Open treatment of medial malleolus fracture, includes internal fixation, when performed
CPT4 code
Name of the Procedure
Open treatment of medial malleolus fracture with internal fixation
Summary
The open treatment of a medial malleolus fracture involves surgically repairing a broken medial malleolus bone – the bony prominence on the inner side of the ankle. This procedure includes the use of internal fixation devices, such as screws or plates, to stabilize the bone and promote healing.
Purpose
The procedure addresses fractures of the medial malleolus, which can result from trauma such as falls, sports injuries, or car accidents. The primary goals are to realign the bone fragments, ensure proper healing, restore ankle stability, and prevent future complications like arthritis or deformity.
Indications
- Severe or displaced medial malleolus fractures
- Inability to bear weight on the affected ankle
- Visible deformity of the ankle
- Persistent pain and swelling
- Failure of non-surgical treatments, like casting or bracing, to improve the condition
Preparation
- Fasting may be required for several hours before surgery.
- Patients may need to stop certain medications (e.g., blood thinners) as instructed by their physician.
- Preoperative diagnostic tests, such as X-rays or CT scans, to assess the fracture.
- Pre-surgical medical clearance and evaluations.
Procedure Description
- The patient is placed under general or regional anesthesia.
- A surgical incision is made over the medial malleolus to expose the fractured bone.
- The bone fragments are realigned (reduced) to their normal position.
- Internal fixation devices, like screws or plates, are used to hold the bone fragments together.
- The incision is closed with sutures or staples, and a sterile dressing is applied.
- Sometimes, a splint or cast is placed on the ankle for additional support.
Duration
The procedure typically takes about 1 to 2 hours.
Setting
This surgery is usually performed in a hospital operating room or a surgical center.
Personnel
- Orthopedic surgeon
- Anesthesiologist
- Surgical nurses
- Surgical technicians
Risks and Complications
- Infection
- Bleeding
- Blood clots
- Nerve or blood vessel damage
- Poor bone healing (nonunion or malunion)
- Reaction to anesthesia
- Hardware irritation requiring future removal surgery
Benefits
- Proper alignment and stabilization of the fractured bone
- Restoration of ankle function and stability
- Reduced pain and swelling
- Prevention of long-term complications, such as arthritis
- Most patients see improvement in pain and mobility within a few weeks.
Recovery
- Post-procedure immobilization in a cast or splint for several weeks.
- Pain management with medications.
- Instructions on weight-bearing limitations and movement restrictions.
- Physical therapy may be required to regain strength and range of motion.
- Follow-up appointments for monitoring healing progress.
- Full recovery may take several months, with a gradual return to normal activities.
Alternatives
- Non-surgical treatments like casting or bracing, typically for less severe fractures.
- Closed reduction and casting (setting the bone without making an incision), suitable for non-displaced fractures.
- Each alternative has its pros and cons, with surgical treatment offering better outcomes for severely displaced or unstable fractures.
Patient Experience
Patients may experience discomfort during and after the procedure, managed with pain relievers. Initial postoperative swelling and bruising are common. Regular follow-up visits and adherence to rehabilitation protocols are crucial for optimal recovery and return to normal activities.