The Journal of Foot & Ankle Surgery 54 (2015) 1202–1205

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The Journal of Foot & Ankle Surgery

journal homepage: www.jfas.org

Use of a Locked Fibular Plate for Fixation of a Vertical Shear

Medial Malleolus Fracture: A Case Report
Sean Blake, DO, DPT 1, George Yakubek, DO 2, James Shaer, MD 1
1
Orthopedist, St. Elizabeth Youngstown Hospital, Youngstown, OH
2
Intern, Kansas City University of Medicine and Biosciences, Kansas City, MO

a r t i c l e i n f o a b s t r a c t

Level of Clinical Evidence: 4 Vertical shear fractures of the medial malleolus are less common than transverse fractures. These fractures are
often treated with lag screws, posteromedial buttress plating, antiglide plates, and neutralization plates with
Keywords:
fibular locking plate screws. We report on a 37-year-old male who had fractured his ankle after tripping and falling into a ditch.
fracture fixation Initially, the patient was treated with closed reduction and a splint for a trimalleolar fracture with a laterally
malleolar fracture subluxed talus. However, on review of his preoperative radiographs and computed tomography studies, we
orthopedic fixation devices confirmed a medial malleolus fracture with a vertical shear pattern and communition. Recently, a contoured
tibia fibular locking plate has been developed. We considered this plate to be effective for containing the bone in
part because of its broader plate design. We present a case in which a fibular locking plate was used suc-
cessfully as a neutralization plate as an alternative fixation method for a vertical shear medial malleolar
fracture.
Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.

Fractures of the ankle are among the most common and frequently (4–6). Studies have shown that both neutralization and antiglide
treated musculoskeletal injuries, in addition to hip and wrist frac- plates and screws placed perpendicular to the fracture line are stable
tures, and ankle and wrist fractures each account for approximately fixation methods (5,6). Neutralization has been shown to offer more
10% of fractures in those aged 60 years (1,2). Somersalo et al (2) rigidity than that of 2 parallel screws placed perpendicular to the
reported that ankle fractures represent 17% of all hospitalized frac- fracture line (5). However, another study demonstrated the converse
tures. When the ankle mortise is displaced, open reduction with in- (6). Vertical shear fractures of the medial malleolus stabilized with
ternal fixation is recommended (3). Within the joint, the talus cortical or cancellous screws placed perpendicular to the fracture had
articulates with the medial and lateral malleolus, along with the tibial greater strength than an antiglide plate (6). In these studies, antiglide
plafond. When the biomechanical configuration of the ankle is not plates have been used successfully for fixation of vertical shear
compromised, the talus articulates in a physiologic pattern, and the fractures.
ankle is considered stable. A stable ankle fracture pattern, such as an The objective of the present case report was to demonstrate the
isolated lateral malleolus fracture without gross displacement or clinical results of an alternative fixation method for the treatment of a
associated deltoid incompetence, is generally managed nonsurgically. medial malleolus vertical shear fracture using a fibular locking plate.
In contrast, unstable ankle fractures (e.g., trimalleolar) typically yield
compromised biomechanics and should be managed surgically (1). Case Report
Managing unstable ankle fractures through surgical intervention has
been shown to have superior clinical outcomes regarding anatomic In April 2010, a 37-year-old male tripped and fell into a ditch,
reduction compared with nonoperative methods (1,4). Vertical shear fracturing his ankle. The patient stated he had experienced immedi-
fractures of the medial malleolus are less common than transverse ate, nonradiating distal ankle pain after the fall. He described sensory
fractures (5). These fractures are often treated successfully with changes over the entire left foot in a nonspecific dermatomal pattern.
buttress or antiglide plates and screws with neutralization plates The patient was unable to ambulate or bear weight, and he was not
able to actively perform plantar flexion, dorsiflexion, or wiggling of
his toes. He denied any other musculoskeletal complaints at that time.
Financial Disclosure: None reported. The left lower extremity on presentation had a splint placed from an
Conflict of Interest: None reported.
Address correspondence to: Sean Blake, DO, DPT, Ohio University College of
outside facility, which was taken down to show intact skin with
Osteopathic Medicine, St. Elizabeth Youngstown Hospital, Youngstown, OH 44501. moderate swelling and fracture blisters. Ecchymosis was most
E-mail address: [email protected] (S. Blake). significantly present over the medial aspect of the ankle and global

1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
http://dx.doi.org/10.1053/j.jfas.2015.06.016
 S. Blake et al. / The Journal of Foot & Ankle Surgery 54 (2015) 1202–1205 1203

Fig. 1. (A) Radiograph of anteroposterior view showing comminution of the medial malleolus fracture. (B) Radiograph of mortise view showing comminution of the medial malleolus
fracture. (C) Later radiograph showing comminution of medial malleolus fracture.

swelling around the ankle joint itself and the foot. He had palpable 9 days after the initial incident. A review of his preoperative films
pulses. The right lower extremity had full, pain-free active range of revealed suspicion for a vertical shear pattern to the medial malleolus
motion and palpable pulses. The rest of the social history and physical fracture (Fig. 1). A computed tomography scan was obtained to further
examination findings revealed that he smoked 10 to 20 cigarettes delineate the fracture pattern. It revealed that the medial malleolus
daily. fracture was larger anteriorly, with a vertical configuration, and
The radiographs from the outside facility were reviewed and thinned out posteriorly with a more transverse orientation with
showed a trimalleolar fracture that had a subluxed talus laterally. The comminution (Figs. 2 and 3).
fracture pattern appeared to be supination adduction.
The management options were discussed with the patient, and Surgical Procedure
open reduction internal fixation was recommended for definitive
management. Because of the swelling and fracture blisters, the pa- The patient was positioned supine with a bump under his left hip,
tient was unable to undergo the chosen procedure for approximately and a tourniquet was applied to the thigh. After application of a

Fig. 2. Computed tomography scan of the coronal view of the ankle showing an oblique Fig. 3. Computed tomography scan of the sagittal view of the ankle showing the
fracture through the distal fibula with associated lateral displacement of the dome of the comminution and the nature of the medial malleolus, which is larger anteriorly and
talus and widening of the ankle mortise, indicating a trimalleolar fracture dislocation. thinner and transverse posteriorly.
1204 S. Blake et al. / The Journal of Foot & Ankle Surgery 54 (2015) 1202–1205

Fig. 4. (A) Anteroposterior view of additional fixation with a 4.0-mm compression screw and a single Kirschner wire. (B) Lateral view of additional fixation with a 4.0-mm compression
screw and a single Kirschner wire.

standard aseptic technique, the surgical procedure began with fix- At 2 weeks postoperatively, the incisions were well healed with no
ation of the fibula through a posterolateral approach. The fracture drainage. The patient had intact sensation and extensor hallucis
did have some comminution and was long and oblique in nature. longus function, and he was able to wiggle his toes. Most of the staples
Instead of using the lateral malleolus plate, a posterior one-third on his medial ankle area were removed. Only a couple of staples were
tubular plate with a lag screw was used on the fibula fracture. The removed from the lateral incision, because swelling was present. The
bump was removed and attention turned to the medial side of the patient was placed back in a 3-sided splint. At 23 days postoperatively,
ankle. the remaining staples and sutures were removed. He had no evidence
A linear incision was made, centered over the medial malleolus, of infection or pressure sores. He was placed in a cast and continued
and the fracture was provisionally reduced with a Kirschner wire. The non-weightbearing status. At 6 weeks postoperatively, his cast
Kirschner wire was left in place to limit the chance of rotation when became wet and fell off. He reported back to the emergency depart-
the compression screw was placed. The StrykerÒ VariAxÔ Fibula ment to undergo have the cast replaced. He denied weightbearing
Locking Plate (StrykerÒ, Kalamazoo, MI) was contoured to fit over the since the cast had fallen off. At that point, sensation was intact, no
medial aspect of the distal tibia without displacing the reduced swelling was present, and the incision site appeared to be healing well
medial malleolus. The fibular locking plate was secured to the medial with no erythema or drainage. At his clinic visit (53 days post-
distal tibia. It was placed to neutralize the shear pattern and allow a operatively), he was placed in a controlled ankle motion walker boot
compression screw to be placed in the area of the fracture that had a and prescribed physical therapy, with toe touch weightbearing to
more transverse orientation (Figs. 3 and 4). Owing to the small progress as tolerated. The patient was able to perform dorsiflexion,
transverse area, it was thought that a second compression screw plantar flexion, knee flexion, and extension.
would not fit. Anatomic reduction of the medial malleolus was visu- At approximately 12 weeks of follow-up, the patient had begun full
alized and confirmed using fluoroscopy. The final decision to use the weightbearing to the left lower extremity. He had no complaints of
locked fibular locking plate on the medial malleolus was based on the implant irritation. He demonstrated a healing fracture and symmetric
following reasons: a broader distal area with the precontoured shape mortise on plain films (Fig. 5). The patient returned 2 years after
to contain the comminution of the medial malleolus and the low fixation for an unrelated hand injury and expressed no issues with
profile of the plate. function or pain in his left ankle.

Fig. 5. (A) Lateral view showing healing fracture and symmetric mortise on plain films at 6 weeks of follow-up. (B) Mortise view showing healing fracture and symmetric mortise on plain
films at 6 weeks of follow-up. (C) Lateral view showing healing fracture and symmetric mortise on plain films at 6 weeks of follow-up.
 S. Blake et al. / The Journal of Foot & Ankle Surgery 54 (2015) 1202–1205 1205

Discussion plate for the fixation of vertical shear medial malleolus ankle frac-
tures. In our patient, a risk existed of creating more comminution, and
Ankle fractures are common injuries (1). Bimalleolar, trimalleolar, the medial malleolus was thinned out posteriorly. Thus, the use of
and bimalleolar equivalent ankle fractures are well accepted to be combined techniques for managing vertical shear fracture patterns
unstable (1). Surgical fixation of these fractures is usually the treat- was successful because the fibular locking plate covered more surface
ment of choice (1). Less frequent than a transverse break, fractures of area of the bone and the compression screw and Kirschner wire
the medial malleolus present with a more inclined fracture line, prevented additional shearing and rotation. Additional studies are
caused by shearing. Two compression screws will stabilize this frac- necessary to further define the outcomes and to determine any
ture type well (1,5,6). A neutralization plate can be used as a sup- complications with the use of combined treatment techniques.
plement to the screws in osteoporotic bone (5). For vertical shear
fracture treatment, both screws placed perpendicular to the fracture
line have been shown to be a stable construct without an antiglide Acknowledgments
plate offering any mechanical advantage (6). However, more recent
data have supported the concept that a neutralization plate results in We would like to thank Elisha Chance, BSAS, Marina Hanes, BA,
significant benefit compared with screws alone (5). and Barbara Hileman, BA, from the Trauma Research Department at
A review of the published data resulted in no other documentation St. Elizabeth Health Center for their formatting and editing assistance.
of a predesigned periarticular distal fibular locking plate used on the
medial malleolus. We used a StrykerÒ VariAxÔ Fibula Locking Plate as References
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