Ankle Fracture Fixation

Indications

Approach to the Lateral Malleolus, radiograph of ankle fracture fixation with a lateral plate
Radiograph of ankle fracture fixation with a lateral plate. Image by Nicolai.Berger, Wikimedia Commons, CC BY-SA 4.0.
  • Talar shift or medial clear space widening
  • Bimalleolar and trimalleolar fractures
  • Syndesmotic instability
  • Weber B fractures with an incompetent deltoid ligament
  • Isolated Weber B fractures with a stable mortise on stress or weight bearing views are treated in a boot

Position

  • Supine, bump under the ipsilateral hip, thigh tourniquet
  • Image intensifier from the opposite side

Operative Steps

  1. Lateral approach over the fibula, protecting the superficial peroneal nerve
  2. Lag screw and neutralisation plate, or posterolateral antiglide plate
  3. Medial malleolus with two partially threaded cancellous screws perpendicular to the fracture
  4. Fix large or displaced posterior malleolar fragments through a posterolateral approach
  5. Stress the syndesmosis with the Cotton test or external rotation stress
  6. Fix syndesmotic instability with screws or suture button under direct or fluoroscopic reduction
  7. Restore fibular length and rotation, checked with the dime sign and talocrural angle
  8. Fix the syndesmosis with the ankle in neutral

Postoperative Care

  • Early weight bearing in a boot when fixation is stable
  • Diabetic and neuropathic patients need longer protection
  • Radiographs at 2 and 6 weeks
  • Hardware removal only if symptomatic

Complications

  • Wound breakdown, worse in diabetes and smokers
  • Syndesmotic malreduction
  • Superficial peroneal nerve injury
  • Symptomatic hardware
  • Wound breakdown, higher in smokers and diabetics
  • Malreduction of the syndesmosis
  • Post-traumatic arthritis

Related Pages

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.