1. ANKLE FRACTURE
DR. Rahmatullah

2. EPIDEMIOLOGY : Highest incidence in elderly women
Incidence – 187 per 1 lakh people per year
Isolated malleolar fractures – 66 %
Bi malleolar fractures – 25%
Tri malleolar fractures – 5 to 10%
Open fractures – 2%
Incresed BMI is a risk factor.

3. ANATOMY Complex hinge joint with complex ligamentous system
The plafond is concave in AP plane & convex in Lateral plane
Plafond is wider anteriorly to allow for congruency with the wedge shaped talus
Talar dome is trapezoidal, with anterior aspect 2.5 cm wider than posterior talus
Chaput's tubercle: insertion site of anterior tibiofibular ligament on the anterolateral tibia
Wagstaffe's tubercle: insertion site of anterior tibiofibular ligament on the anterior fibula
Volkmann's tubercle: tibial insertion of posterior tibiofibular ligament at the posterolateral aspect of tibia
Anterior colliculus: located at anterior, inner aspect of medial malleolus distally,
Insertion site of deltoid ligament.
Larger than posterior colliculus
Posterior colliculs: located at posterior, inner aspect of medial malleolus distally,

4. LIGAMENTS SYNDESMOTIC LIGAMENT COMPLEX :
Exists between distal tibia & fibula
Composed of
1) Anterior Inferior TibioFibular Ligament
2) Posterior Inferior TibioFibular Ligament – thicker & stonger
3) Transverse TibioFibular Ligament
4) Interosseous Ligament

5. LIGAMENTS SYNDESMOTIC LIGAMENT COMPLEX

6. DELTOID LIGAMENT SUPERFICIAL PORTION :
3 ligaments originates from anterior colliculus
Tibionavicular Ligament
Tibiocalcaneal Ligament
Tibiotalar Ligament – most prominent
DEEP PORTION :
Originates on inter collicular groove and posterior colliculus
Deep ant talotibial Ligamen
Deep post talotibial Ligament

7. DELTOID LIGAMENT

8. FIBULAR COLLATERAL LIGAMENT
Not as strong as medial complex
1)Ant Talofibular Ligament
-weakest of lat ligaments
2) Post Talofibular Ligament
-strongest of lat ligaments
3)Calcaneofibular Ligament
Stabilises subtalar joint & limits inversion
Rupture of this ligament causes POSITIVE TALAR TEST

9. Ottawa ankle rules
These rules are used to determine the need for radiographs in patients with an ankle injury. Ankle X-ray series are only required in case of:
Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus.
Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus.
Inability to bear weight for 4 steps both immediately and in the emergency department

10. RADIOGRPHY AP VIEW Tibiofibular overlap should be>10mm
Tibiofibular clear space <5mm
Talar tilt : difference in width of medial & lateral aspect of the superior joint space should be <2mm .

11. LATERAL VIEW
The dome of talus should be centered under the tibia & congruous with tibial plafond
Posterior tuberocity # & avulsion # of talus can be identified

12. MORTISE VIEW
Taken with foot in degrees of internal rotation that is perpendicular to intermalleolar axis
Medial clear space should be equal to superior clear space, should be <4mm, >4mm is abnormal & indicates lateral talar shift
Talocrural angle : angle subtended between the inter malleolar line and a line parallel to the distal tibial articular surface - 8 to 15 degrees.
- should be within 2 to 3 degrees of un injured ankle.
Tibiofibular overlap should be > 1mm, <1mm is syndesmotic injury
Talar shift >1mm is abnormal
Tibiofibular clear space should < 6mm

14. BIOMECHANICS
Normal ROM – dorsiflexion : 30 & plantar flexion – 45 degrees
Minimum of 10 degree of dorsiflexion & 20 degree of plantar flexion are required for normal gait
Axis of ankle flexion runs between 2 malleoli, which is externally rotated 20 degrees
Lateral talar shift of 1mm will decrease surface contact by 40%, & 3mm shift results in >60% decrease
Disruption of syndesmotic ligaments results in decreased tibiofibular overlap & lateral talar shift

15. CLINICAL EVALUATION
Swelling, tenderness, variable deformity from a limp to non ambulatory.
Check for Neurovascular status & extent of soft tissue injury
Squeeze test – positive in high ankle sprains, syndesmotic injuries
Dislocated ankle should be reduced & splinted immediately
CT scan- specially for plafond #s
MRI –for ligament, cartilage, tendon injuries
BONE SCAN – for occult #, continued pain after injury

16. LAUGE-HANSEN (ROTATIONAL ANKLE FRACTURE) CLASSIFICATION
Takes into account
1) the position of the foot at the time of injury
2) the direction of deforming force
Based on cadaveric studies
Patterns may not always reflect clinical reality

17. SUPINATION-ADDUCTION DEFORMITY
10-20% of malleolar #
Only type asso with medial displacement of talus
STAGE-I : Transverse avulsion # fibula (or) Rupture of talofibular ligament
STAGE-II : - Vertical medial malleolus #
-Transverse distal fibula #
-Medial plafond impaction

18. SUPINATION-EXTERNAL ROTATION
40-70% of malleolar # occurs with this mech.
STAGE-I : Disruption of ant tibiofibular lig +/- avulsion #
STAGE- II: Spiral # of distal fibula
STAGE- III: Disruption of post tibiofibular lig (or) # of post malleolus
STAGE- IV: Transverse avulsion # of medial malleolus (or) rupture of deltoid ligament

19. PRONATION-EXTERNAL ROTATION
5-20% of malleolar #
STAGE- I : Transverse medial malleolus # (or) rupture of deltoid ligament
STAGE- II : Disruption of ant tibiofibular lig +/- avulsion #
STAGE- III : Spiral # distal fibula at/above the level of syndesmosis
STAGE- IV : Disruption of post tibiofibular lig (or) avulsion # of posterolateral tibia

20. PRONATION-ABDUCTION 5-20% of malleolar #
STAEGE- I : Transverse fracture of medial malleolus (or) rupture of deltoid lig
STAGE- II : Rupture of syndesmotic lig (or) avulsion # with medial injury
STAGE- III : Transverse/laterally comminuted # fibula with medial injury

21. DENNIS-WEBER CLASSIFICATION
Based on the level of fibular #
The more proximal, the greater risk of syndesmotic disruption & instability
type A
below level of the ankle joint
Tibio fibular syndesmosis intact
Deltoid ligament intact
Medial malleolus often fractured
usually stable : occasionally requires ORIF
type B
at the level of the ankle joint, extending superiorly and laterally up the fibula
tibiofibular syndesmosis intact or only partially torn, but no widening of the distal tibiofibular articulation
medial malleolus may be fractured or deltoid ligament may be torn
variable stability
type C
above the level of the ankle joint
tibiofibular syndesmosis disrupted with widening of the distal tibiofibular articulation
medial malleolus fracture or deltoid ligament injury present
unstable : requires ORIF

22. Maisonneuve fracture - Ankle AP
1 - Disruption of the medial ankle joint with small bone avulsion
2 - Disruption of the distal tibio-fibular syndesmosis
No fibular fracture is visible at the ankle raising the suspicion of a proximal fibular fracture
Spiral fracture of the proximal fibula
It is a pronation & external rotation injury

23. CURBSTONE # : Avusion fracture of posterior tibia is produced by a trippling mechanism
LEFORTE – WAGSTAFFE # :
-Anterior fibular tubercle avulsion fracture by anterior tibiofibular ligament
-Associated with Lauge-Hansen SER type #
THILLAUX – CHAPUT # :
- Anterior tibial tubercle avulsion fracture by anterior tibiofibular ligament
- Counter part of Leforte-Wagstaffe #
VOLKMANNS TRIANGLE:
-Bony avulsion of posterior tibiofibular ligament from the tibia
HERSCOVICI CLASSIFICATION of medial malleolar fractures.
A - tip avulsions (anterior colliculus)
B - intermediate
C - level of plafond
D - above plafond (adduction fractures)
Posterior colliculus fracture :
- the fragment is nondisplaced because of stabilisation by
posterior tibial & flexor digitorum longus tendons
- supra malleolar spike clearly seen on external rotation views.

24. TREATMENT Emergency room :
-Dislocated ankles should be reduced immediately. If reduction fails , go for urgent surgical reduction
- open wounds, abrasions cleansed & dressed
- fracture reduction for displaced fractures
- splint application
STABLE FRACTURES
Ankles with perfect position of the talus and with no medial swelling and tenderness are considered to be stable, follow-up x-ray 1 week after injury to ensure there is no displacement.
if talus is perfectly centered but medial swelling and tenderness, take stress x-rays.
- If there is no sign of talar shift, the ankle is considered to be stable.
removable walking boot or short-leg cast for 6 wks with crutches but bear weight as tolerated
Sport activity limitation for 3 months
Nonoperative
short-leg walking cast/boot
indications
isolated nondisplaced medial malleolus fx or tip avulsions
isolated lateral malleolus fx with < 3mm displacement and no talar shift
posterior malleolar fx with < 25% joint involvement or < 2mm step-off

25. OPERATIVE :
open reduction internal fixation
indications
any talar displacement
displaced isolated medial malleolar fx
displaced isolated lateral malleolar fx bimalleolar fx and functional bimalleolar fracture
posterior malleolar fx with > 25% or > 2mm step-off
Bosworth fracture-dislocations (distal fibula # with posterior dislocation of proximal fibular fragment behind posterior tibial tubercle ) open fractures TECHNIQUE :
goal of treatment is stable anatomic reduction of talus in the ankle mortise
1 mm shift of talus leads to 42% decrease in tibiotalar contact area
OUTCOMES :
overall success rate of 90%
prolonged recovery expected (2 yrs to obtain final functional result)
worse outcomes with: smoking, decreased education, alcohol use, increased age, presence of medial malleolar fracture
ORIF superior to closed treatment of bimalleolar fxs
in Lauge-Hansen supination-adduction fractures restoration of marginal impaction of the anteromedial tibial plafond leads to optimal functional results after surgery

26. Isolated Medial Malleolus Fx Nonoperative
short leg cast
indications
nondisplaced fracture
tip avulsion fractures
Operative
ORIF
If they are displaced, thick periosteum usually folds into the fracture site leading to nonunion.
any displacement or talar shift
technique
lag screw fixation
lag screw fixation stronger if placed perpendicular to fracture line
antiglide plate with lag screw
best for vertical shear fractures
tension band fixation
utilizing stainless steel wire
Used when fragment is small & in osteroporotic fragments
Adverse effect - posterior tibial tendon irritation

27. Pearls and Pitfalls of Medial Malleolar Fixation
4.0 mm partially threaded screws work well for most patterns
Screws should be perpendicular to the fracture line and parallel for maximal compression
Spread two screws for good stability
Ignore or excise small anterior colliculus fractures
Use fluoroscopy to be sure screws are clear of the joint
Beware supination adduction patterns with vertical fracture lines and impacted medial dome fragments
Oblique fractures of posterior colliculus involve posterior lip of the tibia.
- On the AP x-ray- double profile of the medial malleolus.
- better visualized on a slightly externally rotated AP x-ray

28. Isolated Lateral Malleolus Fx Nonoperative
short leg cast
indications
intact mortise,
no talar shift,
< 3mm displacement
Operative
ORIF
if talar shift or > 3 mm of displacment
can be treated operatively if also treating an ipsilateral syndesmosis injury
Techniques :
open reduction and plating
intramedullary retrograde screw placement
isolated lag screw fixation

29. ORIF LATERAL MALLEOLUS
Most commonly fixed with one third tubular plate
3 types of plate orientations : lateral, posterolateral, posterior
Avoid screw impingement on talofibular articular surface in lateral plating
Posterior fibuar plating conditions : when # is more distal, dislocation is posterior, osteopenic bone
- distal part of plate provides buttress & stabilise # even without distal screws
- provides maximum stability
- m/c disadvantage of posterior antiglide plating – peroneal irritation if the plate is too distal
when # is long, oblique, non comminuted - isolated lag screw fixation
Intra medullary screw or rod fixation :
- more limited approach
- particularly difficult in SER type #s
Severly comminuted fibula #s : seen in Pronation-Abduction injuries
- if asso with MM #, first fix MM that stabilises talus which reduces fibula
- Bone grafting is not necessary
- the position of the talus in the mortise should be used as the ultimate guide to accurate position of the distal fibula.

30. Pearls and Pitfalls in lateral malleolus fixation
Avoid injuring the superficial peroneal nerve with anterolateral incisions
Make sure the distal fibula is fully out to length
Laterally comminuted pronation abduction patterns are most difficult
For maximal stability place a plate posterior
Consider the location of syndesmosis fixation when placing a fibular plate
Test the syndesmosis after lateral malleolar fixation
Beware in short distal segments, elderly patients with osteopenic bone, diabetics

31. COMBINED PROCEDURES For bimalleolar or trimalleolar fractures
Fix the fibula fracture before reducing and fixing the medial malleolus.
When the fibula is laterally comminuted and the medial malleolus fracture is large, we reduce and fix the medial malleolus fracture first.
posterior malleolar evaluation and possible reduction and fixation as the last step in ankle fixation.

32. AVOID RISKS
The superficial peroneal nerve is at risk during the lateral approach to the fibula.
The sural nerve lies posterior to the fibula, and during a posterolateral approach to the fibula, it should be identified and protected
The deep peroneal nerve, the anterior tibial artery and branches of the superficial peroneal nerve are at risk when small incisions are made for front-to-back posterior malleolar fixation

33. Functional Bimalleolar Fx (deltoid tear with fibular fracture)
small increase in the medial clear space and valgus sag of the talus might be apparent
The talus is narrowest posteriorly leading to increased space in the mortise in plantar flexion.
absence of the deltoid allows the talus to rotate externally,
technique
not necessary to repair medial deltoid ligament
only need to explore it if you are unable to reduce the mortise
Interposition of the deltoid ligament is one potential cause of residual talar shift , but very unusual.
The clinical outcome of these ankle fractures is not improved by suturing the deltoid ligament

34. POSTERIOR MALLEOLUS #
External rotation lateral x ray view & CT scan are choice
Increased rotation and posterior subluxation of the talus with positive posterior drawer test but have little effect on stability in inversion or eversion
Trimalleolar fractures are known to have a worse prognosis than bimalleolar fractures (23).
Large posterior malleolar fractures lead to poorer outcomes
Approach : direct ( posterior to anterior)
indirect (anterior to posterior)
most important factor in reducing and stabilizing the posterior malleolus is accurate stable fixation of the associated fibular #
In trimalleolar #, first fix MM, LM & then fix post malleolus
When the fibula is reduced, the posterior malleolus is often nearly reduced, and the talus is centered
After fibular fixation check posterior drawer test for posterior stability

35. Rx of posterior malleolus
Non operative : short leg cast
indications
< 25% of articular surface involved
evaluation of percentage should be done with CT, as plain radiology is unreliable
< 2 mm articular stepoff
OPERATIVE : ORIF
> 25% of articular surface involved > 2 mm articular stepoff
ipsilateral syndesmosis injury
technique
use posterolateral or posteromedial approach to the ankle joint to reduce and place fixation
decision of approach will depend on fracture lines and need for fibular fixation
can use anterior to posterior lag screws to capture fragment (if nondisplaced)
syndesmosis injury
stiffness of syndesmosis restored to 70% normal with isolated fixation of posterior malleolus (versus 40% with isolated syndesmosis fixation)
stress examination of syndesmosis still required after posterior malleolar fixation
posteroinferior tibiofibular ligament may remain attached to posterior malleolus and syndesmotic stability may be restored with isolated posterior malleolar fixation

36. Bosworth Fracture-DislocationOverview
rare fracture-dislocation of the ankle where the proximal fibula fragment becomes entrapped behind the posterior tibial tubercle and becomes irreducible
posterolateral ridge of the distal tibia hinders reduction of the fibula
Operative
open reduction and fixation of the fibula
indicated in most cases
Open Ankle Fx Operative
emergent operative debridement and ORIF
external fixation

37. SYNDESMOTIC INJURY Associated Syndesmotic Injury Overview
suspect injury in all ankle fractures
most common in Weber C fracture , L-H pronation type & AO type C pattern.
fixation usually not required when fibula fracture within 4.5 cm of plafond
Higher fibula fractures >4.5cm result in syndesmotic widening despite internal fixation of the fibula fracture and require syndesmotic fixation
When there is a proximal fibula fracture and the talus is shifted or when the talus is shifted without a fibula fracture, there is always a syndesmosis injury with instability
Radiographically, syndesmosis instability should always be suspected when fibula fractures are above the level of the ankle mortise
Stress x-rays : ankle in the mortise position with external rotation force
Pronation-abduction injuries completely tear the entire syndesmosis and lead to greater instability than external rotation injuries

38. Evaluation : measure clear space 1 cm above joint
it has also been reported that there is no actual correlation between syndesmotic injury and tibiofibular clear space or overlap measurements
lateral stress radiograph has more reliability than an AP/mortise stress film
best option is to assess stability intra operatively with abduction /external rotation stress of dorsiflexed foot
the decision to fix or not to fix the syndesmosis must be individualized in each case and preferably should be based on direct stress testing of syndesmosis integrity after internal fixation of other structures.
instability of the syndesmosis is most in the anterior-posterior direction
in the absence of a deltoid injury, fixing the syndesmosis is unnecessary, and if a medial malleolar fracture is securely fixed restoring the deltoid ligament, despite complete disruption of the syndesmosis, tibial fibular fixation is not needed (Boden SD, Labropoulos PA, McCowin P, et al.)

39. OPERATIVE Rx OF SYNDESMOSIS
syndesmosis screw fixation
indications
widening of medial clear space
tibiofibular clear space (AP) greater than 5 mm
tibiofibular overlap (mortise) narrowed
any postoperative malalignment or widening should be treated with open debridement, reduction, and fixation
technique
length and rotation of fibula must be accurately restored
open reduction required if closed reduction unsuccessful or questionable
one or two cortical screw(s) 2-4 cm above joint, angled posterior to anterior degrees
lag technique not desired
maximum dorsiflexion of ankle not required during screw placement (can't overtighten a properly reduced syndesmosis)
SER injury that shows mild syndesmosis diastasis, a single three-cortex 3.5-mm screw is sufficient,
In Maisonneuve's proximal fibula fracture with complete disruption of the syndesmosis without a medial malleolus fracture, fixing the syndesmosis will provide the entire stability of the ankle

40. postoperative
screws should be maintained in place for at least 8-12 weeks
must remain non-weight bearing, as screws are not biomechanically strong enough to withstand forces of ambulation
controversies
3 or 4 cortices (3 – motion between tibia, fibula & 4- stable fixation)
3.5 mm or 4.5 mm screws
implant material (stainless steel screws, titanium screws, suture, bioabsorbable materials)
need for hardware removal
no differences seen in hardware breakage, loosening, or removal at 1 year

41. Pearls and Pitfalls of Syndesmosis
Use syndesmosis fixation when the medial clear space widens on intraoperative stress views after the fibula is fixed
The fibula must be accurately reduced to the tibia in all views including the lateral
Use a 4.5-mm four cortex screw if the patient will weight bear postoperatively
Do not remove syndesmosis screws before 3-4 months postinjury
Achieve a perfectly symmetric tibiotalar clear space
Use syndesmosis fixation only without fixing the fibula fracture when it is above the midfibula
Overcompressing the syndesmosis by applying a screw with the ankle in plantar flexion or using a compression technique should be avoided

42. BIO ABSORBABLE IMPLANTS
Polyglycolide or polylactide implants have been used most commonly
Advantages : eliminating the need for hardware removal, decreasing irritation over prominent screws and plates, and allowing for gradual stress transfer from the implant to bone.
used as screws for the fibula, syndesmosis, and the medial malleolus
Polylactide implants have excellent MRI compatibility
wound infection rate has been reported to be similar to that seen with metallic implants
Chance of redisplacement – 0.9% with simple ankle #
- 8.2% with complex unstable ankle fractures
A local inflammatory granulomatous reaction to polyglycolide has been reported in 4% to 50% of malleolar fractures, in the 3rd or 4th postoperative month, is culture negative, that contains polyglycolide debris
Polylactide implants degrade at a much slower rate than polyglycolide implants
longer time to degrade significantly decreases the rate of reaction to these implants

43. COMPLICATIONS NONUNION – m/c in medial malleolus
MALUNION – due to lateral malleolus shortening & external rotation
WOUND PROBLEMS
INFECTIONS
POST TRAUMATIC ARTHRITIS
REFLEX SYMPATHETIC DYSTROPHY – rare, minimised by anatomical restoration of ankle & early return of function
COMPARTMENT SYNDROME OF LEG, FOOT
TIBIOFIBULAR SYNOSTOSIS – asso with use of syndesmotic screw, usually asymptomatic
LOSS OF REDUCTION – in 25% of unstable # treated non operatively
LOSS OF ANKLE ROM

44. THANK YOU