- 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
ruptured;
- frx above level of the ligamentous attachment leaves deltoid
ligament attached to the distal malleolar
fragment;
-
associatted 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;
- Surgical Technique: 
-
vertical malleolar frx
-
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:
- as pointed out by Ostrum and Litsky, tension band wiring has better
mechanical
properties than 2 cancellous screws (four times stiffer than two screws);
- bone fragment is held in reduced position w/ tenaculum clamp;
- two 0.45 K wires are driven thru the 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);
- the K wires are cut and turned medially and then tapped into the
bone; ;
- ref:
Technical Tip: Fixation of Medial Malleolar Fractures Using a Suture Anchor
