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Introduction
Injury patterns
o isolated medial malleolus fracture
o isolated lateral malleolus fracture
o bimalleolar and bimalleolar-equivalent fractures
o posterior malleolus fractures
o Bosworth fracture-dislocations
o open ankle fractures
o associated syndesmotic injuries
isolated syndesmosis injury
Anatomy
Biomechanics
o deltoid ligament (deep portion)
primary restraint to anterolateral talar displacement
o fibula
acts as buttress to prevent lateral displacement of talus
Imaging
Radiographs
o external rotation stress radiograph
most appropriate stress radiograph to assess competency of deltoid
ligament
a medial clear space of >5mm with external rotation stress
applied to a dorsiflexed ankle is predictive of deep deltoid
disruption
more sensitive to injury than medial tenderness, ecchymosis, or
edema
gravity stress radiograph is equivalent to manual stress radiograph
syndesmosis
decreased tibiofibular overlap
normal >6 mm on AP view
normal >1 mm on mortise view
increased medial clear space
normal less than or equal to 4 mm
increased tibiofibular clear space
normal <6 mm on both AP and mortise views
o radiographic measurements
talocrural angle
measured by bisection of line through tibial anatomical axis and
another line through the tips of the malleoli
shortening of lateral malleoli fractures can lead to increased
talocrural angle
talocrural angle is not 100% reliable for estimating restoration of
fibular length
can also utilize the realignment of the medial fibular
prominence with the tibiotalar joint
Classification
Lauge-Hansen
o based on foot position and force of applied stress/force
o has been shown to predict the observed (via MRI) ligamentous injury in less
than 50% of operatively treated fractures
Anatomic / Descriptive
o isolated medial malleolar
o isolated lateral malleolar
o bimalleolar
o trimalleolar
o Bosworth fracture-dislocation (posterior dislocation of the fibula behind
incisura fibularis)
Danis-Weber (location of fibular fracture)
o A - infrasyndesmotic (generally not associated with ankle instability)
o B - transsyndesmotic
o C - suprasyndesmotic
AO / ATA
o 44A - infrasyndesmotic
o 44B - transsyndesmotic
o 44C – suprasyndesmotic
General Treatment
Nonoperative
o short-leg walking cast/boot
indications
isolated nondisplaced medial malleolus fracture or tip avulsions
isolated lateral malleolus fracture with < 3mm displacement and no
talar shift
posterior malleolar fracture with < 25% joint involvement or < 2mm
step-off
Operative
o open reduction internal fixation
indications
any talar displacement
displaced isolated medial malleolar fracture
displaced isolated lateral malleolar fracture
bimalleolar fracture and bimalleolar-equivalent fracture
posterior malleolar fracture with > 25% or > 2mm step-off
Bosworth fracture-dislocations
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
see fracture patterns below for specific treatment
outcomes
overall success rate of 90%
prolonged recovery expected (2 years to obtain final
functional result)
significant functional impairment often noted
worse outcomes with: smoking, decreased education, alcohol
use, increased age, presence of medial malleolar fracture
ORIF superior to closed treatment of bimalleolar fractures
in Lauge-Hansen supination-adduction fractures, restoration of
marginal impaction of the anteromedial tibial plafond leads to
optimal functional results after surgery
postoperative rehabilitation
time for proper braking response time (driving) returns to
baseline at nine weeks for operatively treated ankle fractures
braking travel time is significantly increased until 6 weeks after
initiation of weight bearing in both long bone and periarticular
fractures of the lower extremity
Operative
o ORIF
indications
any lateral talar shift
technique
fibula
need to fix with one of the options listed in section above
medial malleolus
fixation options
cancellous lag screws
bicortical screws
tension band wiring
antiglide plate to treat a vertical medial malleolus
fracture
orient screws parallel to joint for vertical medial malleolar
fracture (Lauge-Hansen supination-adduction fracture
pattern)
Bosworth Fracture-Dislocation
Overview
o rare fracture-dislocation of the ankle where the fibula becomes entrapped behind
the tibia and becomes irreducible
o posterolateral ridge of the distal tibia hinders reduction of the fibula
Operative
o open reduction and fixation of the fibula in the incisura fibularis
indicated in most cases
Hyperplantarflexion
Variant
Overview
o fracture-dislocation of the ankle due to hyperplantarflexion
o main feature is a vertical shear fracture of the posteromedial tibial rim
o "spur sign" is a double cortical density at the inferomedial tibial metaphysis
Operative
o fixation of posteromedial and posterior fragments with antiglide plating
technique
length and rotation of fibula must be accurately
restored
outcomes are strongly correlated with anatomic
reduction
placing reduction clamp on midmedial ridge and the
fibular ridge at the level of the syndesmosis willa
chieve most reliable anatomic reduction
"Dime sign"/Shentons line to determine length of
fibula
open reduction required if closed reduction unsuccessful
or questionable
one or two cortical screw(s) 2-4 cm above joint, angled
posterior to anterior 20-30 degrees
lag technique not desired
maximum dorsiflexion of ankle not required during screw
placement (can't overtighten a properly reduced
syndesmosis)
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
number of screws
1 or 2 most commonly reported
number of cortices
3 or 4 most commonly reported
size of screws
3.5 mm or 4.5 mm screws
implant material (stainless steel screws, titanium screws,
suture, bioabsorbable materials)
need for hardware removal
no difference in outcomes seen with hardware
maintenance (breakage or loosening) or removal at
1 year
outcome may be worse with maintenance of intact
screws
Complications
Wound problems (4-5%)
Deep infections (1-2%)
o up to 20% in diabetic patients
largest risk factor for diabetic patients is presence of peripheral
neuropathy
Post-traumatic arthritis
o rare with anatomic reduction and fixation
o corrective osteotomy requires anatomic fibular and mortise correction for
optimal outcomes