Ankle Fracture ORIF

CPT 27769
Approach Open
Add-on / Variant CPTs
  • 27766 — Open treatment medial malleolus fracture
  • 27829 — Open treatment distal tibiofibular joint disruption with fixation
Preoperative Diagnosis:

Right [left] [bimalleolar / trimalleolar / lateral malleolus / medial malleolus] ankle fracture, [Weber A / B / C] [/ Lauge-Hansen classification]

Postoperative Diagnosis:

Same

Procedure Performed:

Right [left] ankle fracture open reduction and internal fixation, [fibula plate and screws / medial malleolus screws / posterior malleolus screw fixation]

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Resident/PA name]

Anesthesia:

Spinal [/ general endotracheal] with popliteal sciatic and saphenous nerve block

Indications:

The patient is a [age]-year-old [male/female] who sustained a right [left] [bimalleolar / trimalleolar] ankle fracture after [mechanism: twisting injury / fall]. Radiographs demonstrate [fracture pattern] with [medial clear space widening / talar shift / unstable pattern] requiring surgical fixation. The risks, benefits, and alternatives were discussed and informed consent was obtained.

Findings:

The lateral malleolus fracture was at the [level of / above] the ankle mortise (Weber [B/C]) with [transverse / short oblique / spiral] morphology. The medial malleolus was [fractured / avulsed / with deltoid ligament injury evidenced by medial clear space widening]. [The posterior malleolus involved [<25% / >25%] of the articular surface.] Reduction of the fibula restored the ankle mortise. Fluoroscopic views confirmed [anatomic alignment / talar centering in the mortise / <2 mm articular step-off].

Description of Procedure:

The patient was positioned supine with a bump under the ipsilateral hip. A thigh tourniquet was applied. The ankle was prepped and draped.

[LATERAL MALLEOLUS:]
A posterolateral incision was made over the fibula. The peroneal tendons were retracted. The fracture was exposed, reduced, and held with a pointed reduction clamp. Anatomic reduction was confirmed fluoroscopically. A [1/3 tubular / anatomic distal fibula] plate was contoured and applied to the lateral (posterior) fibula with [X] bicortical screws proximally and [X] screws distally. Reduction and hardware position were confirmed on AP, lateral, and mortise fluoroscopic views.

[MEDIAL MALLEOLUS:]
A medial incision was made. The medial malleolus fracture was exposed and reduced with a pointed clamp. Two [4.0-mm] partially-threaded cancellous screws [/ one screw and anti-rotation K-wire] were placed perpendicular to the fracture. Reduction was confirmed fluoroscopically.

[POSTERIOR MALLEOLUS:]
[The posterior malleolus fragment was reduced indirectly by fibular reduction and fixed with an anterior-to-posterior lag screw / directly via a posterolateral approach with a plate or lag screw.]

[SYNDESMOSIS:]
[The syndesmosis was assessed by the Cotton test: stable / unstable. If unstable, fixation was performed with a [3.5-mm] tricortical syndesmotic screw at [2–4] cm above the tibial plafond, placed in [30°] external rotation.]

Final fluoroscopic views confirmed anatomic ankle mortise, symmetric medial and lateral clear spaces, and appropriate hardware position. Tourniquet deflated. Wounds were closed in layers. A posterior splint was applied.

Complications:

None

Specimens:

None

Estimated Blood Loss:

Minimal (tourniquet)

Drains:

None

Disposition:

The patient was taken to the PACU in a posterior splint. Non-weight-bearing was prescribed for [6 weeks]. Follow-up with repeat radiographs in [2 weeks] for wound check and splint change to boot.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: Right/Left *** ankle fracture, Weber ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Right/Left ankle fracture ORIF, ***
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: Spinal + nerve block

INDICATIONS: .PTAGE-year-old .PTSEX with *** ankle fracture, *** mechanism. Unstable pattern. Consent obtained.

FINDINGS: Lateral malleolus: Weber *** at ***. Medial malleolus: ***. Posterior malleolus: ***. Syndesmosis: ***. Reduction: anatomic mortise, talar centering.

PROCEDURE:
Supine, hip bump. Tourniquet. Posterolateral incision. Peroneal tendons retracted. Fracture reduced, clamp. *** plate applied, *** screws proximal, *** distal. [Medial malleolus: *** × 4.0 mm screws.] [Posterior malleolus: ***.] [Syndesmosis: *** mm screw, *** cortices, *** cm above plafond, 30° ER.] Final fluoro: anatomic mortise, symmetric clear spaces. Tourniquet down. Closed in layers. Posterior splint.

EBL: Minimal
COMPLICATIONS: None
DISPOSITION: NWB × 6 weeks. Follow-up 2 weeks.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Syndesmotic Fixation: Suture Button (TightRope)

Syndesmotic instability was confirmed with a positive Cotton test after fibular fixation. A syndesmotic suture button (Arthrex TightRope) was used instead of a metallic screw. Two fibular drill holes and one tibial cortical tunnel were created. The suture button was passed and tightened with the ankle held at 90° in neutral rotation. The suture button does not require routine removal and permits more physiologic micromotion at the syndesmosis compared to rigid screw fixation.

Charting Tips
  • Document syndesmosis stability assessment. Every ankle fracture ORIF requires documentation of syndesmosis testing (Cotton test, external rotation stress test) and the result. Missed syndesmotic injury leads to chronic ankle instability. If stable, document 'Cotton test negative, syndesmosis stable.' If fixed, document technique.
  • Document mortise fluoroscopic view quality. The mortise view (15–20° internal rotation) is the critical view for assessing talar centering and symmetric clear spaces. A symmetric medial and superior clear space of ~4 mm confirms anatomic reduction. Document that the view was obtained and the result.
  • For trimalleolar fractures, document posterior malleolus fragment size as a percentage of the articular surface. Fragments >25% of the articular surface require fixation to prevent posterolateral subluxation. Document the measurement and fixation decision.
Billing Tips
  • Bill 27766 for medial malleolus ORIF (7.69 wRVU, 90-day global). Bill 27784 for fibula fracture ORIF (lateral malleolus, 9.43 wRVU). Bill 27814 for bimalleolar ORIF (10.35 wRVU). Bill 27769 for posterior malleolus ORIF (9.89 wRVU).
  • For trimalleolar fractures, bill 27814 (bimalleolar) plus 27769 (posterior malleolus) with modifier -51. Document each fracture component and the fixation technique used for each.
  • Syndesmotic fixation (screw or suture-button) is typically bundled into the ankle fracture ORIF code. Do not separately bill syndesmosis repair unless it is performed as an isolated procedure.
  • 90-day global period: cast or boot management, weight-bearing protocol, and routine wound checks are bundled. Hardware removal at a later date is a separate billable procedure (27610).
  • Document neurovascular exam findings pre- and postoperatively, fracture classification (Lauge-Hansen or Weber), and all implants used (manufacturer, lot number), as these are required for implant registry and medicolegal documentation.