Medial Malleolus

Indications

  • Open reduction and internal fixation of medial malleolar fractures.
  • Exploration and repair of the deltoid ligament.
  • Medial malleolar osteotomy for access to the talar dome.

Position

  • Supine with the leg externally rotated, or the opposite hip lifted to roll the leg out.
  • Thigh tourniquet.

Landmarks and incision

  • Palpate the medial malleolus, its anterior and posterior borders and the anteromedial joint line.
  • Make a 6 to 10 cm incision centred on the malleolus. Curve it slightly anteriorly at the tip.
  • An anteromedial incision lets the surgeon view the anteromedial corner of the plafond to check reduction and clear any periosteum trapped in the fracture.
  • A posteromedial incision gives better access to tibialis posterior and the posteromedial plafond.

Internervous plane

  • The medial malleolus is subcutaneous, so there is no internervous plane.

Superficial dissection

  • Find the great saphenous vein and saphenous nerve, which lie together along the anterior border of the malleolus.
  • Mobilise the vein and nerve as one bundle and retract them anteriorly.
  • Raise full thickness flaps directly on bone.

Deep dissection

  • Clear the fracture edges and remove interposed periosteum.
  • Make a small anterior arthrotomy to view the joint surface.
  • Reduce and fix with partially threaded cancellous screws, a tension band or an antiglide plate, depending on fracture pattern.

Structures at risk

  • Great saphenous vein.
  • Saphenous nerve. It divides about 3 cm above the tip of the malleolus into anterior and posterior branches that end close to the bone.
  • Tibialis posterior tendon, which lies in a groove directly behind the malleolus.
  • Flexor digitorum longus, posterior tibial artery, tibial nerve and flexor hallucis longus behind tibialis posterior. These are at risk with posterior dissection or long drills.

Extensions

  • Proximally along the subcutaneous medial tibia for spiral fractures.
  • Posteromedially between tibialis posterior and flexor digitorum longus, or behind the neurovascular bundle, to reach a posterior malleolar fragment.

Exam traps

  • Know the order of structures behind the medial malleolus.
  • Interposed periosteum and deltoid tissue are common blocks to reduction.
  • A vertical medial malleolar fracture in a supination adduction injury suggests marginal impaction and needs an antiglide plate or horizontal screws. Elevate the impaction first.
  • Avoid placing the incision directly over the screw heads. See the ankle approaches.

References

1. Hoppenfeld S, deBoer P, Buckley R. Surgical exposures in orthopaedics, the anatomic approach. 5th ed. Philadelphia, Wolters Kluwer, 2017.

2. Mercer D, Morrell NT, Fitzpatrick J, Silva S, Child Z, Miller R, DeCoster TA. The course of the distal saphenous nerve, a cadaveric investigation and clinical implications. Iowa Orthop J. 2011, 31, 231-5.

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 17 October 2026.