Case for small group discussion Malleolar fracture Case for small group discussion AOTrauma—Foot & Ankle Module 1a: Ankle trauma—ankle fractures Stefan Rammelt, DE

Case description 48-year-old woman Sports injury, mild soft-tissue swelling CT-scan shows no impaction Type of fracture? Options for reduction and fixation?

Weber’s trick

Fibular fixation Show that there is not much displacement but there is osseous stabilization of the posterior and anterior syndesmotic ligaments. Syndesmotic stability should be checked at the end of the fixation. If stable no additional syndesmotic fixation required.

Discussion points Insertion of the screws from anterior to posterior or vice versa? When to use posterior antiglide plates? Posterolateral or medial approach? Need for syndesmotic stability?

Take-home messages Large posterior malleolar fragments can be fixed from the front with lag screw Direct vision possible through fibular fracture For assessment of reduction, fix posterior malleolus first Be aware of hyperflexion mechanism of the injury Check syndesmotic stability in all cases References: Rammelt S, Zwipp H, Mittlmeier T. [Operative treatment of pronation fracture--dislocations of the ankle]. Oper Orthop Traumatol. 2013 Jun;25(3):273–291; quiz 291-3. Rammelt et al. Oper Orthop Traumatol. 2013;25:273–291 Weber BG. Die Verletzungen des oberen Sprunggellenkes. Bern: Hans Huber; 1966