Read on Twitter
[1/9] My mentor once said “if you can understand ankles, you can understand all of orthopaedics.” You can tell this ankle will be trouble due to fibula comminution. On lateral can see great example of how fibula (red) travels with posterior mal (yellow) because they’re attached.
![[1/9] My mentor once said “if you can understand ankles, you can understand all of orthopaedics.” You can tell this ankle will be trouble due to fibula comminution. On lateral can see great example of how fibula (red) travels with posterior mal (yellow) because they’re attached.](https://pbs.twimg.com/media/EVaikqOWkAEuz6q.jpg "[1/9] My mentor once said “if you can understand ankles, you can understand all of orthopaedics.” You can tell this ankle will be trouble due to fibula comminution. On lateral can see great example of how fibula (red) travels with posterior mal (yellow) because they’re attached.")
![[1/9] My mentor once said “if you can understand ankles, you can understand all of orthopaedics.” You can tell this ankle will be trouble due to fibula comminution. On lateral can see great example of how fibula (red) travels with posterior mal (yellow) because they’re attached.](https://pbs.twimg.com/media/EVaikqOXgAASqci.jpg "[1/9] My mentor once said “if you can understand ankles, you can understand all of orthopaedics.” You can tell this ankle will be trouble due to fibula comminution. On lateral can see great example of how fibula (red) travels with posterior mal (yellow) because they’re attached.")
[2/9] This is obviously not reduced on the lateral (arrow), but you can even tell on the AP because the joint is very tilted, and that’s abnormal for something that’s reduced.
![[2/9] This is obviously not reduced on the lateral (arrow), but you can even tell on the AP because the joint is very tilted, and that’s abnormal for something that’s reduced.](https://pbs.twimg.com/media/EVailQMWAAI4-ox.jpg "[2/9] This is obviously not reduced on the lateral (arrow), but you can even tell on the AP because the joint is very tilted, and that’s abnormal for something that’s reduced.")
![[2/9] This is obviously not reduced on the lateral (arrow), but you can even tell on the AP because the joint is very tilted, and that’s abnormal for something that’s reduced.](https://pbs.twimg.com/media/EVailQqX0AQlKq_.jpg "[2/9] This is obviously not reduced on the lateral (arrow), but you can even tell on the AP because the joint is very tilted, and that’s abnormal for something that’s reduced.")
[3/9] Because of other injuries patient could not go prone, so CT doesn’t add anything at this point because I know my approach will be supine and therefore percutaneous. Here after medial mal fixed, you can see some comminution at the joint but that the posterior mal is small.
![[3/9] Because of other injuries patient could not go prone, so CT doesn’t add anything at this point because I know my approach will be supine and therefore percutaneous. Here after medial mal fixed, you can see some comminution at the joint but that the posterior mal is small.](https://pbs.twimg.com/media/EVailsRWoAARoCq.jpg "[3/9] Because of other injuries patient could not go prone, so CT doesn’t add anything at this point because I know my approach will be supine and therefore percutaneous. Here after medial mal fixed, you can see some comminution at the joint but that the posterior mal is small.")
![[3/9] Because of other injuries patient could not go prone, so CT doesn’t add anything at this point because I know my approach will be supine and therefore percutaneous. Here after medial mal fixed, you can see some comminution at the joint but that the posterior mal is small.](https://pbs.twimg.com/media/EVailskWoAAISst.jpg "[3/9] Because of other injuries patient could not go prone, so CT doesn’t add anything at this point because I know my approach will be supine and therefore percutaneous. Here after medial mal fixed, you can see some comminution at the joint but that the posterior mal is small.")
[4/9] Also note how nicely the talus reduces after medial malleolus is fixed— through the deltoid ligament. This is why I nearly always do that side first, to get the talus where it belongs. I do bicortical screws but metaphyseal are fine too.
![[4/9] Also note how nicely the talus reduces after medial malleolus is fixed— through the deltoid ligament. This is why I nearly always do that side first, to get the talus where it belongs. I do bicortical screws but metaphyseal are fine too.](https://pbs.twimg.com/media/EVaimG5XgAAtatc.jpg "[4/9] Also note how nicely the talus reduces after medial malleolus is fixed— through the deltoid ligament. This is why I nearly always do that side first, to get the talus where it belongs. I do bicortical screws but metaphyseal are fine too.")
![[4/9] Also note how nicely the talus reduces after medial malleolus is fixed— through the deltoid ligament. This is why I nearly always do that side first, to get the talus where it belongs. I do bicortical screws but metaphyseal are fine too.](https://pbs.twimg.com/media/EVaimG4WsAAkgo3.jpg "[4/9] Also note how nicely the talus reduces after medial malleolus is fixed— through the deltoid ligament. This is why I nearly always do that side first, to get the talus where it belongs. I do bicortical screws but metaphyseal are fine too.")
[5/9] I decided that even though the piece was smaller than I had thought, fixing it would help with stability and potentially avoid syndesmotic screws. So I clamped from front to back, with the back tine lateral to Achilles (assumed this was haraguchi 1 which is most common).
![[5/9] I decided that even though the piece was smaller than I had thought, fixing it would help with stability and potentially avoid syndesmotic screws. So I clamped from front to back, with the back tine lateral to Achilles (assumed this was haraguchi 1 which is most common).](https://pbs.twimg.com/media/EVaimaIXYAAihri.jpg "[5/9] I decided that even though the piece was smaller than I had thought, fixing it would help with stability and potentially avoid syndesmotic screws. So I clamped from front to back, with the back tine lateral to Achilles (assumed this was haraguchi 1 which is most common).")
[6/9] Here can see drill for lag screw. Please note to get here, the neuro bundle is at risk so don’t perc it! Open it and make sure you’re directly on bone. Article here (for nails but same idea): https://pubmed.ncbi.nlm.nih.gov/28198793/?from_term=Posterior+Plea+for&from_pos=2
![[6/9] Here can see drill for lag screw. Please note to get here, the neuro bundle is at risk so don’t perc it! Open it and make sure you’re directly on bone. Article here (for nails but same idea): https://pubmed.ncbi.nlm.nih.gov/28198793/?from_term=Posterior+Plea+for&from_pos=2](https://pbs.twimg.com/media/EVaimueXQAIs8LO.jpg "[6/9] Here can see drill for lag screw. Please note to get here, the neuro bundle is at risk so don’t perc it! Open it and make sure you’re directly on bone. Article here (for nails but same idea): https://pubmed.ncbi.nlm.nih.gov/28198793/?from_term=Posterior+Plea+for&from_pos=2")
[7/9] After screw went in I fixed fibula and then went back to lateral. Here I was unhappy with what I saw. The joint was still gapped (yellow), threads were not all the way across fracture (blue), likely because screw was too short and didn’t grab well (red). This wouldn’t work.
![[7/9] After screw went in I fixed fibula and then went back to lateral. Here I was unhappy with what I saw. The joint was still gapped (yellow), threads were not all the way across fracture (blue), likely because screw was too short and didn’t grab well (red). This wouldn’t work.](https://pbs.twimg.com/media/EVainDDWsAIR31B.jpg "[7/9] After screw went in I fixed fibula and then went back to lateral. Here I was unhappy with what I saw. The joint was still gapped (yellow), threads were not all the way across fracture (blue), likely because screw was too short and didn’t grab well (red). This wouldn’t work.")
![[7/9] After screw went in I fixed fibula and then went back to lateral. Here I was unhappy with what I saw. The joint was still gapped (yellow), threads were not all the way across fracture (blue), likely because screw was too short and didn’t grab well (red). This wouldn’t work.](https://pbs.twimg.com/media/EVainD5WkAY_IDS.jpg "[7/9] After screw went in I fixed fibula and then went back to lateral. Here I was unhappy with what I saw. The joint was still gapped (yellow), threads were not all the way across fracture (blue), likely because screw was too short and didn’t grab well (red). This wouldn’t work.")
[8/9] I went back and changed to a longer screw, first inserting wire to keep fragment from moving and losing the hole I had made. Once screw found the hole, I removed wire and now it compressed the joint well (arrow). It’s a little long because of that but I accepted, it’s safe.
![[8/9] I went back and changed to a longer screw, first inserting wire to keep fragment from moving and losing the hole I had made. Once screw found the hole, I removed wire and now it compressed the joint well (arrow). It’s a little long because of that but I accepted, it’s safe.](https://pbs.twimg.com/media/EVainWDXgAARnmK.jpg "[8/9] I went back and changed to a longer screw, first inserting wire to keep fragment from moving and losing the hole I had made. Once screw found the hole, I removed wire and now it compressed the joint well (arrow). It’s a little long because of that but I accepted, it’s safe.")
![[8/9] I went back and changed to a longer screw, first inserting wire to keep fragment from moving and losing the hole I had made. Once screw found the hole, I removed wire and now it compressed the joint well (arrow). It’s a little long because of that but I accepted, it’s safe.](https://pbs.twimg.com/media/EVainWXWsAE82aU.jpg "[8/9] I went back and changed to a longer screw, first inserting wire to keep fragment from moving and losing the hole I had made. Once screw found the hole, I removed wire and now it compressed the joint well (arrow). It’s a little long because of that but I accepted, it’s safe.")
[9/9] Here you can see direction of the A to P screw laterally which is where that posterior mal fragment is. Also you see that I removed one of the fibula screws to make the construct more flexible and create the bridge I wanted. Stress/cotton tests were stable.
![[9/9] Here you can see direction of the A to P screw laterally which is where that posterior mal fragment is. Also you see that I removed one of the fibula screws to make the construct more flexible and create the bridge I wanted. Stress/cotton tests were stable.](https://pbs.twimg.com/media/EVainoyWkAM6wb4.jpg "[9/9] Here you can see direction of the A to P screw laterally which is where that posterior mal fragment is. Also you see that I removed one of the fibula screws to make the construct more flexible and create the bridge I wanted. Stress/cotton tests were stable.")
