Introduction Indications ORIF of medial malleolus fxs ORIF of pilon fxs Deltoid ligament repair Planes No internervous plane Preparation Anesthesia options include block vs. general Preparation c-arm, mini vs. full-size to confirm fracture reduction Position supine place foot in slight external rotation to allow better visualization of medial malleolus if a bump is utilized, it can be removed to allow extremity to externally rotate Tourniquet optional - can be used on the thigh or leg Approach Incision Make 10cm longitudinal, curved incision on medial ankle begin 5cm proximal to medial malleolus over subcutaneous tibia continue incision across anterior third of medial mallelous this can be curved apex anteriorly for improved visualization of the ankle joint finish 5cm distal and 5cm anterior to tip of medial malleolus Superficial dissection mobilize skin flaps identify and protect long saphenous vein just anterior to medial malleolus identify and protect long saphenous nerve, if possible, next to vein clear remaining tissues down to periosteum Deep dissection expose fracture site for medial malleolus fracture make small incision in anterior joint capsule to visualize joint and dome of talus split fibers of deltoid ligament to allow hardware to seat directly on bone posterior tibial tendon should be visualized to ensure that it remains intact Dangers Saphenous nerve prevent injury by protecting and preserving the long saphenous vein often too small for direct visualization damage to nerve may cause formation of painful neuroma numbness over medial foot Long Saphenous vein prevent injury by mobilizing anterior skin flaps with caution preservation is ideal so it can be utilized as a vein graft in future