1. Arash Aminian MD June 7, 2013

2.  I have no conflicts of interest

3. 20% of all ankle sprains 10% of all ankle fractures

4. A deltoid tear can be seen with medial malleolar fracture? T Medial tenderness is predictive of deep deltoid tear? F Intra-operative post reduction stress views should be performed after lateral malleolus fixation? T

5. Bone quality Pre-reduction films: energy of injury Patient factors: BMI Commonly mal-reduced: IR or anterior translation Not every fracture is the same Don’t be in a hurry

6. AITF PITF Transverse TF IOS

7. Deltoid Ligament: Superficial Deep: prevents lateral shift and resists ER

8. Contribution from peroneal/AT Peroneal artery perforates IO membrane 3 cm proximal to ankle JBJS 2012

9. Fibula migrates 2.4 mm and ER with DF Deltoid cut 2 mm shift/15 degrees valgus – Harper 1987

10. Can have a high fibula fx without complete rupture of the IO, deep deltoid 39% Weber B – Tornetta JOT 2007 Boden JBJS 1989

11. Maintain talus in mortise 1 mm shift-42% loss of contact surface RH 1976, 40% Lloyd FAI 2006 2 mm – 49% pressure Zindrick 1985

12. Medial Tenderness Anterior tenderness – nonspecific ER test Squeeze test Check proximal fibula tenderness

13. AP WB x-rays Mortise: Medial clear space “Shenton’s line” Talocural angle 83 +/- 4 degrees on mortise Tib fib overlap/clear space

14. Stable vs Unstable Acute vs Chronic Latent vs Frank

15. Hook test sensitivity/specificity 0.25/0.98 ER test sensitivity/specificity 0.58/0.96

17. 3 vs 4 cortices? 3.5 vs 4.5 mm? Biomechanically similar (FAI 2000) Location of the screw? Postero-lateral to anteromedial TSS fixation level above plafond? 2-5 cm

18. Use a clamp? Prevents motion, shifting of the drill hole Position of the ankle? DF (JBJS 2001) HWR? Fix a high fibula fracture vs only screws? Fixing the posterior malleolus? Displacement/stability

19. 2 wks in splint, then CAM NWB 6 wks WBAT with boot for 6 wks Counsel about hardware breakage

20. Thank you