Purpose: The incidence of ankle fractures is rapidly increasing in the geriatric population. Of the four fracture patterns described in the Lauge-Hansen classification system, supination-external rotation accounts for most ankle fractures. This video demonstrates surgical repair of a supination-external rotation type 4 ankle fracture in a geriatric patient.

Methods: Supination-external rotation type 4 ankle fractures are considered unstable and generally are managed via surgical fixation. After placement of a plate and screws, intraoperative stress tests can be used to assess for syndesmotic widening. If necessary, the syndesmosis can be reduced open, with screw fixation placed parallel to the joint. Patients should be non–weight bearing for 6 weeks postoperatively.

Results: This video discusses the case presentation of a 66-year-old woman who sustained a fall with a twisting mechanism of injury, which resulted in an unstable supination-external rotation type 4 ankle fracture requiring surgical repair. Intraoperative stress tests revealed medial clear space widening that required syndesmotic reduction.

Conclusions: A supination-external rotation type 4 ankle fracture is a common injury that must be properly managed so patients can return to baseline functional status. The surgical technique described in this video affords good stabilization and allows for early range of motion, with advancement to weight-bearing status as tolerated at 6 weeks postoperatively.