Medial Malleolus Plating

Overview

Indications for Plate Fixation

From Miller's Review of Orthopaedics 9th Ed: "Medial buttress plate/screws parallel to joint - vertical fracture patterns (supination-adduction). Compression of fracture through plate affords neutralization function additionally."

Fracture Pattern Context: SAD Type 2

• The shear forces are directed vertically - a horizontally placed lag screw will not resist this
• The plate is applied to the medial surface, acting as a buttress/antiglide construct
• The fibular fracture (transverse, at or below the joint) may be stabilized with a plate, nail, or tension band
• Rockwood & Green's Fractures in Adults 10th Ed 2025, p. 3423
• Miller's Review of Orthopaedics 9th Ed, p. 6006

Surgical Technique (ORIF Medial Malleolus with Plate)

Patient Setup and Approach

• Position: Supine with a bolster under the ipsilateral hip to rotate the limb medially; radiolucent platform elevating the ankle is useful for fluoroscopy
• Tourniquet: Applied; inflate to 250-325 mmHg after exsanguination
• Incision: Anteromedial, beginning ~2 cm proximal to the fracture line, extending distally and slightly posteriorly, ending ~2 cm distal to the tip of the medial malleolus
  • This protects the posterior tibial tendon and sheath
  • Allows visualization of the anteromedial articular surface
  • Protect the greater saphenous vein and its accompanying nerve
• Skin handling: The blood supply to this region is poor - handle with care, reflect the flap intact with underlying subcutaneous tissue to avoid skin sloughing

Reduction

1. The distal fragment is typically displaced distally and anteriorly
2. A small fold of periosteum is commonly interposed at the fracture site - this must be removed sharply to expose the fracture surfaces
3. Debride small loose osseous/chondral fragments; preserve and bone graft large osteochondral fragments
4. Reduce the malleolus with a bone-holding clamp or pointed tenaculum
5. Hold reduction with 1.6-2 mm smooth K-wires as temporary fixation

Plate Application

• Verify reduction with AP and lateral fluoroscopy
• Apply a small one-third tubular plate or low-profile minifragment plate as a buttress
• Place screws parallel to the joint surface (orthogonal to the vertical fracture line) to achieve compression across the fracture
• For very small or comminuted fragments: minifragment screws, K-wires, or tension band wiring may supplement or replace the plate

Campbell's Operative Orthopaedics 15th Ed 2026: "Large vertical fractures of the medial malleolus that involve proximal comminution often require a buttress plate to prevent loss of reduction; a small, one third tubular plate or low-profile minifragment plates usually are sufficient. To avoid wound complications, extreme care must be taken when applying bulky implants to this area of poor skin coverage."

AO technique: Medial malleolus held reduced with two K-wires bent out of the way, prior to definitive fixation (Campbell's Operative Orthopaedics 15th Ed 2026)

Final Checks

• Inspect the ankle joint interior, especially the superomedial corner, to confirm no screw crosses the articular surface
• Confirm syndesmosis stability (stress test) - if unstable, stabilize with syndesmotic screw or suture button device

Postoperative Care

• Ankle immobilized in posterior plaster splint in neutral position and elevated
• If bone quality is good and fixation secure: splint removed at first postoperative visit, replaced with removable splint or fracture boot; ROM exercises begun
• Weight bearing restricted for 6 weeks (in the absence of syndesmotic injury), then progressive partial weight bearing
• If skin conditions, bone quality, comorbidities (diabetes, neuropathy), or other factors compromise fixation: protected longer in short-leg cast, non-weight bearing until 8-12 weeks
• Campbell's Operative Orthopaedics 15th Ed 2026

Plating vs. Lag Screw: Current Evidence

Key Points to Remember

• Vertical fractures (SAD pattern) = buttress plate - this is the classic exam answer
• Plate screws run parallel to the joint to resist vertical shear
• The medial malleolus region has poor skin coverage - avoid bulky implants and handle skin with care
• One-third tubular or low-profile minifragment plates are preferred to minimize soft tissue complications
• Always check joint for articular screw penetration after fixation
• Medial malleolar nonunions require bone grafting + internal fixation; percutaneous approaches are inadequate as they do not allow debridement of nonunion scar tissue
• Campbell's Operative Orthopaedics 15th Ed 2026, pp. 5840-5893
• Rockwood & Green's Fractures in Adults 10th Ed 2025, pp. 3423, 3658-3664
• Miller's Review of Orthopaedics 9th Ed, pp. 6006, 6987-6997