Bimalleolar Ankle Fracture ORIF

Open reduction and internal fixation of the lateral and medial malleoli, usually a plate and screws on the fibula and screws across the medial malleolus, under fluoroscopy and a thigh tourniquet. The rhythm is: expose, clean the fracture, reduce and hold, fix, check with images, then test the syndesmosis.

Position and prep

Supine on a radiolucent table; bump under the same-side hip so the ankle points up; thigh tourniquet; C-arm from the opposite side.

Prep: Leg from the thigh tourniquet to the toes; foot included.

Room setup

C-arm and lead for everyone in the room
Thigh tourniquet (set and tested)
Power drill and wire driver (tested, batteries fresh)
Bump or folded blankets for the hip
Ramp or bone foam to lift the leg for lateral images, per surgeon
Splint material, padding and water ready before closing

Implants

Fibular plate: one-third tubular or precontoured lateral distal fibula plate, per surgeon
3.5 mm cortical and 4.0 mm cancellous screws
Medial malleolus: partially threaded cancellous or cannulated screws, or a tension-band construct
K-wires for provisional fixation
Syndesmotic fixation only if the stress test is positive: screw or suture-button device, per surgeon

Instruments

Small fragment set (plates, screws, drills, guides, depth gauge, screwdrivers)
Pointed reduction clamps (Weber), small and large
Small Hohmann retractors
Freer elevator, dental pick and small curette
K-wires and wire driver
Senn retractors, rakes and a small Weitlaner
Basic orthopedic or hand tray for the soft tissue

In the free instrument guide: Hohmann retractor, Verbrugge Bone Holding/Reduction Forcep, Curette, Weitlaner Retractor, Adson Forceps, Drill.

How the case runs

Time-out, including laterality; confirm the implant set is complete and sterile; tourniquet up
Lateral incision over the fibula; protect the superficial peroneal nerve when the surgeon points it out
Expose and clean the fracture: curette, dental pick, irrigation
Reduce with a pointed reduction clamp; images to check

The rest of the case is in the app

8 more steps, the Mayo setup, draping order, closing, pearls, and a three-stage “what would you do next?” case. Free to start.

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Clinically reviewed by William Guglielmo on October 15, 2026. Generic teaching content. Your surgeon's preference card, the implant system's technique guide and facility policy always come first.