Steps of Fibular Plating (ORIF of the Lateral Malleolus/Fibula)

1. Patient Positioning

• Supine with a bump/sandbag placed under the ipsilateral buttock to internally rotate the limb and bring the lateral side up
• Alternatively, prone if a posterolateral approach is planned (e.g., trimalleolar fractures, antiglide plate technique)
• Apply a tourniquet to the thigh if desired
• Fluoroscopy (C-arm) positioned for intraoperative imaging

2. Approach - Lateral/Posterolateral

• Make a longitudinal incision along the posterior margin of the fibula, centered over the fracture site
• Extend approximately 2 cm distal to the tip of the lateral malleolus if needed
• Identify and protect neurovascular structures:
  • Sural nerve and short saphenous vein running posterior to the fibula
  • Superficial peroneal nerve crosses from posterior to anterior compartment ~10 cm proximal to the tip of the fibula
  • Terminal branches of the peroneal artery lie deep to the medial surface of the distal fibula (stay subperiosteal to avoid injury)
• Elevate skin flaps with their subcutaneous tissue intact

• Preferred for antiglide plating or when accessing the posterolateral tibia (Volkmann's fragment) through the same incision
• Allows bicortical distal fixation in a posterior-to-anterior direction

3. Deep Dissection and Fracture Exposure

• Longitudinally incise the periosteum of the subcutaneous surface of the fibula
• Strip only just enough periosteum to expose the fracture site - preserve soft tissue attachments to maintain blood supply
• Expose the fibula in an extraperiosteal fashion
• Irrigate the fracture site; remove hematoma and small loose osseous/chondral fragments
• Identify fracture pattern and assess for comminution

4. Fracture Reduction

• Use bone reduction forceps (pointed reduction tenaculum / Weber clamps) to achieve anatomic reduction
• Restore fibular length, rotation, and alignment - these are the critical elements
• For oblique/spiral fractures: reduction clamp placed longitudinally across the fracture
• For comminuted fractures: indirect reduction techniques to restore fibular length (often with the plate itself as a tension device)
• Confirm reduction with fluoroscopy (AP, lateral, and mortise views)
• Temporary K-wire fixation can hold the reduction while definitive fixation is applied

5. Lag Screw Fixation (if applicable)

• If the fracture is sufficiently oblique, with good bone stock and no comminution:
  • Insert 1-2 interfragmentary lag screws from anterior to posterior
  • Space screws approximately 1 cm apart
  • Screws must engage the posterior cortex but must NOT protrude enough to encroach on the peroneal tendon sheaths
  • This provides interfragmentary compression before neutralization plating

6. Plate Selection and Contouring

• Contour the plate to match the fibula if using a non-precontoured implant
• Precontoured anatomic plates (available as left/right specific) reduce the need for bending

7. Plate Placement

• Apply the plate to the lateral surface of the fibula
• Center the plate over the fracture site
• Provisionally hold the plate with a K-wire or bone forceps

• Apply the plate to the posterior surface of the fibula
• The plate buttresses against the proximal spike of the distal fragment, resisting shear forces
• Particularly advantageous in osteoporotic bone

8. Screw Fixation

• Proximal to fracture: Insert 3 cortical screws into the fibular shaft
  • Use bicortical fixation for maximum purchase
  • Standard: 3.5 mm cortical screws for 1/3 tubular plates
• Distal to fracture: Insert 2-3 screws into the distal fragment/lateral malleolus
  • Use unicortical cancellous screws below the level of the tibial plafond (to avoid violating the joint)
  • For locking plates: locking screws provide angular stability, especially valuable in osteoporotic bone
• For larger patients or more proximal fractures: use a 3.5 mm dynamic compression plate (DCP)

9. Syndesmotic Assessment and Fixation (if needed)

• After fibular fixation, test the syndesmosis with the Cotton test or hook test under fluoroscopy
• If the syndesmosis is unstable (>2 mm of lateral talar shift, or positive hook test):
  • Insert a syndesmotic screw (3.5 or 4.5 mm cortical) or suture button
  • Can be placed through a hole in the fibular plate or directly against the fibula
  • Directed from lateral fibula to anteromedial tibia, ~2-4 cm above the joint, engaging 3-4 cortices
  • Ankle dorsiflexed to 10° during insertion to avoid over-compression of the syndesmosis

10. Fluoroscopic Check

• Confirm fracture reduction and hardware position with intraoperative fluoroscopy (AP, lateral, mortise views)
• Verify:
  • Anatomic reduction of the fracture
  • Restoration of fibular length and alignment
  • No intra-articular screw penetration
  • Symmetric ankle mortise (medial clear space = superior clear space = ~4 mm)
  • No peroneal tendon impingement from posterior screw tips

11. Wound Closure

• Irrigate wound thoroughly
• Close periosteum/deep fascia if possible
• Interrupted sutures for skin closure - handle with care as lateral ankle skin has relatively poor blood supply
• Subcuticular or interrupted skin sutures
• Sterile dressing and posterior plaster slab or splint in neutral dorsiflexion

Key Anatomic Dangers to Avoid

Plate Options Summary

• 1/3 tubular plate - most common for simple Weber B fractures; low profile
• 3.5 mm DCP/LCP - for larger patients or more proximal fractures
• Antiglide plate (posterolateral) - for oblique fractures, osteoporotic bone
• Precontoured locking periarticular plate - for comminuted/osteoporotic distal fibula; fixed-angle construct