OT notes · Orthopaedics

ORIF of ankle (bimalleolar) fracture

Usual anaesthesia
Spinal (subarachnoid block)
Position
Supine on a radiolucent table, thigh tourniquet
Setting
emergency

Operative note template for open reduction and internal fixation of a bimalleolar ankle fracture, with a filled example for a Weber B bimalleolar fracture fixed with a fibular one-third tubular plate and medial malleolar screws under spinal anaesthesia.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • wound breakdown or skin necrosis, especially medially
  • wound infection
  • superficial peroneal or saphenous nerve injury, numbness
  • prominent or painful implant, later removal
  • loss of reduction, malunion or non-union
  • syndesmosis malreduction, need for syndesmotic screw
  • ankle stiffness and post-traumatic arthritis
  • deep vein thrombosis

Pre-operative details for this operation

  1. Side and fracture typeWeber A / B / C (or Lauge-Hansen), medial malleolus or deltoid injury, posterior malleolus, talar shift, open or closed
  2. Soft tissueSkin wrinkles present, no blistersFracture blisters (site)Severe swelling: surgery deferredday of injury; dislocation reduced and splinted on arrival (time)
  3. Pre-op distal neurovascular statusdorsalis pedis and posterior tibial pulses, capillary refill, sensation over dorsum and sole, toe movement
  4. Diabetes / smoking / peripheral vascular diseaseblood sugar value
  5. Implants and C-arm availableone-third tubular / distal fibular locking plate, 4 mm cancellous screws, K-wires, syndesmotic screws

Anaesthesia and position

  1. AnaesthesiaSpinalGeneralSpinal with popliteal block
  2. PositionSupineLateral / prone for posterolateral approach
  3. Tourniquetthigh; pressure mmHg; inflation and release times
  4. C-armside of entry

Operative findings

  1. Fibular fracturelevel relative to syndesmosis, oblique / transverse / comminuted
  2. Medial malleolusfragment size, comminution, interposed periosteum
  3. Joint surfacetalar dome and plafond: chondral or osteochondral injury, loose fragments removed
  4. Syndesmosis after fixationStable on Cotton / external rotation stress testUnstable: fixed
  5. Mortise on final C-armmedial clear space, talar shift, fibular length

Procedure (steps)

  1. Order of fixationLateral firstMedial first (comminuted fibula)
  2. Lateral incisionDirect lateral longitudinalPosterolaterallength; superficial peroneal nerve protected
  3. Fibula reducedlength and rotation restored, clamp used
  4. Fibular lag screwNot used3.5 mm lag screw anterior to posteriorTwo lag screws only
  5. Fibular plateOne-third tubular (lateral neutralisation)Posterolateral antiglidePrecontoured distal fibular locking plateIntramedullary screw / rodK-wires with tension bandholes; screws above fracture (cortical, number) and below (cancellous, unicortical, number)
  6. Medial incisionanteromedial, from 2 cm above fracture to 2 cm below malleolar tip; saphenous vein and nerve protected
  7. Medial malleolus reducedperiosteum cleared from fracture, joint seen, held with clamp and two K-wires
  8. Medial malleolus fixationTwo 4 mm partially threaded cancellous screwsOne screw and one K-wireK-wires with tension bandButtress plate (vertical fracture)
  9. Joint checksuperomedial corner seen to ensure no screw in joint
  10. Syndesmosis test and fixationtest used; if fixed: screw size, number of cortices, level above plafond, or suture button
  11. C-armAP, mortise and lateral; images saved (number)
  12. Tourniquet released, haemostasistime

Closure, drains and dressing

  1. Subcutaneous tissueabsorbable suture
  2. SkinInterrupted nylonStaplesLeft open for delayed closure
  3. DrainNoneSuction drain
  4. SplintBelow-knee posterior slab, ankle neutralBelow-knee cast
  5. Distal neurovascular status at end

Specimens and implants

  1. Fibular implantplate type, holes, number and length of screws above and below fracture, lag screw, make, lot/batch, sticker
  2. Medial malleolar implantscrew type, size, length, number; K-wires / tension band; lot/batch, sticker
  3. Syndesmotic fixationscrew size, cortices, or suture button; lot/batch
  4. C-arm images saved

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Limb elevationabove heart level on pillows
  2. Neurovascular watchtoe capillary refill, toe movement, sensation, pain
  3. Weight bearingnon-weight bearing on operated leg with walker; state duration
  4. Thromboprophylaxisas per unit risk assessment
  5. Check X-rayAP, mortise and lateral ankle
  6. Wound checklook for blisters and medial wound edge necrosis
  7. Splint change and range of motionat first visit if fixation secure: removable splint or boot and ankle exercises
  8. Blood sugar monitoringif diabetic

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mr. R.M., 38 years, twisted his right ankle getting off a bus. Closed Weber B bimalleolar fracture of the right ankle with lateral talar shift. Dislocation reduced and slab applied in casualty. Operated within 12 hours of injury.

Case details

Date: 21/07/2026. Emergency list. OT 2.

In OT 21:00. Spinal 21:10. Tourniquet inflated 21:24. Incision 21:26. Tourniquet released 22:40. Closure completed 22:55.

Surgeon: Dr A. (3rd-year resident, Orthopaedics). Assistant: Dr B. Consultant: Dr C., available on call and informed.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Closed bimalleolar fracture right ankle: short oblique fibular fracture at the level of the syndesmosis (Weber B), transverse medial malleolar fracture, lateral talar shift. Posterior malleolus intact.

Soft tissue: moderate swelling, no blisters, skin intact. Dislocation reduced in casualty at 11:30 and posterior slab applied.

Pre-op: dorsalis pedis and posterior tibial pulses palpable, capillary refill under 2 s, sensation normal over dorsum and sole, toes moving.

Non-diabetic, non-smoker. Consent taken in Hindi. Site marked. WHO checklist done.

Inj cefazolin 2 g IV at 21:14, before tourniquet inflation.

Anaesthesia and position

Spinal anaesthesia. Supine on radiolucent table.

Pneumatic tourniquet on right thigh over padding. Parts painted with povidone-iodine and draped. Limb elevated. Tourniquet inflated to 300 mmHg at 21:24.

Procedure

Lateral side first. 9 cm direct lateral longitudinal incision over the fibula. Superficial peroneal nerve not crossing the field, protected.

Short oblique fibular fracture at syndesmosis level. Haematoma cleared. Length and rotation restored with pointed reduction clamp.

One 3.5 mm cortical lag screw anterior to posterior, 16 mm, engaging the posterior cortex.

One-third tubular plate, 6 holes, stainless steel, on the lateral surface as a neutralisation plate: 3 bicortical 3.5 mm cortical screws above the fracture, 2 unicortical 4 mm cancellous screws below.

Medial side: anteromedial incision from 2 cm above the fracture to 2 cm below the malleolar tip. Great saphenous vein and nerve protected. Skin flap handled gently.

Periosteal fold removed from the medial fracture with a curette. Anteromedial joint seen: talar dome cartilage intact, no loose fragments.

Medial malleolus reduced with a towel clip, held with two 2 mm K-wires. Reduction confirmed on C-arm. Each K-wire replaced in turn by a 4 mm partially threaded cancellous screw (40 mm and 40 mm), parallel.

Superomedial joint corner checked: no screw in the joint.

Cotton test with bone hook on fibula: no lateral shift. External rotation stress on C-arm: medial clear space not widened. Syndesmosis stable, not fixed.

C-arm: AP, mortise and lateral views. Mortise congruent, fibular length restored, medial clear space normal. 5 images saved.

Tourniquet released at 22:40 (total 76 minutes). Haemostasis secured.

Closure

Subcutaneous tissue with polyglactin 910 (Vicryl) 2-0. Skin with interrupted nylon (Ethilon) 3-0 on both sides. No drain.

Sterile dressing. Below-knee posterior plaster slab with ankle in neutral.

At end: toes pink, capillary refill under 2 s. Pulses palpable through dressing window at dorsalis pedis.

Specimens and implants

No specimen.

Fibula: one-third tubular plate 6-hole SS; 3 cortical 3.5 mm screws proximal (12, 14, 14 mm); 2 cancellous 4 mm screws distal (14, 16 mm); 1 lag screw 3.5 mm cortical 16 mm. Make and lot/batch no. as on sticker; stickers pasted in case sheet and implant register.

Medial malleolus: 2 x 4 mm partially threaded cancellous screws, 40 mm. Sticker pasted.

C-arm: 5 images saved.

End of procedure

Estimated blood loss 80 ml. Mop, needle and instrument count correct. No intra-operative complications.

Shifted to recovery, stable. Pulse 82/min, BP 128/76 mmHg.

Post-op orders

Right leg elevated on two pillows. Check toe capillary refill, movement and sensation when spinal wears off.

Strict non-weight bearing on right leg; walker training by physiotherapist.

Analgesia as per anaesthesia chart. Thromboprophylaxis as per unit risk assessment.

Check X-ray right ankle AP, mortise and lateral. Wound check on POD 2.

Signature

Dr A., JR-3, Orthopaedics. Reg. no. ________. 21/07/2026, 23:10.

Must document for this operation

  • Soft tissue state and time from injury. Wound necrosis after ankle fixation is judged against whether surgery was done in the right window for the skin.
  • Syndesmosis test done and its result. A missed syndesmotic injury is a common cause of a poor result; the next surgeon needs to know it was checked.
  • Implant details: plate, screws above and below the fracture, medial screws, lot/batch number, sticker. Needed for implant removal later, recall and the implant register.
  • Check that no screw enters the joint, and C-arm images saved. An intra-articular medial screw causes early arthritis; the note and images show it was excluded.
  • Distal neurovascular status before and after surgery. Needed to judge any later nerve or vascular complaint.
  • Tourniquet pressure and duration. Required when tourniquet-related nerve or skin injury is reviewed.

Common mistakes in these notes

  • Writing 'ORIF done' without the fracture level relative to the syndesmosis.
  • No mention of whether the syndesmosis was tested.
  • Not recording the number of screws above and below the fracture.
  • Leaving out skin condition and blisters before surgery.
  • No weight-bearing instruction in the post-op orders.

Indian practice and paperwork

  • Record the batch and serial number of every implant in the case sheet; NABH also asks for it in the implant logbook and the discharge summary. (NABH Accreditation Standards for Hospitals, 5th ed. (2020), MOM.10(d))

Sources

  • Campbell's Core Orthopaedic Procedures. Elsevier; 2024, Technique 24, Fixation of the lateral and medial malleoli (Rudloff MI), pp. 119-121.
  • Campbell's Operative Orthopaedics. 15th ed. Elsevier, Ch 59, Ankle fractures: bimalleolar fracture, syndesmosis; Ch 2, Tourniquets, pp. 2564-2574; 137-138.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Table 1: cefazolin 2 g IV (3 g if 120 kg or more) within 60 min before incision; cefazolin recommended for implantation of internal fixation devices. academic.oup.com/ajhp/article/70/3/195/5112717
  • Campbell's Operative Orthopaedics 15e, Ch 2, Tourniquets, pp. 137-138: tourniquet time 2 hours or less in healthy adults under 50; 175-305 mmHg satisfactory for the lower limb.

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

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