Loose hematoma and infolded periosteum is removed from the fracture site, and the joint is copiously irrigated. The distal fragment of the medical malleolus is identified, and the periosteal tissue is excised from the fracture site. The saphenous vein is identified and preserved, and tributaries are coagulated using the bovie electrocautery. A longitudinal incision is made over the medial malleolus. With the lateral side repaired, attention is then turned medially. Two or more bicortical nonlocking screws are placed proximally in the construct. Anteroposterior (AP) and lateral x-rays are taken intraoperatively to confirm fracture reduction. Next, 2 unicortical locking screws are placed for improved fixation in osteoporotic bone. Several 3.5-mm fully threaded screws are drilled, measured, and placed to affix the plate laterally. It is the author's preference to use a locked 1/3 tubular locking plate for all fibula fractures when the plate is applied laterally because of the benefit of unicortically locked screws distally. Next, a 1/3 tubular locking plate is placed as a neutralization device. Lag screw placement allows for good compression of the fracture. A 3.5-mm glide hole is drilled proximally followed by a 2.5-mm compression hole the length of the screw is measured and the near cortex is countersunk. Once fracture reduction is confirmed, an anterior-to-posterior lag screw is placed. A lion jaw clamp was preferred over a pointed reduction clamp to disperse the forces more evenly over the osteoporotic bone. While holding the fracture to length and internally rotating, a lion jaw clamp is used to reduce the fracture site. The fracture site is exposed using a Homan lever, and the ankle is then externally rotated to expose the fracture surface to remove loose hematoma using a curette and irrigation. Care is taken to protect the superficial peroneal nerve, which crosses from the lateral to anterior compartment 7 cm above the lateral malleolus. The fibula fracture is addressed first, and an incision is made along the lateral side of the fibula over the fractured site. ![]() No tourniquet is used during the procedure. The patient is positioned supine on the table with a large padded bump below the affected ankle. Given the instability of this fracture pattern and the activity level of the patient, she was indicated for surgical fixation. Initial and after reduction radiographs reveal a SER type 4 fracture. The patient is a 66 year-old woman who sustained a rotational ankle fracture after a low-energy fall with a twisting mechanism. 5 This Supplemental Digital Content 1 (see video, ), shot on an iPhone 6S, demonstrates surgical repair of a SER type 4 ankle fracture seen in a geriatric patient. 4 Unstable ankle fractures (ie, mortise instability) are usually managed with open reduction and internal fixation, and should be assessed for syndesmotic injury. 1–3 Lauge-Hansen supination-external rotation (SER) ankle fractures, also classified as Weber B or Orthopaedic Trauma Association type B, represent most ankle fractures. The surgical technique described in this video provides for good stabilization and allows for early range of motion with advancement to weight-bearing as tolerated at 6 weeks postoperatively.Īnkle fractures are a common injury pattern whose incidence is increasing among geriatric populations. SER type 4 ankle fractures are a common injury that must be properly managed to return patients to baseline functional status. Intraoperative stress test revealed medial clear space widening requiring syndesmotic reduction. This video, shot on an iPhone 6S, shows the case of a 66-year-old female status after a fall with twisting mechanism resulting in an unstable SER type 4 fracture requiring operative repair. Patients are kept non–weight-bearing for 6 weeks after surgery. If necessary, the syndesmosis can be reduced open, with screw fixation placed parallel to the joint. After placement of plate and screws, intraoperative stress tests can be used to assess for syndesmotic widening. SER type 4 ankle fractures are considered unstable and are generally treated with surgical fixation. This video demonstrates surgical repair of a SER type 4 ankle fracture in a geriatric patient. Of the 4 fracture patterns described by the Lauge-Hansen classification system, supination-external rotation (SER) accounts for most ankle fractures. The incidence of ankle fractures is rapidly increasing in geriatric populations.
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