- 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
- Non Operative Treatment:
-
Conservative treatment of isolated fractures of the medial malleolus.
-
Non-operative treatment of the medial malleolus in bi- and trimalleolar ankle fractures. A Randomized Controlled Trial.
- Radiographic Studies
- usually distal frag of medial malleolus is displaced anteriorly & distally;
- eval for osteochondral;
- r/o frx of talar neck;
- Surgical Technique:
- bicortical fixation screws:
-
Lag Screw Fixation of MM Frx: A Biomechanical, Radiographic, and Clinical Comparison of Unicortical Lag Screws and Bicortical Screws.
-
Comparison of pullout strength between 3.5-mm fully threaded, bicortical screws and 4.0-mm partially threaded, cancellous screws in fixation of MM frx.
-
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.
-
screw fixation:
vertical malleolar frx 
-
screw fixation:
horizontal-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;
-
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