Medial Malleolar Fractures
Epidemiology
Isolated medial malleolus fractures 3% of ankle fractures
Herscovici Classification
Type A: Avulsion
Type B: Between tip and plafond
Type C: At level of plafond
Type D: Vertical fracture
Management
Isolated medial malleolar fractures
Lokerman et al J Foot Ankle Surg 2019
- systematic review of 18 studies and 2500 patients
- isolated medial malleolar fractures
- ORIF: nonunion 1.7%
- cast: nonunion 3.5%
- 57 isolated medial malleolar fractures treated in a cast
- mean displacement 3.8 mm
- 55/57 united
- 2 nonunions with 3 - 4 mm displacement required ORIF + bone graft
Hanhisuanto et al Foot Ankle Surg 2017
- isolated medial malleolar fractures
- 60 treated with surgery: mean displacement 2 mm
- 53 non operative: mean displacement 1 mm
- worse outcomes with non operative management > 2 mm displacement
Bimalleolar / Trimalleolar fractures
Carter et al JAMA Netw Open 2024
- RCT of operative versus nonoperative medial malleolus
- 144 patients with ORIF fibular +/- posterior malleolus
- medial malleolus in satisfactory position
- nonunion: fixation 0%, non operative 20% (1/13 required surgery)
Displaced
- ORIF
- 20% risk of non union
Undisplaced
- can usually manage in cast
- still small risk of non union
Approaches
AO surgery reference posteromedial approach ankle
Fixation options
| Large fracture | Small fracture | Vertical fracture |
|---|---|---|
| 2 partially threaded screws | Tension band wire | Buttress plate |
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Non-union
