Timing of the Operation
Both with open and closed fractures, especially in cases where the skin is contused, we recommend surgery within eight to ten hours, even when this is outside normal operating room hours in the evening or at night. Experience shows that the danger of infection increases materially after this time, particularly when the skin is contused or a sharp piece of bone is pressing the skin up. This is especially true with a transverse fracture of the medial malleolus where the skin is stretched over the sharp bony edge and damaged from the inside. Generally, therefore, a transverse fracture of the medial malleolus is either operated upon within the ten hour period or it is treated primarily by closed reduction and operated on in three to five days. If the operation cannot be performed within the eight hour limit one should wait for four to eight days by which time local hyperemia may have produced more favourable conditions. Generally speaking, the earlier surgery is performed, the better is the healing rate and the appearance of the resulting wound. Reduction of the fracture is also more difficult after 24 hours, as inflammatory reaction has then already set in.