OPERATION IN DETAIL: The patient was brought to the operating room and laid supine on the operating room table. General anesthesia was induced. A tourniquet was placed high up on the right thigh but was never inflated during the procedure. Next, the right lower extremity was prepped and draped in the usual sterile fashion. A longitudinal incision was made with a standard approach to the lateral malleolus. Dissection was carried down to the level of the fracture, which was noted to be highly comminuted in several pieces. Dissection was carried out proximally, and the superficial peroneal nerve was identified and protected during the remainder of the procedure. The fracture fragments were then provisionally reduced and held with a 1.6 mm K-wire. Two lag screws were placed from anterior to posterior, obtaining fixation of one of the fragments more proximally. These lag screws were inserted in standard AO fashion. Next, the distal malleolar piece was reduced. The distal lateral malleolus was fragmented into two large pieces. Another lag screw was inserted from anterior to posterior, obtaining fixation of the distal malleolar tip. Next, a 10-hole LCDC plate was then fashioned to the distal fibula. The plate was contoured to fit the mold of the fibula. Next, three cortical screws were placed proximal to the fracture and three cancellous screws were placed at the distal lateral malleolus. The comminuted fragment was spanned with the plate. The plate essentially functioned as a bridge plate spanning the comminuted segment. After all screws were tightened, C-arm fluoroscopy was used to confirm good reduction of the fracture as well as restoration of length of the fibula. Next, attention was directed to the medial malleolus. A standard medial approach was performed, taking care to protect the greater saphenous vein. Next, the medial malleolar fracture was identified. The fracture was cleaned of periosteum. A tenaculum was used to hold the fracture reduced. Two 4.0 mm cancellous screws, partially threaded, each 45 mm in length, were then inserted in standard fashion from the tip of the distal malleolus up into the tibial metaphysis. The fracture was held reduced while the screws were being inserted. C-arm fluoroscopy was used to confirm excellent reduction of the fracture and positioning of the screws. Next, plain films were obtained in the operating room and the fixation was felt to be adequate. The ankle mortise was symmetric. All screws on both the medial and lateral sides were of adequate length. Next, both wounds were then thoroughly irrigated and closed with 2-0 Vicryl suture in the subcutaneous layer followed by staples in the skin. Next, a sterile dressing was applied and the patient was placed into an AO splint. The patient was then awakened from anesthesia, transferred back onto stretcher, and taken to the postanesthesia care unit for recovery.
