Ankle Fracture, ABOS Oral Boards Preparation

This is a 34-year-old male software engineer who plays recreational basketball. He injured his left ankle during a game, an inversion and external rotation mechanism. He felt a pop and could not bear weight. He has no medical comorbidities and no prior injuries.

On exam, there was significant swelling and ecchymosis around both malleoli. The skin was tented over the lateral malleolus but intact. He was tender over the medial malleolus, the lateral malleolus, and the deltoid region. The squeeze test at the mid-calf was positive, so I was concerned about syndesmotic involvement. I examined the proximal fibula, no tenderness, ruling out a Maisonneuve pattern. Distal pulses were intact and neurologic exam was normal.

AP, lateral, and mortise views showed a short oblique distal fibula fracture at the level of the syndesmosis, a Weber B pattern, along with a transverse medial malleolus fracture. Medial clear space was 6mm on the mortise view, confirming instability. The tibial plafond was intact. I obtained full-length tibia-fibula films which were normal.

This is an unstable bimalleolar ankle fracture in a young, active patient. Non-operative management would not restore the mortise, so we discussed operative fixation and he agreed to proceed.

I fixed the lateral malleolus with a one-third tubular neutralization plate and the medial malleolus with two partially threaded cannulated screws. Intraoperative stress testing confirmed the syndesmosis was stable, so I did not place syndesmotic fixation. Final fluoroscopic images confirmed an anatomic mortise with symmetric clear spaces.

He was placed in a short leg splint, non-weight-bearing. At two weeks, sutures were removed and he transitioned to a CAM boot. At six weeks, X-rays showed healing and I started progressive weight-bearing. At three months, he was walking without a limp and had symmetric ankle range of motion. However, at four months he developed prominent hardware pain over the lateral malleolus, he could feel the plate through the skin, especially in dress shoes. The fracture was healed and the mortise was anatomic on films. At six months, he was playing basketball without functional limitations but still had hardware irritation with direct pressure. We discussed hardware removal. At nine months, I removed the lateral plate and medial screws as an outpatient procedure. At his final follow-up, he was pain-free over the lateral malleolus and back to all activities without restrictions.

The patient was satisfied with the final result. If I were to do this case again, I would have used a lower-profile plate on the lateral side. The one-third tubular plate worked well for fixation, but in a thin patient with minimal subcutaneous tissue over the lateral malleolus, a precontoured anatomic plate might have reduced the hardware prominence. I was vigilant for syndesmotic widening on follow-up films, and the mortise remained anatomic throughout his recovery.