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Duke Orthopaedics
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Wheeless' Textbook of Orthopaedics

Medial Malleolar Fractures   


- Discussion:
    - medial malleolar frx result from direct impact of talus or from tension as talus rotates or moves laterally following fibula;
    - in children medial malleolus frx may represent supination inversion frx;
    - injury patterns: 
          - deep deltoid ligament may be torn, leaving malleolus intact;
          - anterior colliculus may be avulsed by superficial deltoid, leaving deep deltoid ligament either intact or ruptured;
          - frx above level of the ligamentous attachment leaves deltoid ligament attached to the distal malleolar fragment;
    - associated injuries: (w/ "isolated" medial malleolar fractures)
          - maisonneuve fracture;
          - talus neck fracture;
          - cuboid fracture;
          - deltoid ligament injuries arising from ankle frx 

- Radiographic Studies
    - usually distal frag of medial malleolus is displaced anteriorly & distally;
    - eval for osteochondral;
    - r/o frx of talar neck;

- Non Operative Treatment:
       - Conservative treatment of isolated fractures of the medial malleolus.
       - Nonoperative treatment of the medial malleolus in bimalleolar and trimalleolar ankle fractures: a randomized controlled trial.

- Surgical Treatment:   
    - screw fixationvertical malleolar frx
    - screw fixationhorizontal-oblique frx 
    - comminution:
          - if medial malleolus is fractured in coronal plane or is comminuted, screw purchase may be difficult;
          - small, one third tubular plate can be contoured to run along anterior, distal, & posterior edges of malleolus;
          - individual fragments can also be reduced & fixed with a single K wire; 
          - series of figure of 8 wires can then be placed around these K wires to secure the fragments;
          - impaction of articlar surface should be elevated during reduction;
          - bone grafting may be needed;
    - avulsion fractures:
          - avulsion frx of medial malleolus may be treated closed if isloated, minimally displaced, & involve distal portion of malleolus;
           - reduced after exposing both the anterior and medial aspects of frx by sharply turning back the periosteum and attached fascia;
    - short screw theory:
           - better fixation with shorter 30 mm partially threaded cancellous screws which engage the physeal scrar;
           - ref: Screw fixation of medial malleolar fracture. A cadaveric biomechanical study challenging the current AO philosophy   
    - bicortical fixation screws:
           - Lag screw fixation of medial malleolar fractures: a biomechanical, radiographic, and clinical comparison of unicortical partially threaded lag screws and bicortical fully threaded lag screws.
           - Comparison of pullout strength between 3.5-mm fully threaded, bicortical screws and 4.0-mm partially threaded, cancellous screws in the fixation of medial malleolar fractures.
           - Medial malleolar fractures: a biomechanical study of fixation techniques.
           - Bicortical fixation of medial malleolar fractures: a review of 23 cases at risk for complicated bone healing.
      - tension band technique:
           - Ostrum and Litsky, tension band wiring has better mechanical properties than 2 cancellous screws (4 times stiffer than two screws);
           - bone fragment is held in reduced position w/ tenaculum clamp;
           - two 0.45 K wires are driven thru deltoid ligament and tip of medial malleolus and across frx site, but not into proximal tibial cortex;
           - tension band figure of 8 wire (20 gauge) can be anchored proximally thru an anterior to posterior drill hole in metaphysis (or
                      by wrapping wire around head of the screw placed oblique in metaphysis);
           - 20 gauge wire is then passed around the K wires and tightened in a figure of 8 fashion (double twist technique is more reliable);
           - K wires are cut and turned medially and then tapped into the bone; 
           - references:
                  - Technical Tip: Fixation of Medial Malleolar Fractures Using a Suture Anchor
                  - Tension band fixation of medial malleolus fractures.  
                  - Modified tension band wiring of medial malleolar ankle fractures
                  - Comparison of tension band wire and cancellous bone screw fixation for medial malleolar fractures

                                   

---------------------------------------------------------------------------------------------------------------
Hardware in the medial malleolus: is it intra-articular?

Safe Zone for the Placement of Medial Malleolar Screws

Medial Malleolar Fractures: A Biomechanical Study of Fixation Techniques

Stress fracture of the medial malleolus.



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Friday, January 3, 2014 11:18 am