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Open Reduction and Internal Fixation of a Trimalleolar Ankle Fracture

Michael Weaver, MD
Brigham and Women's Hospital


After the operative leg has been marked, anesthesia is induced and the patient is brought to the operating room.


  1. Positioning of Leg
    • Patient positioned supine with arms out or tucked
    • Trochanter roll placed under patient
  2. Prep/Sterilization of Surgical Site
    • Shave surgical site
    • Wash and sterilize entire leg
  3. Draping
  4. Cover Site with Ioband Adhesive Sterile Sheet
    • Seal calf and toes
  5. Make Skin Markings
  6. Apply Tourniquet
    • Exsanguinate the extremity up to the thigh
    • Apply pressure
  7. Surgical Time Out
    • Identify patient, problem, correct side, procedure to be performed, medications given prior to procedure, expected time to completion

Fibular Fixation

  1. Make a Lateral Skin Incision
    • Along subcutaneous border of fibula
    • Angle slightly anteriorly distally
  2. Incision into Fascia
    • Superficial peroneal nerve branches at subcutaneous or fascial level
    • Once on bone, make space for plate
    • Expose fracture site with a 2mm periosteotomy on each side
    • Clean out fracture site with small curette
  3. Perform Fibular Reduction with Pointer Forceps
    • Grab distal fibula and pull traction to achieve length
  4. Fit and Contour Fibular Plate
    • Contour six-hole ⅓ tubular plate using locking towers for grip to match distal fibula
    • Position and use K-Wires to fix provisionally
  5. Proximal Non-locking Screw
    • Drill through both fibular cortices with a 2.5mm drill
    • Use depth gauge to determine length
    • 4.0mm non-locking screws should be used initially to contour plate to the bone
    • Note: Using slightly longer screws allows for better purchase in the medial cortex
  6. Distal Non-locking Screw
    • Repeat above steps
  7. Fill Remaining Gaps with Locking Screws
    • It is important to use locking screws, especially distally at the level of the lateral malleolus, to prevent skin irritation due to prominence
    • Once complete, use clamps to pull on fibula (Cotton test) and assess status of syndesmosis

Syndesmotic Fixation

  1. Exposure of Syndesmosis
  2. Provisional K-Wire Fixation
    • Fix the Tillaux fragment to the tibia
    • Use a second K-Wire to fix the fibula to the tibia
  3. 1st Syndesmotic Tricortical Screw
    • Drill through three cortices with 3.2mm drill
    • Drill to, but not through, the medial cortex of the tibia
    • Measure with depth gauge
    • Use a 4.5mm cortical screw
  4. Lag Screw fixation of Tillaux Fracture
    • Drill through fragment into tibia with 3.2mm drill
    • Use 4.0mm partially threaded cancellous screw to lag by design
  5. 2nd Syndesmotic Tricortical Screw
    • Repeat steps for 1st syndesmotic screw

Medial Malleolus Fixation

  1. Prep Medial Side
    • Mark approach - in this case, a curved approach anterior to the medial malleolus
  2. Make Medial Incision
    • Be cautious of the posterior tibial tendon and saphenous nerve
  3. Reduce Fragment with Pointed Reduction Clamps
  4. Provisional K-Wire Fixation
    • Use two K-Wires to keep fragment from rotating
  5. 1st Tibia Lag Screw
    • Drill though fragment into tibia with 3.2mm drill
    • Use 4.0mm partially threaded cancellous screw
  6. 2nd Tibia Lag Screw
    • Repeat above steps

Final Images

  1. Take AP and Lateral X-ray Images to Confirm Reduction and Construct Placement

Irrigation and Wound Closure