1. Ankle Fracture Tips
Mitchell Goldflies

2. Ankle Anatomy
Complex joint comprising the articulation of the tibia and fibula with the foot at the talus
Talar dome tibial plafond are trapeziodail (2.5 mm wider anteriorly)
Intrinsic stability arises from congruous bony articulations and muscular forces across the ankle
Extrinsic stability arises from the medial and lateral ligament complex and capsule
Relatively thing soft tissue envelope

3. Ankle Biomechanics Tri-plane motion
Load bearing force in stance phase of gait is 4 times body weight
Normal ROM:
- 20 degrees of extension
- 40 degrees of flexion
At least 10 degrees of dorsiflexion (extension) needed for normal gait
1 mm of lateral talar shift decreases tibi/talar surface contact up to as much 40%

4. Radiographic Evaluation
Plan Films
AP, Mortise, Oblique views of ankle
Image entire tibia to knee
Foot films when tender to palpation
Common associated fractures:
5th metatarsal base fracture
Calcaneal fracture

5. Anteroposterior View Quantitative analysis Tibiofibular overlap
<10 mm is abnormal – implies syndesmotic injury
Tibiofibular clear space
>5 mm is abnormal- implies syndesmotic injury
Talar Tilt
>2 mm is considered abnormal
Consider a comparison with radiogrpahs of the normal side if there are unresolved concerns of injury

6. Mortise View Foot is internally rotated and AP projection is performed
Abnormal findings:
Medial joint space widening
Talocrural angle <8 or>15 degrees (comparison to normal side is helpful_
Tibia/finula overlap <1mm

7. Lateral View Posterior malleolar fractures
Anterior/posterior subluxation of the talus under the tibia
Angulation of distal fibula
Talus fractures
Associated injuries

8. Other Imaging Modalities
Stress Views of the Ankle
Evaluate integrity of the syndesmosis CT
Helps to delineate joint involvement
Aids in pre-operative planning
Evaluate hindfoot and midfoot if needed
MRI
Identify ligament and tendon injury and well as talar
Syndesmosis injuries

9. Understanding Ankle Fracture Classification
Major Classification system
Lauge-Hansen
Weber
OTA

10. Lauge-Hansen Based on cadaveric study
First word refers to position of foot at time injury
Second word refers to force applied to foot relative to tibia at time of injury
Remember the injury starts on the tight side of the ankle! The lateral side is tight in supination, while the medial side is tight in pronation

11. Lauge-Hansen
In each type of fracture there are several stages of injury
Not every fracture fits exactly into one category

12. Supination-External Rotation
Stage 1 Anterior tibia-fibular ligament
Stage 2 Fibula fx
Stage 3 Posterior malleolus fx or posterior tibia-fibular ligament
Stage 4 Deltoid ligament tear or medial malleolus fx

13. SER Fractures
Classic short oblique fibula fracture. Begins at the mortise anteriorly and extends posterior-proiximal. The SER fibula fracture is ideal for a posterior lateral antiglide plate.
The medial injury can be fracture or a deltoid figament tear, or a combination of both.
SER Stage 2 injuries are stable and can be managed closed
SER Stage 4 injuries are unstable and require operative fixation

14. SER Fractures Bimalleorlar Fractures – Unstable
Soft-Tissue SER 4 - Unstable

15. A Comparison of Physical Findings (swelling, Tenderness, Ecchymosis and Stress X-ray)
Swelling and Eccymosis Scale
None
Mild
Moderate
Severe

16. Stress Radiograph Performed if mortise reduced on initial films
No talar subluxation
Medical clear space 4mm or less
Ankle in neutral dorsiflexion
External rotation stress
@ 8 lbs
Ankle positioned in Mortise view for stress radiograph

17. Instability = SE 4 Medical clear space > 4mm
At least 1mm more than superior joint space
Any talar subluxation

18. Supination Adduction
Stage 1 Fibula fracture is transverse below mortise.
Stage 2 Medical malleolus fracture is classical vertical pattern.
Marginal impaction is common at the medical edge of the platform

19. SAD Only 2 injuries stages
Medial fracture may require a buttress screw or plate to prevent fracture displacement.
Marginal impaction needs reduction and fixation with bone graft and implants

20. Pronation-External Rotation
Stage 1 Deltoid liagment tear or medial malleolus fx
Stage 2 Anterior tibio-fibular ligament and interosseous membrane
Stage 3 Spiral, proximal fibula fracture
Stage 4 Posterior malleolus fx or posterior tibio-fibular ligament

21. PER Proximal spiral fibula fracture
Must x-ray knee to ankle to asses injury
Syndesmosis is disrupted in most cases
Epiponym Maisonneuve Fracture
Restoration of the mortise and syndesmosis are the keys to treatment
The fibula must be have length and rotation restored

22. Pronation-Abduction
Stage 1 Transverse medial malleolus fx distal to mortise
Stage 2 Posterior malleolus fx or posterior tibia-fibular ligament
Stage 3 Fibula fracture, typically proximal to mortise, often with a butterfly fragment

23. PAB
Fibula fracture typically distal ½ of fibula. Plating of fibula may be helpful.
Medial malleolus fx can be difficult to purchase with standard screws. Tension bond fixation may be helpful

24. Weber Classification
Based on location of fibula fracture relative to mortise
Weber A fibula distal to mortise
Weber B fibula at level of mortise
Weber C fibula proximal to mortise
Concept- the higher the fibula the more severe the injury

25. Initial Management
Closed reduction (conscious sedation may be necessary)
Compression dressing, splint, elevate
May take unstable fracture to OR if soft tissues not overly edematous (i.e. skin wrinkles absent, fracture blisters present).
Otherwise, wait for soft tissue to settle.
Pain control

26. Nonoperative Treatment
Indications:
Nondisplaced stable fracture with intact syndsmosis
Patient whose overall condition is unstable and would not tolerate and operative procdure
Management:
Below the knee cast 4-6 weeks
Follow with serial x-rays and transition to walking boot or short-leg walking cast

27. Surgical Indication Instability Malposition Talar subluxation
Joint incongruity
Articular stepoff

28. Operative Fixation
In general when a bimalleolar ankle fracture is operated it is helpful to open the medical side prior to lateral fixation. This allows better visualization of the mortise to assess cartilage damage and remove osteochondral fragments.

29. Posterior Malleolus Fracture
> 25% of joint surface involved on lateral of ankle is typical indication for fixation. The fragment is often larger than that seen on lateral view.
The fracture is nearly always associated with the pull of the posterior tib-fib ligament. So the fragment is nearly always larger laterally than medially, and it is typically obliquely oriented.
The fracture typically involves the incisura, where the fibula articulates with the tibia to form the syndemosis

30. Posterior Malleolus Fracture
Internal fixation is done with lag screws typically
The screws can be put in from anterior or posterior
Attempt to visualize the plaford prior to reduction of the fibula is difficult because the posterior malleolus if often attached to the distal fibula. Generally reducing the fibula and dorisglexing the ankle are the final steps in reduction. Occasionally a posterior approach may be necessary for reduction.

31. Lateral Fixation Antiglide plating SER fibula patterns
Can add log screw
Posterolateral

32. Syndesmotic Fixation
It has been traditionally thought to dorisflexion when inserting a syndesmotic screw to prevent malreduction of the morise by over tightening the joint
However Dorisflexion is not necessary
Cannot Over tighten when the syndesmosis is reduced
Make sure syndesmosis is anatomic!

33. Syndesomtic Screws Controversies
3.5 mm vs 4.5 mm screw(s)
3 corticies vs 4 corticies
Retain vs Removal
Every surgeon has their own protocol. No consensus un literature on these points!

34. Open Ankle Fractures
Treat with appropriate antibiotics pre-op and 48 hr post-op
I & D with immediate ORIF if clean wound
ORIF and Ex Fix if severe soft tissue damage present to allow for wound care
Low grade open results similar to closed fractures
High grade open results have increased costs increased number of complications and poorer overall outcomes

35. Soft Tissue Problems Dislocation with kin compromise
Immediate reduction required!
If the talus is not reduced beneath the plafond, there is increased pressure on the skin and increased risk of skin breakdown, that all may lead to wound breakdown and infection
10% have skin slough when a timely reduction is not obtained

36. Disbetic Ankle Fractures
Neuropathy, nephropathy, retinopathy, and PVD increase the risk of complications (Marsh, OTA, 2003)
Significant for amputation
6% for closed injuries (Marsh, OTA, 2003)
43% for open fractures (White, OTA, 2003)
Increased risk of superficial and deep wound infections
Increased risk of malunion/nonunion
Transarticular fixation with tibial-calcaneal nail has been proposed (Jani, OTA, 2003)
Healing and rehabilitration time may be as much as double the non-diabetic patient

37. Postoperative Care Compression dressing/ splint or cast Drain?
Ice and elevation
Non weight-bearing with progression to weight-bearing based on fracture pattern, stability of fixation, patient compliance and philosophy of the surgeon
Early ROM
Late removal of symptomatic hardware as needed

38. Postoperative Care Casting vs. Removable Boot with early ROM
May have some wound problems with boot
Not study shows a significant
Difference between the treatments
In general early return of motion
Is preferred when the fixation
Is stable and the patient can comply
With post-operative recommendations\

39. Osteopenic Ankle Fractures
Increased incidence with older population
Poor hardware fixation with an increased risk of failure of fixation
May augment fixation with k-wires
Periosteum preserving technique with bridge plating in comminuted fibula fractures
Use of an anti-glide plate to get a better screw purchase from posterior to anterior scres and has maximal mechanical stability
Consider an intramedullary screw if there is not adequate distal bone

40. Outcome
Position of the mortise at union and stability of talus are critical factors!
Obtain an anatomic reduction
Hold to union
If loss of position is noticed
Re-reduce if possible

41. Results
Stable ankle fractures without lateral talarshift treated conservatively 90% good to excellent results
Operative fixation of unstable ankle fractures have 85-90% good to excellent results
2 year follow up
80-90% have unlimited ability to work, walk and participate in leisure activities
20-30% report swelling or stiffness
41% have reduced dorisflexion (Lindsjo, Clin, Orthhop, 1985)

42. Results Predictors of worse results Bimallelor fracture
Anterolateral impaction injuries of the tibial plafond
Large posterior malleolar fragments
Talar don’t injuries
Talus fractures
Associated foot/ ankle injuries
Delay in fixation
Age >50 years
Diabetes mellitus

43. Complicatoins Malunion
Usually associated with shortened or malroated distal fibula
Failure to reduce the syndesmotic injury
Treated with fibular lengthening and/or derotational osteotomy +/- sydesmotic fixation
Good results with fibular osteotomy to prevent arthrosis
Ankle fusion for advanced arthrosis or osteomy failure

44. Complications Non-union
Usually involving the medial malleolus due to soft tissue (i.e. posterior tibial tendon) interposition
Treated with electrical stimulation, ORIF, bone graft, or excision of fragment
Patient may have co-morbidities such as diabetes, peripheral vasuclar diesase or smoking
Noncompliance and premature weight bearing

45. Complications Wound problems Edge necrosis (3%) Dehiscence
Risk is decreased by minimizing swelling, not using a tourniquet, and careful atraumatic soft tissue handling
ORIF on the presence of fracture blisters and larger abrasions have more than twice the average wound complication rate

46. Complications Infection Occurs in less than 2% of closed fractures
Increased incidence in Diabetics, Age >50 and Alcoholics
Treated with antibiotics
Implants usually left in place to maintain stability for optimal soft tissue perfusion
May require serial debridements +/- VAC dressing
Arthrodesis used as a savage procedure

47. Complications
Post traumatic arthrosis secondary either to articular damage at the time of injury or inadequate reduction resulting in abnormal mechanics.
Treated with NSAIDs, AFO ankle fusion ot ankle implant

48. Complications Compartment Syndrome
Can occur in immediate postoperative period
Treated with fasciotomie followed by delayed closure or skin graft
Complex Regional Plan Syndrome Type I (RSD)
Minimized by appropriate reduction and early return to function
Tibiofibular synotosis
Associated with syndesmotic screw use and is usually asymptomatic

49. Summary Careful clinical and radiographic evaluation
Restoration of ankle joing anatomy
Fibular length
Syndesmotic stability
Neutral varus/valgus orientation
Delay ORIF until the surrounding soft tissue swelling and blisters have resolved
Prepare patient for possible development of post traumatic arthrosis