Ankle Fracture ORIF
Right [left] [bimalleolar / trimalleolar / lateral malleolus / medial malleolus] ankle fracture, [Weber A / B / C] [/ Lauge-Hansen classification]
Same
Right [left] ankle fracture open reduction and internal fixation, [fibula plate and screws / medial malleolus screws / posterior malleolus screw fixation]
[***, MD/DO]
[Resident/PA name]
Spinal [/ general endotracheal] with popliteal sciatic and saphenous nerve block
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.
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].
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 fibula / posterior fibula (antiglide technique for short oblique Weber B patterns)] 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 and external rotation stress test and found [stable / unstable]. [If unstable, fixation was performed with a [3.5-mm] [tricortical / quadricortical] syndesmotic screw placed [2–3] cm above the tibial plafond, angled approximately 30° anteriorly from the coronal plane (posterolateral-to-anteromedial trajectory). The ankle was held in neutral/slight dorsiflexion during screw tightening.]]
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.
None
None
Minimal (tourniquet)
None
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, angled 30° anteriorly from coronal plane, ankle in neutral dorsiflexion.] 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
.TODAYVariants
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 normal medial clear space is ≤4 mm and symmetric with the superior clear space (mean ~2.7–3.2 mm in uninjured adults). Document that the mortise view was obtained and confirm the medial clear space is within normal limits and symmetric — not simply 'approximately 4 mm.'
- For trimalleolar fractures, posterior malleolus fixation decisions should not rely on the 25% rule alone. Modern criteria include: articular fragment displacement ≥2 mm, posterior talar subluxation, and CT morphology (fibular notch involvement, Bartoníček classification). Fragments <25% may still warrant fixation based on these factors. Document the fragment size, CT findings, talar stability, and fixation rationale.
Documentation & Reimbursement Considerations
- Report Ankle Fracture ORIF as the primary service when it is the definitive operation performed.
- Never stack these reporting options for the same ankle.
- Distinct-service reporting required.
- 90-day global period: cast or boot management, weight-bearing protocol, and routine wound checks are bundled.
- Document neurovascular exam pre- and postoperatively, fracture classification (Lauge-Hansen or Weber), and all implants used (manufacturer, model, UDI/lot number) per FDA UDI requirements.