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Vertical Frx of Medial Malleolus

- Discussion:
    - results from supination-adduction fracture (Weber A)
    - adduction forces result in a vertical fracture of the medial malleolus at the junction of the plafond and malleolus;
           - transverse fibular frx or tear of lat collat occurs concomitantly;
           - medial soft tissues are intact so that interpostion is not problem;
    - main problem is comminution at medial corner of mortise;
           - plafond may be comminuted w/ impacted fragments, leading to varus tilt of mortise & post traumatic arthritis;

- Surgical Technique:


    - vertical frx of medial malleolus are fixed w/ cancellous screws placed perpendicular to the fracture site;
           - usually 2 cancellous screws are required;
    - washers may be needed because of thinner medial cortex;
    - when choosing site of screw insertion, avoid areas likely to produce further comminution of the fragment;
    - screws should be seated in dense bone of the central distal tibial metaphysis and thus should be approximately 40 mm long;
           - do not attempt to anchor them in the far cortex, which is too thin to provide much purchase;

- Comminution:
    - medial surface should be inspected for articular crush of tibial surface or talar dome;
    - w/ joint congruity, impacted fragments need to be reduced w/ bone graft applied to metaphyseal defects;
    - if proximal portion of vertical frx is comminuted, butress plate may be required;
           - w/o use of butress plate a varus deformity of talus may develope;
           - plate may be small DC plate, one third, a T or clover leaf plate will suffice

Vertical Shear Fractures of the Medial Malleolus: a biomechanical study of five internal fixation techniques. 

Bicortical fixation of medial malleolar fractures: a review of 23 cases at risk for complicated bone healing.

Comparison of Surgical Techniques of 111 Medial Malleolar Fractures Classified by Fracture Geometry.

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