This educational case presents the surgical management of a trimalleolar ankle fracture with a distinctive inverted oblique fracture line of the medial malleolus. The case emphasizes procedural reasoning rather than prescriptive technique, highlighting how fracture morphology can influence positioning, surgical approach, reduction strategy, and implant selection.

The lesson follows the sequence of lateral malleolus exposure through a posterolateral approach, assessment of a long oblique fibular fracture, indirect reduction using plate-assisted mechanics, fixation of the posterior malleolar fragment, conversion of patient positioning for medial access, and intraoperative decision-making for a small distal medial malleolar fragment with an atypical obliquity.

Particular attention is given to anatomical landmarks around the ankle, including the peroneal tendons, Achilles tendon interval, syndesmotic structures, posterior malleolus, medial malleolus, periosteal handling, and articular reference points used during reduction. The case also illustrates how preoperative imaging and intraoperative findings may require adaptation of the fixation plan, especially when conventional retrograde screw trajectories are not ideal for the fracture pattern.

INCLUDED CONTENT

• Case-based surgical walkthrough
• Discussion of preoperative fracture pattern assessment
• Posterolateral approach considerations for the ankle
• Lateral malleolus reduction and fixation reasoning
• Posterior malleolus fixation concept
• Medial malleolus exposure and fragment evaluation
• Discussion of atypical screw trajectory selection
• Anatomy-focused procedural commentary
• Fluoroscopy-based reduction assessment concepts
• Educational review points for orthopedic trauma learners

TARGET AUDIENCE

• Orthopedic trauma surgeons
• Orthopedic surgery residents and fellows
• Foot and ankle surgery trainees
• Medical students with interest in musculoskeletal trauma
• Operating room professionals involved in orthopedic trauma education
• Medical educators developing procedural anatomy content

EDUCATIONAL NOTICE

This content is intended for medical and procedural education only. It does not replace formal surgical training, institutional protocols, specialist supervision, or individualized clinical judgment. No clinical outcome is promised or implied. All procedural content should be reviewed by qualified medical professionals before educational or clinical use.