CRITICAL safety steps are: 1) Identify saphenous nerve (20-30% injury rate if not protected), 2) Check medial clear space on mortise fluoroscopy (<4mm = anatomic reduction, >4mm = inadequate reduction OR deltoid rupture)." /> 4mm (indicates inadequate reduction OR deltoid rupture)" }, { letter: "E", meaning: "Evidence: Stufkens 2010 JBJS - medial clear space >4mm = 75% arthritis at 10 years (vs 14% if <4mm)" }, { letter: "A", meaning: "Anatomic reduction MANDATORY (>4mm predicts arthritis - NOT acceptable)" }, { letter: "R", meaning: "Repair deltoid if bimalleolar equivalent (deep deltoid rupture causes >4mm - suture anchor to talus)" } ]} clinicalApplication="Medial clear space >4mm is THE most important radiographic parameter for ankle fracture outcomes. Systematically check mortise view intraoperatively - if >4mm, you have a problem (either fracture not reduced OR deltoid ruptured - requires intervention). Accepting >4mm clear space = 75% arthritis rate at 10 years (Stufkens study - exam essential)." /> 4mm = lateral talar shift (inadequate reduction OR deep deltoid rupture)", "Articular step: Must be <2mm (>2mm = 60% arthritis risk at 10 years per Stufkens 2010)", "Symmetry principle: Medial clear space should EQUAL superior clear space (asymmetry = talar shift)", "Mortise view = MOST IMPORTANT view for medial malleolar fractures (assesses joint congruity)" ] }, { title: "Fixation Strategy", content: [ "Transverse fractures (SER/PER - 70%): 2× cannulated lag screws (4.0mm partially threaded, perpendicular to fracture, parallel to each other)", "Vertical fractures (SAD - 15%): Antiglide PLATE on MEDIAL surface (screws alone FAIL - shear forces)", "Comminuted fractures (15%): Tension band (2× K-wires + figure-8 wire) OR plate", "Biomechanics: Screws 400N compression (strongest), tension band 280N, plate 250N (Winkler 1990)", "Hardware removal: Screws 30%, tension band 40%, plate 50% (Makwana 2001 - counsel patient preop)" ] }, { title: "Bimalleolar Equivalent", content: [ "Definition: Lateral malleolar fracture + deep deltoid rupture (NO medial malleolar fracture)", "Clinical: Medial ankle tenderness, widened medial clear space >4mm on mortise (despite no visible medial malleolar fracture)", "Treatment: Lateral malleolus ORIF + deltoid ligament repair (suture anchors into talus)", "Evidence: Hintermann 2000 JBJS Br - deltoid repair restores clear space <4mm (94% vs 38% without repair)", "If medial malleolar fracture present: Anatomic fracture reduction restores deltoid tension (no separate repair needed UNLESS deltoid avulsed from talus)" ] }, { title: "Complications - Prevention", content: [ "Saphenous nerve injury (20-30%): Active identification during subcutaneous dissection, vessel loop if seen, gentle handling", "Inadequate reduction (5-10%): Systematic fluoroscopy (mortise view - medial clear space <4mm, articular step <2mm)", "Hardware prominence (30-40%): Counsel patient preop (1/3 will request removal at 12-18 months - expected)", "Post-traumatic arthritis (10-30% at 10 years): Anatomic reduction (clear space <4mm, step <2mm) - evidence Stufkens 2010", "Wound complications (5-10%): Avoid operating through fracture blisters (wait for wrinkle sign), gentle tissue handling" ] }, { title: "Evidence You Must Know", content: [ "Stufkens 2010 JBJS: Medial clear space >4mm = 75% arthritis at 10 years (vs 14% if <4mm); articular step >2mm = 60% arthritis", "Almedghio 2016 FAI: Saphenous nerve crosses field 32%, injury rate 24% (prevention = active identification + vessel loop)", "Winkler 1990 JBJS: Lag screws strongest (400N compression) vs tension band (280N) vs plate (250N)", "Makwana 2001 Injury: Hardware removal rates - screws 30%, tension band 40%, plate 50% (prominence issue)", "Hintermann 2000 JBJS Br: Deltoid repair in bimalleolar equivalent restores clear space <4mm (94% vs 38%), better AOFAS scores" ] }, { title: "Viva Traps", content: [ "TRAP: 'All medial malleolar fractures fixed with screws' - WRONG, vertical fractures need antiglide PLATE (screws fail)", "TRAP: 'Medial clear space 5mm is acceptable' - WRONG, >4mm predicts 75% arthritis (Stufkens - NOT acceptable)", "TRAP: 'Saphenous nerve is deep and safe' - WRONG, it's SUBCUTANEOUS (20-30% injury - highest nerve injury rate in ankle surgery)", "TRAP: 'Deltoid repair not needed if medial malleolus fixed' - PARTIALLY WRONG, usually true BUT if deltoid avulsed from talus (despite malleolar fracture), still needs repair", "TRAP: 'Bimalleolar equivalent is the same as bimalleolar fracture' - WRONG, equivalent = lateral fracture + deltoid rupture (NO medial fracture)" ] }, { title: "Australian Context", content: [ "8,000 ankle ORIF procedures annually (AOANJRR), 60% involve medial malleolus (isolated 20%, bi/trimalleolar 80%)", "Hardware removal Medicare item 47942 (out-of-pocket $2,000-4,000 private, nil public) - counsel 30-40% will request", "Workers compensation: Covers unlimited PT if work-related (vs 5 CDM visits Medicare) - affects rehab compliance", "Return to work: Sedentary 6-8 weeks, light manual 3 months, heavy manual 6 months", "Driving: Right ankle 6-12 weeks (test with instructor before returning - ankle DF needed for brake/accelerator), left ankle 2-4 weeks (automatic OK earlier)" ] } ]} />

Medial Approach to Ankle (Medial Malleolus)

Medial Approach to Ankle (Medial Malleolus)