View calculated CPT fee values specifically for your Medicare locality. 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. / The Current Procedural Terminology (CPT) code 27829 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. What characteristics allow plants to survive in the desert? endstream endobj 23 0 obj <> endobj 31 0 obj <> endobj 36 0 obj <, Foot and Ankle Systems Coding Reference Guide. Open: You should report 27766 (Open treatment of medial malleolus fracture, includes internal fixation when performed) when the orthopedist uses an open method to treat the fracture. View the CPT code's corresponding procedural code and DRG. The specific site (distal) of fracture is captured in the disease code and can be captured by adding free text on the procedure code descriptor. -You would need to bill this method with an unlisted procedure code (27899, Unlisted procedure, leg or ankle),- Woodward says. But don't flip to a different section of CPT just yet. Benefit: If you-re in Alabama and reporting 27829 to Medicare, you could add $545.19 to your bottom line. -Otherwise, when the physician needs to address/fix the tibial posterior lip, you would report 27823.- In fact Medicare data indicate that practices report code 27828 considerably more often than they report either 27826 or 27827 indicating that surgeons normally stabilize both the tibia and fibula at the same time. They were given the same Op Report but insist it is a 27822. Calculated for National Unadjusted (00000), Clinical Labor (Non-Facility)- Direct Expense, Additional Code Information (Global Days, MUEs, etc. Orthopedic surgeons must be specific when documenting fracture repair because CPT's index breaks down the ankle fracture codes into five types: lateral, medial, bimalleolar, trimalleolar, or posterior malleolus. Because the descriptors refer to internal or external fixation you may be able to bill an additional code for your fixation services. CPT code 28615 would be reported for the fixation of the dislocation. The report you have above describes bimalleolar ORIF. I would print out the op note and underline the note where the posterior lip was performed. This cookie is set by GDPR Cookie Consent plugin. 300-400 new vignettes are added each year as codes added, revised and reviewed. OpenType - PS This includes fixation of the fracture which extends into the joint space. CPT 11010 Code: Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (e.g., excisional debridement); skin and . The femur is the large bone in the upper part of your leg. You can still bill these as open treatment codes,- Woodward says. We NEVER sell or give your information to anyone. converted . pilon or tibial plafond) with internal or external fixation; of fibula only. Where appropriate, there are also Pre- and Post-service descriptions. POSTOPERATIVE DIAGNOSIS: UNUNITED AVULSION FRA Hello, I'm having a tough time deciding which way to code this non-union fracture repair. But don't flip to a different section of CPT just yet. View a chart showing the last 8+ years of Medicare denial rates, Medicare Allowed amounts, and Medicare billed amounts. There was no fracture of the actual joint prosthesis. These are the tibia (shinbone), the fibula (the smaller bone in your leg), and the talus (a bone in your foot). These cookies track visitors across websites and collect information to provide customized ads. xmp.id:41edf1cc-60be-495f-aaf4-2fc2f154e384 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). These codes actually represent bimalleolar fractures, which means the patient fractured both the lateral and medial malleoli. CPT Vignettes illustrate code use through sample patientexamples. Monotype Typography Open reduction and internal fixation (ORIF) is a type of surgery used to stabilize and heal a broken bone. 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). 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. With ICD-10-PCS if a provider is used to just documenting a bimalleolar or trimalleolar fracture like the CPT codes below, additional documentation will be required to understand the exact bones and location involved to properly code . Now - to convince the insurance company. 27828 - of both tibia and fibula. Vignettes are reviewed annually and updated when necessary. In such a case "the tibial fixation indirectly stabilizes the fibula " Kosmatka says. SlatePro-Bold The insurance company is stating this should be 27822. You can still bill these as open treatment codes,- Woodward says. Mistaking bimalleolar and trimalleolar fracture codes? Vignettes are reviewed annually and updated when necessary. then the fracture would be sequenced first and then the periprosthetic fracture code as a secondary diagnosis code. 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. If so, you could be costing your practice almost $100-- the difference in reimbursement between the open repair codes for these ankle fractures. Patients who have distal tibia fractures often require more than a tibia-only or fibula-only fixation Swal says. The AMA, however, advises you report either the lateral malleolus fracture treatment codes (27786-27792) or medial malleolus fracture treatment codes (27760-27766). ), Related CPT CodeBook Guidelines (Reverse Guideline Lookup). NCCI doesn't cover every single instance of improper coding. The MT fractures are also treated by ORIF by separate incisions. from application/x-indesign to application/pdf I have looked at 27695, 27792, 27826 & 28193 but unsure as none of these seem to truly fit to me. Periprosthetic fractures are coded within Chapter 13 of ICD-10-CM in category M97. 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. uuid:012e2f35-afb4-114a-9c91-eb3108d190d5 View a table of UCR, Worker's Comp, and Medicare Fees here, as well as see UCR Fees in the charts below. Because your surgeon will probably repair the fracture with plates and screws don't forget to bill separately for the external fixation when warranted. Report External Fixation Separately American Hospital Association ("AHA"), EXCISION OF AVULSION FRACTURE, LEFT LATERAL MALLEOLUS WITH REPAIR OF THE LATERAL LIGAMENTS avulsion fracture fibula excision ankle excision fibula, CANPC HANDOUTS FOR LOCAL CHAPTER AAPC EL PASO, TEXAS 042020, Syndesmosis Repair with ORIF lateral malleolus. Follow our coding advice to put your pilon fracture coding on the right track. Subscribe to. On the other hand, you would use -27788 when the fracture is displaced and needs to be reduced.-. 27826 - Open treatment of fracture of weight-bearing articular surface/portion of distal tibia (e.g. Open treatment of distal radial extra-articular fracture or epiphyseal separation; with internal fixation. If you work with several fee schedules or would like to create custom fee comparison reports, you need our exclusive Compare-A-Feetool. 3190048988 35 0 obj <>>> endobj 62 0 obj <>stream 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). But you shouldn't assume that the physician's work performing external fixation is included in the main procedure. 7 Ankle fracture surgery is indicated for patients who suffer a displaced unstable ankle fracture involving either the bone on the inside of the ankle (the medial malleolus), the bone on the outside of the ankle (the lateral malleolus which is also known as the fibula), or both. Patients who underwent open reduction internal fixation (ORIF) of a distal radius fracture were identified with CPT codes 25607, 25608, and 25609. reverse_index/reverse_index_content.php?set=CPT&c=27827, cpt/cpt_reference_guidelines_content.php?set=CPT&c=27827, newsletters/newsletter_content.php?set=CPT&c=27827, webacode/webacode_content.php?set=CPT&c=27827, medlabtests/medlabtests_content.php?set=CPT&c=27827, crosswalks/crosswalk_content.php?set=CPT&c=27827, ncciedits/ncci_content.php?set=CPT&c=27827, coverage/coverage_content.php?set=CPT&c=27827, commercial-payers/commercial-payers-content.php?set=CPT&c=27827, NPI Look-Up Tool (National Provider Identifier), Major Complications or Comorbidities (MCC/CC), Create UNLIMITED Customized Fee Schedule reports - for ALL localities, ALL specialties, See fees for ALL localities (all ZIP codes) as well as National fees, Load UNLIMITED Fee Schedules with your fees or fees from your payers, Choose to compare fees (national or adjusted for your locality) from built-in data sets and the fee schedules you enter. For instance, your orthopedist may document -distal fibula- fracture instead. Pilon fractures sometimes involve the fibula 90XA is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. 1.000 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). This section showsAPC information including: Status Indicator, Relative Weight, Payment Rate, Crosswalks, and more. "The fibula fracture doesn't necessarily constitute a 'separate' injury but rather is part and parcel of the 'pilon' or 'plafond' fracture " 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. Enjoy a guided tour of FindACode's many features and tools. -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. Bonus: Don't Overlook 27829, Debridement Codes We NEVER sell or give your information to anyone. -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. What is the ICD 10 code for femur fracture? New option: You may come across a physician treating medial malleolus fractures with closed manipulation and percutaneous fixation, but there is no CPT code for this procedure. She was noncompliant with her immediate postoperative weight-bearing instructions and went on to fixation failure. Next, you need to determine which surgical method the orthopedist performed:closed or open. -Coders need to remember their physician should document fractures of two of the malleoli, which can include the posterior malleolus,- Woodward adds. The insurance denied both the professional fee and the facility fee. Therefore if the patient has tibia and fibula fractures but the physician only performs fixation on the tibia you should report 27827. If you choose [], Get Meniscectomies, Chondroplasties Straight, Question: What percentage of the meniscus must the surgeon remove before we should bill the [], Make the Levels Versus Interspaces Distinction, Question: If the surgeon fuses vertebrae L1 through L3, should I report 22612, 22614; or [], Evaluate This CPT Errata and Update Your Manual, Question: The inside cover jacket of my CPT manual says that the definition for modifier [], Question: I am having trouble with Blue Cross Blue Shield (BCBS) with my medial meniscectomy [], Coding additional procedures can boost your bottom line by $500. Type 5: Apply 2008 Codes to Posterior Malleolus Fx Slate Pro These are called , Periprosthetic fractures are fractures that occur around a prosthesis. Example: The surgeon fixes the patient's fibula on the day of the injury and places a temporary external fixator to stabilize the tibia. Thank you for choosing Find-A-Code, please Sign In to remove ads. The delay allows the patient's soft-tissue injuries to resolve making it easier for the surgeon to address the tibial injury. Subscribers may add their own notes as well as "Admin Notes" visible to all subscribers in their account. reverse_index/reverse_index_content.php?set=CPT&c=27786, cpt/cpt_reference_guidelines_content.php?set=CPT&c=27786, newsletters/newsletter_content.php?set=CPT&c=27786, webacode/webacode_content.php?set=CPT&c=27786, medlabtests/medlabtests_content.php?set=CPT&c=27786, crosswalks/crosswalk_content.php?set=CPT&c=27786, ncciedits/ncci_content.php?set=CPT&c=27786, coverage/coverage_content.php?set=CPT&c=27786, commercial-payers/commercial-payers-content.php?set=CPT&c=27786, NPI Look-Up Tool (National Provider Identifier), Major Complications or Comorbidities (MCC/CC), Create UNLIMITED Customized Fee Schedule reports - for ALL localities, ALL specialties, See fees for ALL localities (all ZIP codes) as well as National fees, Load UNLIMITED Fee Schedules with your fees or fees from your payers, Choose to compare fees (national or adjusted for your locality) from built-in data sets and the fee schedules you enter. CPT code information is copyright by the AMA. Learn why strategic planning is essential for coding managers and compliance directors and how to create a plan for your organization. Update Your Skin Substitute Code List for 2023, Hospices CERT Improper Payment Rate Up In 2022, Data Breach Involves 254K Medicare Beneficiaries, 10 Areas That Will Impact Your Healthcare Organization in 2023, A Guide to Strategic Planning in Healthcare. For clinical responsibility, terminology, tips and additional info start codify free trial. Instead you should simply report code 27827 only. Every vignette contains a Clinical Example/Typical Patient and a description of Procedure/Intra-service. Three bones make up the ankle joint. He often uses [], Question: Our trauma surgeon treated a patient who had an injury caused by a motorcycle [], Copyright 2023. I agree. A minimum of two codes are required when reporting the periprosthetic fractures. 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. Open reduction and internal fixation (ORIF) is surgery used to stabilize and heal a broken bone. CT often needed to evaluate percentage of joint surface involved. See our privacy policy. -Coders need to remember their physician should document fractures of two of the malleoli, which can include the posterior malleolus,- Woodward adds. Trap: If your physician sees a patient for a -bimalleolar equivalent fracture,- you may be tempted to report the bimalleolar fracture treatment codes for this injury. So far I am virus free. xmp.did:05d8e06f-c27c-4db7-ab06-766da5b197a4 The patient was worked up and it was found that the fracture was due to underlying osteoporosis. In this case I think it is not appropriate to code 27828." The Centers for Medicare 38 Medicaid Services CMS confirms that Healthcare Management Solutions LLC HMS a subcontractor Set your business up for success by focusing on these key concerns. Enjoy a guided tour of FindACode's many features and tools. American Hospital Association ("AHA"), Fracture Coding: Solve Pilon Fracture Puzzles with These Tips, Reader Question: Select Right Code for ORIF Lower Leg, Reader Questions: How to Receive Full Payment for Pilon Fractures. -You would need to bill this method with an unlisted procedure code (27899, Unlisted procedure, leg or ankle),- Woodward says. -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. -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. "In most cases physicians use a combination of plates and screws to realign and stabilize the distal tibia portion of the injury " Kosmatka says. 0 You might need this procedure to treat your broken shin bone (tibia) or your fibula. 25608. Necessary cookies are absolutely essential for the website to function properly. It is 27814. View calculated CPT fee values specifically for your Medicare locality. SlatePro-Bk The MT fractures are also treated by ORIF by separate incisions. 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. A pilon" or tibial plafond fracture is an intra-articular fracture of the distal tibia " says Kenneth Swal MD an orthopedic surgeon in Dallas. That's why these three codes are grouped the way they are - to address one particular injury complex and its various treatments. 27823 for sure. In this case, report ICD-10 CM codes M84.422A (Pathological fracture, left humerus, initial encounter for fracture) as the principal/first listed diagnosis followed by M97.32XA (Periprosthetic fracture around internal prosthetic left shoulder joint, initial encounter) as a secondary diagnosis. These cookies will be stored in your browser only with your consent. Where appropriate, there are also Pre- and Post-service descriptions. In this case I think it is not appropriate to code 27828." xmp.did:05d8e06f-c27c-4db7-ab06-766da5b197a4 Don't miss: Also, always -read the op report to carefully determine the extent of fracture contamination and debridement,- Woodward says. Here's How, Learn how 0054T-0056T can ease your CAD claims, Coding Triple Hip Reduction Often Requires Modifiers, Prosthesis dislocations during global can be payable, if you know how to bill, " Pilon fractures sometimes involve the fibula, 4 Scenarios Put Your Same-Day Modifier Use to the Test, Multiple procedures or spinal levels may merit modifiers, but not always, Question: We recently treated a radial fracture (25600). No charge. In fact Medicare data indicate that practices report code 27828 considerably more often than they report either 27826 or 27827 indicating that surgeons normally stabilize both the tibia and fibula at the same time. Tip: "One selects the appropriate code based on which portions of the injury receive fixation not based on which bone is broken " Kosmatka says. What is the CPT code for ORIF? Three CPT codes describe pilon fracture treatments: Mistaking bimalleolar and trimalleolar fracture [], Copyright 2023. One code for the periprosthetic fracture and another for the type of fracture, such as traumatic vs. pathological with the underlying condition. As coders, we see physicians document elevat After much confusion, we were finally given a Can cardiac arrest and cardiac shock be coded Weekly medical coding tips and coding education delivered directly to your inbox. Disease can also cause a bone to fracture, and this fracture type is known as a pathological fracture. If you-re in Manhattan, the additional amount is $466.93. In a click, check the DRG's IPPS allowable, length of stay, and more. Type 4: For Trimalleolar, Examine Posterior Lip. There is a 125130 inclination angle between the head and neck and the femoral body. Adobe InDesign CC 14.0 (Macintosh) This section showsAPC information including: Status Indicator, Relative Weight, Payment Rate, Crosswalks, and more. Open: If the surgeon performs open treatment, report 27792 (Open treatment of distal fibular fracture [lateral malleolus], includes internal fixation when performed). "In most cases physicians use a combination of plates and screws to realign and stabilize the distal tibia portion of the injury " Kosmatka says. Viewhistorical information about the code including when it was added, changed, deleted, etc. American Hospital Association ("AHA"). You will be able to see the most common modifiers billed to Medicare along with this code. Other uncategorized cookies are those that are being analyzed and have not been classified into a category as yet. These fractures are not coded as a complication since they. **For Part B of A services, the following CPT codes should be used: What is CPT code for open reduction internal fixation? Don't miss: Also, always -read the op report to carefully determine the extent of fracture contamination and debridement,- Woodward says. 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). 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 Diagnosis for this injury is 845.03 (Sprains and strains of tibiofibular [ligament], distal). Some coders might do a double take when reading the above code descriptors because two of the three codes mention fibula fixation even though pilon fractures occur in the distal tibia. actually involve the implant. Cancel anytime. "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. Tip: "One selects the appropriate code based on which portions of the injury receive fixation not based on which bone is broken " Kosmatka says. 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). 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.