1. Diagnostics, classification and treatment of malleolar fractures
Diagnostics, classification and treatment of malleolar fractures. Pilon fractures.

2. What are malleolar fractures?
Fractures of the ankle!!!

3. Anatomy??? What makes up the ankle joint? Bones
Soft tissues: ligaments and muscles

4. Bones Distal tibia (plafond and medial malleolus
Distal fibula (lateral malleolus)
Talus (highly congruent articulation with plafond)
Truncated cone

5. Ligaments Medial stabilizers: deltoid ligament (5 components)
Lateral stabilizers:
anterior talofibular ligament
posterior talofibular ligament
calcaneofibular ligament
Ligaments binding tibia and fibula together:
anterior and posterior inferior tibiofibular ligaments
inferior transverse ligament
interosseous ligament (strongest)

6. Medial stabilizers
Deltoid ligament
5 components
Resists abduction

7. Lateral stabilizers Anterior talofibular ligament
Posterior talofibular ligament
Calcaneofibular ligament

8. Syndesmosis Anterior tibio-fibular ligament
Posterior tibio-fibular ligament
Interosseus ligament

9. Malleolar fractures: Diagnostics
History
Clinical examination
Observation: swelling, pain, deformity, possible hematoma
Physical examination: comparison of temperature of both sides (possible vessel injury)
Radiological examination
CT if necessary

10. Malleolar fractures: Diagnostics
Radiological examination
AP and lateral views
May also use a 30 degree internally rotated view (mortise)

11. Malleolar fractures: what to look for on x-ray
Position of lateral and medial ankle
Dislocations
How parallel the surfaces of the tibia and talus are with regard to one another
Position of the Weber tip of the lateral ankle
Unevenness of the talar surface (osteochondral fractures)
Distance between the medial ankle and talus (if >4mm and the Weber tip is displaced proximally subluxation of the joint is probable)

12. Classification: Why classify??
Aim of classification is demonstration of different types of fractures and their organization
Fracture classification aids in determination of the best treatment and also gives an idea of fracture prognosis
Should be simple and useable

13. Classification of malleolar fractures
Ankle fractures can be classified purely along anatomical lines as monomalleolar, bimalleolar, or trimalleolar.
Lauge-Hansen classification takes into account the position of the forefoot (pronation or supination) and the direction of the force which causes the fracture (abduction, adduction, outward rotation).
Weber classification of lateral ankle fractures takes into account the level of the fracture in a frontal view (AO classification is similar to this).

14. Lauge-Hansen classification
Supination-adduction injury: with the forefoot in supination, the force acts in a varus direction thus adducting the foot.
Transverse avulsion-type fracture of the fibula below the level of the joint or tear of lateral collateral ligaments
Vertical fracture of medial malleolus

15. Lauge-Hansen classification
Supination-external rotation injury: most common. Forefoot in supination and force in direction of external rotation further stresses the forefoot.
Disruption of the anterior talofibular ligament
Spiral oblique fracture of the distal tibia
Disruption of the posterior tibiofibular ligament or fracture of the posterior malleolus
Fracture of the medial malleolus or rupture of the deltoid ligament 3

16. Supination external rotation

17. Lauge-Hansen classification
Pronation-abduction injury: quite common, besides forced abduction, the forefoot is in pronation.
Transverse fracture of the medial malleolus or rupture of the deltoid ligament
Rupture of the syndesmotic ligaments or avulsion fracture of their insertions
Short, horizontal oblique fracture of the fibula above the level of the joint

18. Pronation-abduction

19. Lauge-Hansen classification
Pronation-external rotation injury: more rare, forefoot in pronation with a forced external rotation
Transverse fracture of the medial malleolus or disruption of the deltoid ligament
Disruption of the anterior tibiofibular ligament
Short oblique fracture of the fibula above the level of the joint
Rupture of the posterior tibiofibular ligament or avulsion fracture of the posterolateral tibia

21. Weber and AO classification
Weber A: Fibula fracture below syndesmosis
AO:
A1: isolated
A2: with fracture of medial malleolus
A3: with a posteromedial fracture

22. Weber and AO classification
Weber B: fracture of the fibula at the level of the syndesmosis
AO:
B1: isolated
B2: with medial lesion (malleolus or ligament)
B3: with a medial lesion and fracture of posterolateral tibia

23. Weber and AO classification
Weber C: fracture of the fibula above the level of the syndesmosis.
AO:
C1: diaphyseal fracture of the fibula, simple
C2: diaphyseal fracture of the fibula, complex
C3: proximal fracture of the fibula

24. Treatment of malleolar fractures
With fractures of the ankle, only slight variation from normal is compatible with good joint function:
The normal relationships of the ankle mortise must be restored
The weight-bearing alignment of the ankle must be at a right angle to the longitudinal axis of the leg
The contours of the articular surface must be as smooth as possible
The best results are obtained by anatomical joint restoration

25. Anatomical joint restoration
Closed manipulation with plaster casting (conservative treatment)
Open reduction and internal fixation (operative treatment)

26. Conservative treatment
Indications: non-displaced fractures, stable fractures (Weber B, pronation-adduction fractures)
Technique: reduction using opposite to mechanism of injury
Time: 6-8 weeks cast, no weight-bearing for 3 weeks
Complications: when swelling goes down, cast becomes loose and fracture can re-dislocate. Frequent follow-up is necessary!!

27. Operative treatment
Indications: all open fractures, unstable fractures, failure of closed reduction (retention?), displaced fractures
If possible, immediately. If not, within 12 hours. After this, bullae or skin necrosis can develop which further delay surgery

28. Operative treatment Osteosynthesis of lateral malleolus
Plate and screws
Interfragmental screw in case of diagonal fracture

29. Operative treatment Osteosynthesis of medial malleolus
Isolated medial malleolus fractures are rare, look for proximal fibular fracture in these cases
Tension band wiring
Cancellous screws

30. Operative treatment
Osteosynthesis of the Posterior malleolus (25-30% of articular surface)
Can often be reduced with closed reduction
Cancellous screw introduced from the ventral surface

31. Operative treatment Injuries of the syndesmosis:
Anterior syndesmosis ligament injuries are associated with both pronation and supination injuries
Instability occurs when the interosseous membrane is lesioned to the level of the lateral malleolar fracture (only in Weber C or pronation-external rotation injuries).
Reduction and stabilization of the membrane using temporary pinning or reduction clamp and insertion of syndesmotic screw (for anterior syndesmolysis)
Reduction and stabilization of the Volkmann triangle (for posterior syndesmolysis)

32. Operative treatment Syndesmosis lesions
Hard to assess radiographically
May stabilize if lateral and medial ankle are fixed
Cotton test (pull with bone hook intraoperatively)
External rotation under image intensifier
Instability: > mm widening or medial clear space > 4mm

33. Pilon fractures
Pilon fractures = Intraarticular fractures of the distal tibia
Pilon fractures = Extraarticular fractures of distal tibia which are closer to joint than the diameter of the tibia
Can be caused by low energy rotational forces or by high energy axial compressional forces (car accidents or falling from height).
Not frequent: make up about 1% of fractures

35. Pilon fractures: Mechanism of injury
Relatively less malignant fracture if the injury is indirect, small energy and usually rotational. Less connective tissue damage, and dislocation of articular surface is minimal.
Fracture is worse if high energy, direct trauma with force either in axial direction or as torsion force. More damage to bone, cartilage and connective tissues.

36. Pilon fractures: Diagnosis
Clinical examination: pain, swelling, loss of function, determine amount of connective tissue damage, circulation, innervation
X-ray
Doppler sonography (in cases where circulation is suspect)
Angiography
Intraoperatively often find other injuries like impression fractures, ligament and syndesmosis lesions.
Pay attention to compartment syndrome!!!

37. Pilon fractures: Classification
2 important classifications:
AO classification
Rüedi-Allgöwer classification

38. Pilon fractures: AO classification
Type A: extraarticular distal tibial fractures subdivided into A1, A2, A3 depending on amount of metaphyseal comminution
Type B: partial articular fractures in which a portion of the articular surface remains in continuity with the shaft; subdivided into B1, B2, B3 depending on the amount of articular impaction and comminution
Type C: complete metaphyseal fractures with articular involvement; subdivided into C1, C2, C3 depending on extent of metaphyseal and articular comminution

39. Pilon fractures: Rüedi-Allgöwer classification
Type I: non-displaced cleavage fractures that involve the joint surface
Type II: have cleavage-type fracture lines with displacement of the articular surface but minimal comminution
Type III: are associated with metaphyseal and articular comminution

40. Pilon fractures: tissue damage
At time of injury in pilon fractures, often soft tissues are seriously damaged
Pressure to skin, abrasions, bullae, and variable degrees of open injuries can occur

41. Pilon fractures: Treatment
Treatment is usually difficult due to the fact that the injury is usually caused by high energy forces that lead to serious cartilage, bone and soft tissue damage
The aim of treatment is painless, complication-free, bony healing
It should be pointed out that in some cases injuries are so serious that treatment is limited to the prevention of septic complications and the preparation of a situation where arthrodesis is possible.
Restoration of the articular surface, stable osteosynthesis and early mobilization decrease the risk of post-traumatic arthrosis

42. Pilon fractures: conservative treatment
The only time conservative treatment is utilized in pilon fractures is when operative treatment is absolutely contraindicated
In theory, non-displaced or displaced but reducable fractures can be treated conservatively.

43. Conservative treatment
Plaster casting
Following reduction cast reaches the top of the thigh
No weight-bearing for 6 weeks
Cast remains for weeks but in some cases can change cast to PTB (patella tendon bone) cast in the 6-8th week depending on the fracture.

44. Conservative treatment
Traction
Following reduction we put a Steinman nail into the calcaneus and pull the limb with 3kgs weight
Traction uses ligamentotaxis to help reduction
After 3 weeks the patient is put in a cast without weight-bearing and the cast is kept on for 8-16 weeks

45. Pilon fractures: operative treatment
Open reduction internal fixation
Closed indirect reduction and external stabilization
Minimal invasive osteosynthesis
External fixator

46. 63 year old male patient

47. Operative treatment

48. 49 year old male patient

50. After treatment
Thrombosis prophylaxis
Functional treatment

51. Thank you for your attention