cpt code for orif fibula fracture

-In some cases, physicians are treating the fracture with open reduction-- actually seeing the fracture with the naked eye, not via x-ray-- but they are placing the fixation percutaneously. Open: You should use 27822 (Open treatment of trimalleolar ankle fracture, includes internal fixation, when performed, medial and/or lateral malleolus; without fixation of posterior lip) or 27823 ( with fixation of posterior lip) for open trimalleolar treatments. Get timely coding industry updates, webinar notices, product discounts and special offers. 300-400 new vignettes are added each year as codes added, revised and reviewed. " Type 2: Master Medial Malleolus Fracture Coding. Many ankle fractures also involve disruption of the syndesmosis or distal tibiofibular joint. Coding solution: The surgeon should report 27826 and 20690 on the first date of service followed by 27827 on the second date of service. One to three weeks later the patient returns to the OR and the surgeon removes the external fixator and converts to internal fixation after the soft swelling has decreased. 25607. You can bill this in addition to the ankle fracture repair code using 27829 (Open treatment of distal tibiofibular joint [syndesmosis] disruption, includes internal fixation when performed), Woodward says. Patient is admitted for new periprosthetic fracture of the lower end of the left femur after falling down 4 steps. Access to this feature is available in the following products: "The fibula fracture doesn't necessarily constitute a 'separate' injury but rather is part and parcel of the 'pilon' or 'plafond' fracture " xmp.did:05d8e06f-c27c-4db7-ab06-766da5b197a4 23670 Open treatment of shoulder dislocation, with fracture of greater humeral tuberosity, includes internal fixation, when performed 23680 Open treatment of shoulder dislocation, with surgical or anatomical neck fracture, includes internal fixation, when performed CPT Code Defined Ctgy Description 23000 Removal of subdeltoid calcareous . Instead you should simply report code 27827 only. This section showsAPC information including: Status Indicator, Relative Weight, Payment Rate, Crosswalks, and more. 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The AMA, however, advises you report either the lateral malleolus fracture treatment codes (27786-27792) or medial malleolus fracture treatment codes (27760-27766). 28485. What is the CPT code for ORIF? Further, there is a 15 anteversion angle between the plane passing through the condyles of the femoral head and the femur neck. We NEVER sell or give your information to anyone. Open: If the surgeon performs open treatment, report 27792 (Open treatment of distal fibular fracture [lateral malleolus], includes internal fixation when performed). -You would need to bill this method with an unlisted procedure code (27899, Unlisted procedure, leg or ankle),- Woodward says. View calculated CPT fee values specifically for your Medicare locality. The cookie is used to store the user consent for the cookies in the category "Other. Enjoy a guided tour of FindACode's many features and tools. These are called , Periprosthetic fractures are fractures that occur around a prosthesis. ARTHROPLASTY, ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REPLACEMENT (TOTAL HIP ARTHROPLASTY), WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT. "The fibula fracture doesn't necessarily constitute a 'separate' injury but rather is part and parcel of the 'pilon' or 'plafond' fracture " ICD-10-CM/PCS Coding Clinic, Fourth Quarter ICD-10 2016 Page: 42, ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2018 Page: 21, https://www.niams.nih.gov/health-topics/hip-replacement-surgery, Coding Tip: Coding Changes for Pulmonary Hypertension, Part 1: New ICD-10 Codes and IPPS Changes for 2023. Read a CPT Assistant article by subscribing to. then the fracture would be sequenced first and then the periprosthetic fracture code as a secondary diagnosis code. Be sure to include the op note, a description of the procedure, and a letter describing a comparable established procedure. The surgeon treats the fracture of the shaft with an open reduction and internal fixation (ORIF) and internally fixates both fractures as a single unit. In this case, the correct CPT code for the initial treatment is 27750 Closed treatment of tibial shaft fracture (with or without fibular fracture); without manipulation. Cancel anytime. View fees for this code from 4 different built-in fee schedules and from those you've added using the Compare-A-Feetool. "In most cases physicians use a combination of plates and screws to realign and stabilize the distal tibia portion of the injury " Kosmatka says. Other uncategorized cookies are those that are being analyzed and have not been classified into a category as yet. Subscribers will be able to see codes in a code-book page-like view here. It is 27814. endstream endobj 23 0 obj <> endobj 31 0 obj <> endobj 36 0 obj <, Foot and Ankle Systems Coding Reference Guide. Closed: You should report 27808 (Closed treatment of bimalleolar ankle fracture [e.g., lateral and medial malleoli,or lateral and posterior malleoli or medial and posterior malleoli]; without manipulation) or 27810 ( with manipulation) if the orthopedist performs closed fracture care on a bimalleolar fracture. The insurance company is stating this should be 27822. For instance, your orthopedist may document -distal fibula- fracture instead. Open: If the surgeon performs open treatment, report 27792 (Open treatment of distal fibular fracture [lateral malleolus], includes internal fixation when performed). As the fracture does not involve the ankle the only option available in ACHI is 47566-01 [1510] Open reduction of fracture of shaft of tibia with internal fixation. Know the Ropes When You Tackle Pilon Fracture Coding, Want to Ace Hip Procedure Coding? Mistaking bimalleolar and trimalleolar fracture codes? 27826 Is Correct for 2-Part Procedures Mistaking bimalleolar and trimalleolar fracture [], Copyright 2023. Now - to convince the insurance company. I agree. Subscribers may add their own notes as well as "Admin Notes" visible to all subscribers in their account. Type 4: For Trimalleolar, Examine Posterior Lip Instead you should simply report code 27827 only. Kosmatka says. Subscribers will be able to see codes in a code-book page-like view here. xmp.iid:f6deefeb-42e9-4eb4-82d5-85a43c7364e3 If you work with several fee schedules or would like to create custom fee comparison reports, you need our exclusive Compare-A-Feetool. No charge. 3190048988 Anatomical Terminology Is Key Closed: For closed fracture treatment of the lateral malleolus, report either 27786 (Closed treatment of distal fibular fracture [lateral malleolus]; without manipulation) or 27788 (- with manipulation). Sounds like your going to need to appeal. Coding solution: The surgeon should report 27826 and 20690 on the first date of service followed by 27827 on the second date of service. This section showsAPC information including: Status Indicator, Relative Weight, Payment Rate, Crosswalks, and more. "These injuries are usually caused by a trauma to the ankle that can also damage the soft tissues so these fractures can be very difficult to treat." One to three weeks later the patient returns to the OR and the surgeon removes the external fixator and converts to internal fixation after the soft swelling has decreased. 6 What is the difference between 27125 and 27236? Do you need underlay for laminate flooring on concrete? Disease can also cause a bone to fracture, and this fracture type is known as a pathological fracture. Coding Tip: Periprosthetic Fracture Reporting and Sequencing, There are approximately 6.3 million fractures reported each year in the, and most are due to trauma. View matching HCPCS Level II codes and their definitions. Closed: When your orthopedist performs a closed method, you would report either 27767 (Closed treatment of posterior malleolus fracture; without manipulation) or 27768 (- with manipulation). But you shouldn't assume that the physician's work performing external fixation is included in the main procedure. Three CPT codes describe pilon fracture treatments: 27826 - Open treatment of fracture of weight-bearing articular surface/portion of distal tibia (e.g. NCCI doesn't cover every single instance of improper coding. I thought I was missing something. OpenType - PS 0 ), Related CPT CodeBook Guidelines (Reverse Guideline Lookup). APC information including: Status Indicator, Relative Weight, Payment Rate, Crosswalks, and more. In this case I think it is not appropriate to code 27828." What is the CPT code for ORIF distal femur fracture? -Otherwise, when the physician needs to address/fix the tibial posterior lip, you would report 27823.-, Type 5: Apply 2008 Codes to Posterior Malleolus Fx. Search across Medicare Manuals, Transmittals, and more. default Don't forget: You should append modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) to 27827 because the physician performed the initial fixation with the intent of returning to the OR to convert to internal fixation Kosmatka says. The Current Procedural Terminology (CPT) code 27552 as maintained by American Medical Association, is a medical procedural code under the range Fracture and/or Dislocation Procedures on the Femur (Thigh Region) and Knee Joint. The cookies is used to store the user consent for the cookies in the category "Necessary". Bonus: Don't Overlook 27829, Debridement Codes The insurance denied both the professional fee and the facility fee. On the other hand, you would use -27788 when the fracture is displaced and needs to be reduced.- CPT 27792, Under Fracture and/or Dislocation Procedures on the Leg (Tibia and Fibula) and Ankle Joint The Current Procedural Terminology (CPT ) code 27792 as maintained by American Medical Association, is a medical procedural code under the range - Fracture and/or Dislocation Procedures on the Leg (Tibia and Fibula) and Ankle Joint. I-10 Coding Handbook ICD-10-CM/PCS Coding Clinic, Fourth Quarter ICD-10 2016 Page: 42 ICD-10-CM/PCS Coding Clinic . Closed: You should report 27808 (Closed treatment of bimalleolar ankle fracture [e.g., lateral and medial malleoli,or lateral and posterior malleoli or medial and posterior malleoli]; without manipulation) or 27810 ( with manipulation) if the orthopedist performs closed fracture care on a bimalleolar fracture. Open treatment of bimalleolar ankle fracture (eg,[B][COLOR=rgb(235, 107, 86)] lateral and medial malleoli[/COLO 27792 was precerted, and documented in patient chart. That's why these three codes are grouped the way they are - to address one particular injury complex and its various treatments. 300-400 new vignettes are added each year as codes added, revised and reviewed. Every vignette contains a Clinical Example/Typical Patient and a description of Procedure/Intra-service. Main Differences between HCPCS and CPT HCPCS was developed by the Centers for Medicare and Medicaid while CPT was developed by American Medical Association. Be sure to include the op note, a description of the procedure, and a letter describing a comparable established procedure. Totally minimally invasive fixation may rarely be indicated when the joint surface fracture is nondisplaced, and perhaps very simple fractures that can be reduced percutaneously and assessed completely reliably with x-ray control. A pathological fracture is usually spontaneous but may also result from a minor trauma that fractures from the diseased bone. S72. Closed: If the orthopedist performs closed medial malleolar fracture treatment, report either 27760 (Closed treatment of medial malleolus fracture; without manipulation) or 27762 ( with manipulation, with or without skin or skeletal traction). "Since these are complex injuries the patient may receive temporary fixation on the day of injury and receive permanent fixation at a later date " Kosmatka says. Open: When the orthopedist uses an open surgical method to treat a bimalleolar fracture, report 27814 (Open treatment of bimalleolar ankle fracture, [e.g., lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli], includes internal fixation when performed) with 824.4 (Fracture of ankle; bimalleolar, closed) or 824.5 ( bimalleolar, open) as the diagnosis. But don't flip to a different section of CPT just yet. See our privacy policy. Because the descriptors refer to internal or external fixation you may be able to bill an additional code for your fixation services. 0 We would appreciate any opinions on whether this should be 27823 or 27822. CPT code 28615 would be reported for the fixation of the dislocation. Tarsometatarsal dislocation of the right midfoot along with mid-shaft fractures of the 2nd, 3rd and 4th MTs: The dislocation is treated by open reduction internal fixation (ORIF). "Thus one could argue that the fibula has been 'fixed ' but not by any direct instrumentation. A pilon" or tibial plafond fracture is an intra-articular fracture of the distal tibia " says Kenneth Swal MD an orthopedic surgeon in Dallas. Diagnosis can be made with plain radiographs of the ankle. In fact, the role of deltoid ligament repair in the treatment of bimalleolar equivalent ankle fractures is one that has been very controversial. Diagnosis for this injury is 845.03 (Sprains and strains of tibiofibular [ligament], distal). 2825763434 SlatePro-Bold If you work with several fee schedules or would like to create custom fee comparison reports, you need our exclusive Compare-A-Feetool. This includes fixation of the fracture which extends into the joint space. "Depending on the fracture configuration one may also stabilize the distal fibula with a plate and screws or a rod/pin." Learn how to get the most out of your subscription. This cookie is set by GDPR Cookie Consent plugin. 2019-01-14T15:52:45.960-06:00 Therefore if the patient has tibia and fibula fractures but the physician only performs fixation on the tibia you should report 27827. Don't miss: Also, always -read the op report to carefully determine the extent of fracture contamination and debridement,- Woodward says. You are using an out of date browser. View calculated CPT fee values specifically for your Medicare locality. Vignettes are reviewed annually and updated when necessary. What is the CPT code for ORIF? 27827 - of tibia only For instance, your orthopedist may document -distal fibula- fracture instead. Get timely coding industry updates, webinar notices, product discounts and special offers. View any code changes for 2023 as well as historical information on code creation and revision. Save time with a Professional or Facility subscription! Trimalleolar fractures involve the same components asbimalleolar (medial and lateral) as well as the posterior lip of the tibia, which is termed the posterior malleolus for the purposes of this classification, although technically it is not a malleolus. Coding additional procedures can boost your bottom line by $500. They tend to occur in older patients, and in those who have osteoporosis. Proximal femoral fractures are a subset of fractures that occur in the hip region. Combat the #1 denial reason - mismatched CPT-ICD-9 codes - with top Medicare carrier and private payer accepted diagnoses for the chosen CPT code. CPT is divided into three categories while HCPCS is divided into three levels HCPCS encourage free access due to HIPAA while CPT has paid access service due to a copyrighted issue. If you think you can't bill external fixation codes along with pilon fracture treatment, you've fallen prey to one of the many myths surrounding pilon fracture coding. Open reduction and internal fixation (ORIF) is surgery used to stabilize and heal a broken bone. This section showsAPC information including: Status Indicator, Relative Weight, Payment Rate, Crosswalks, and more. Type 1: Decide if Lateral Malleolus Fracture Is Open Versus Closed The MT fractures are also treated by ORIF by separate incisions. Tarsometatarsal dislocation of the right midfoot along with mid-shaft fractures of the 2nd, 3rd and 4th MTs: The dislocation is treated by open reduction internal fixation (ORIF). For instance if the physician performs internal and external tibia fixation you should include the internal fixation in your charge for 27827 but you can separately bill the external fixation with 20690 (Application of a uniplane [pins or wires in one plane] unilateral external fixation system). Four new HCPCS Level II codes are payable under Medicare. If the reason for admission/encounter is for the fracture, then the fracture would be sequenced first and then the periprosthetic fracture code as a secondary diagnosis code. If this is your first visit, be sure to check out the. Tarsometatarsal dislocation of the right midfoot along with mid-shaft fractures of the 2nd, 3rd and 4th MTs: The dislocation is treated by open reduction internal fixation (ORIF). CPT code 28615 would be reported for the fixation of the dislocation. These cookies ensure basic functionalities and security features of the website, anonymously. Important: -The fracture itself can be an open fracture (puncture through the skin at the time of the injury) or closed (no break in the skin),- says Ruby Woodward,BSN, ACS-OR, coding and research specialist for Twin Cities Orthopedics in Minneapolis, Minn. Subscribe to. CPT Code Description Internal Fixation (cont.) Type 4: For Trimalleolar, Examine Posterior Lip. CPT Code information is available to subscribers and includes the CPT code number, short description, long description, guidelines and more. Discover how to save hours each week. Calculated for National Unadjusted (00000), Clinical Labor (Non-Facility)- Direct Expense, Additional Code Information (Global Days, MUEs, etc. Therefore if the patient has tibia and fibula fractures but the physician only performs fixation on the tibia you should report 27827. ICD-10-CM has specific codes for periprosthetic fractures. -Open treatment means treatment of a fracture/dislocation by surgically exposing the fracture/dislocation site,- says Kathleen F. Nelson, CPC, orthopedics professional coder at Fletcher Allen Health Care in Burlington, Vt. You can bill this in addition to the ankle fracture repair code using 27829 (Open treatment of distal tibiofibular joint [syndesmosis] disruption, includes internal fixation when performed), Woodward says. View the CPT code's corresponding procedural code and DRG. These codes actually represent bimalleolar fractures, which means the patient fractured both the lateral and medial malleoli. Next, you need to determine which surgical method the orthopedist performed:closed or open. Three CPT codes describe pilon fracture treatments: Patient is 6 weeks out from a fall, had fractured ribs and an ankle, the ribs were more painful so he delayed 27792 is not correct. If you work with several fee schedules or would like to create custom fee comparison reports, you need our exclusive Compare-A-Feetool. Patients who have distal tibia fractures often require more than a tibia-only or fibula-only fixation Swal says. (OBQ20.15) Figure A is the radiograph of a 55-year-old female who is a poorly-controlled diabetic with neuropathy and peripheral vascular disease (PVD) that underwent ankle open reduction internal fixation (ORIF) two years ago at an outside facility. 25608. View a table of UCR, Worker's Comp, and Medicare Fees here, as well as see UCR Fees in the charts below. What is the ICD 10 code for femur fracture? Functional cookies help to perform certain functionalities like sharing the content of the website on social media platforms, collect feedbacks, and other third-party features. 2019-01-09T10:53:58.000-06:00 Open: For the open method, you should use 27769 (Open treatment of posterior malleolus fracture, includes internal fixation, when performed). Pilon Fractures Can Include the Fibula These fractures are not coded as a complication since they. Example: The surgeon fixes the patient's fibula on the day of the injury and places a temporary external fixator to stabilize the tibia. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly. Patients who underwent open reduction internal fixation (ORIF) of a distal radius fracture were identified with CPT codes 25607, 25608, and 25609. Vignettes are reviewed annually and updated when necessary. from application/x-indesign to application/pdf These cookies track visitors across websites and collect information to provide customized ads. Materials and methods: The 2015-2016 American College of Surgeons National Surgical Quality Improvement Program database was queried for patients 65 years of age undergoing hip fracture surgery, due to trauma, using CPT-Codes for total hip arthroplasty (27130), Hemiarthroplasty (27125) and Open Reduction/Internal . OpenType - PS For a better experience, please enable JavaScript in your browser before proceeding. Get timely coding industry updates, webinar notices, product discounts and special offers. Available for over 5000 of the most common CPT codes. If youre wondering how much review pressure your hospice is likely to encounter this year Medicares recent Comprehensive Error Rate Testi A business associate of a government contractor is hit with a ransomware attack. registered for member area and forum access. If you-re in Manhattan, the additional amount is $466.93. Patients who have distal tibia fractures often require more than a tibia-only or fibula-only fixation Swal says. You can still manage open fractures in a closed fashion, so -realistically, you still have the option of reporting 11010-11012 (Debridement - associated with open fracture[s] and/or dislocation[s] ) codes with one of the closed management codes.- If you-re coding for extensive debridement in Alabama and submitting to Medicare, you could see a boost of $374.36. Save time with a Professional or Facility subscription! false 27826 - Open treatment of fracture of weight-bearing articular surface/portion of distal tibia (e.g. CPT Vignettes illustrate code use through sample patientexamples. Benefit: If you-re in Alabama and reporting 27829 to Medicare, you could add $545.19 to your bottom line. We use cookies on our website to give you the most relevant experience by remembering your preferences and repeat visits. Orthobullets Technique Guides cover information that is "not testable" on ABOS Part I, Fracture Preparation and Reduction (Fibula), Soft Tisue Dissection (Posterior Malleolus), Fracture Preparation and Reduction (Posterior Malleolus), firmly hold proximal tibia while contralateral hand dorsiflexes and externally rotates foot, 3-0 nylon for skin with horizontal mattress stitches, in diabetics or patients with high risk for skin breakdown, use modified Allgower-Donati stitch to reduce tension on skin, advance weight-bearing status in CAM boot, if syndesmotic screw(s) placed need to be non-weightbearing, Leg Compartment Release - Single Incision Approach, Leg Compartment Release - Two Incision Approach, Arm Compartment Release - Lateral Approach, Arm Compartment Release - Anteromedial Approach, Shoulder Hemiarthroplasty for Proximal Humerus Fracture, Humerus Shaft ORIF with Posterior Approach, Humerus Shaft Fracture ORIF with Anterolateral Approach, Olecranon Fracture ORIF with Tension Band, Olecranon Fracture ORIF with Plate Fixation, Radial Head Fracture (Mason Type 2) ORIF T-Plate and Kocher Approach, Coronoid Fx - Open Reduction Internal Fixation with Screws, Distal Radius Extra-articular Fracture ORIF with Volar Appr, Distal Radius Intraarticular Fracture ORIF with Dorsal Approach, Distal Radius Fracture Spanning External Fixator, Distal Radius Fracture Non-Spanning External Fixator, Femoral Neck Fracture Closed Reduction and Percutaneous Pinning, Femoral Neck FX ORIF with Cannulated Screws, Femoral Neck Fracture ORIF with Dynamic Hip Screw, Femoral Neck Fracture Cemented Bipolar Hemiarthroplasty, Intertrochanteric Fracture ORIF with Cephalomedullary Nail, Femoral Shaft Fracture Antegrade Intramedullary Nailing, Femoral Shaft Fracture Retrograde Intramedullary Nailing, Subtrochanteric Femoral Osteotomy with Biplanar Correction, Distal Femur Fracture ORIF with Single Lateral Plate, Patella Fracture ORIF with Tension Band and K Wires, Tibial Plateau Fracture External Fixation, Bicondylar Tibial Plateau ORIF with Lateral Locking Plate, Tibial Plafond Fracture External Fixation, Tibial Plafond Fracture ORIF with Anterolateral Approach and Plate Fixation, Ankle Simple Bimalleolar Fracture ORIF with 1/3 Tubular Plate and Cannulated Screw of Medial Malleol, Ankle Isolated Lateral Malleolus Fracture ORIF with Lag Screw, Calcaneal Fracture ORIF with Lateral Approach, Plate Fixation, and Locking Screws, RETIRE Transtibial Below the Knee Amputation (BKA), identify joint involvement and articular step-off (>25%, >2mm requires ORIF), rolls under chest and knees and bump under hip for neutral rotation, between FHL (tibial nerve) and peroneal muscles (SPN), lobster claw or pointed clamps with hand rotation to reduce fibular fracture, move to posterior malleolus and free up fragments, place buttress plate 1/3 tubular or T-plate over posterior malleolus, anterior to posterior screws and 1/3 tubular plate over fibula, perform Cotton test / external rotation stress test to determine if syndesmosis injured, 1 or 2 screws, 3.5/4.5mm, tricortical or quadricortical, 2 wks non-weight bearing in postmold sugartong splint, 4-6 wks in CAM boot with progression of weight bearing and range of motion exercises, identify amount of joint involvement and articular step-off (>25%, >2mm requires ORIF), posterior malleolus fractures <25% of joint surface and <2mm articular step-off can be treated non-operatively in short leg walking cast vs. cast boot, CT often needed to evaluate percentage of joint surface involved, identify ankle fracture pattern (Lauge-Hansen SA, SER, PA, PER) and associated injuries, need to evaluate syndesmotic injury with stress exam, stiffness of syndesmosis restored to 70% of normal with isolated posterior malleolus fixation alone, standard OR table with radiolucent end, c-arm from contralateral side perpendicular to table, monitor at foot of bed in surgeon direct line of site, 2.0/2.5mm drills, 2.7/3.5mm cortical screws, 4.0mm cancellous screws, 1/3 tubular plates (Synthes Small Fragment Set), prone with feet at the end of the bed, bump under hip to get limb into neutral rotation, thigh tourniquet placed while patient supine high on thigh before flipping prone, internervous plane between FHL (tibial nerve) and peroneal muscles (SPN), incision along posterior border of fibula, access fibula with posterior retraction of peroneals, access posterior malleolus with anterior retraction of peroneals, blunt dissection between FHL and peroneals, stack of blue towels under anterior ankle to elevate limb, mark out lateral malleolus, anterior and posterior borders of fibula, borders of Achilles, incision ~6-8cm in length along posterolateral border of fibula, 15 blade through skin then tenotomy scissors to spread subcutaneous tissue with minimal soft tissue stripping, identify SPN with more proximal fractures, take fascia down sharply over posterior border of fibula anterior to peroneal tendons, sharp dissection down to bone with subperiostel dissection at fracture edges, extraperiosteal dissection proximal and distal to fracture site with knife and wood handled elevator, clean out fracture site using freer to open fracture site, curettes, small rongeur, dental pick, and irrigation to remove hematoma and interposed soft tissue, use lobster clamp and pointed clamps to reduce fracture, use hand rotation and contralateral thumb to help guide fragments together, lobster clamp has good hold on bone while pointed clamps have a more fine-tuned feel for reduction, need to be perpendicular to vector of fracture line, place temporary kwires to provisionally fix fragments, identify interval between peroneals and FHL, identify FHL by flexing hallux and watching for muscle belly movement, need to protect and retract posterior tibial neurovascular bundle medial to FHL, place self retainers and incise periosteum over post mal with 15blade, clean fracture site as above with fibula, do not release PITFL off of fragment as this will destabilize syndesmosis and devitalize fragment, fracture should reduce with reduction of fibula, reduce with direct pressure pushing down onto fragment, two 3.5mm screws (2.5mm drill) anterior to posterior in T-plate distal, 2 screws proximal into distal tibia, check placement of plate and screws under fluoro, make sure screws are perpendicular to bone, do not want distal screws (typically 40mm) to protrude anterior and irritate tibialis anterior, after fixing posterior malleolus move back to fibula fracture, place lag screw (2.7mm screw/2.0mm drill) followed with 1/3 tubular plate using antiglide technique on posterior aspect of fibula, place 2-3 3.5mm bicortical screws (2.5mm drill), most distal screw will likely be 4.0 cancellous since its close to joint and/or syndesmosis, check plate and screw positions with fluoro on AP and Lat views, reduction tenaculum is placed ~2cm above joint and lateral pull applied, opening of the syndesmosis on mortise view is indicative of a positive stress test, if increased opening of tibia-fibular overlap syndesmosis is injured, anterior-posterior instability exam is most sensitive for syndesmosis injury, formally open the anterior aspect of the syndesmosis (anterior to fibula), remove interposing tissue if preventing reduction, place Weber pointed clamp or large periarticular clamp across syndesmosis, one tine on medial tibia and other on lateral fibula, hold foot in neutral dorsiflexion andinspect syndesmosis from lateral incision, inspect syndesmosis from lateral incision to ensure anatomic reduction, use 2.5mm (or 3.5mm) long drill bit to drill across fibula into tibia, drill bit orientation parallel to joint 2-4cm above joint, drill bit is angled ~20-30 posterior to anterior due to fibular position in syndesmosis, obtain final AP, mortise, and lateral radiographs, irrigate wounds thoroughly and deflate tourniquet if used, deep fascial closure over plate with 0-vicryl, soft incision dressing followed by postmold sugartong splint with extra padding under heel for immobilization, remove splint and place in short-leg cast boot, non-weight bearing, can allow ROM if soft tissue is appropriate, advance weight-bearing if diabetic, insensate, or syndesmotic screws present, syndesmotic screws to stay in for at least 12 weeks, syndesmotic screws will loosen or break if maintained, superficial and deep infections (1-2%, up to 20% in diabetics), peroneal irritation from posterior fibula antiglide plating, iatrogenic injury to SPN during fibula exposure, PITFL, posterior tibial neurovascular bundle during FHL exposure.

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