Ankle fractures are common injuries that occur due to twisting of the ankle. Diagnosis is made using x-rays of the ankle. Treatment may be non-operative with a cast or operative with internal fixation depending on the fracture displacement and stability. Ankle anatomy includes the tibia, fibula, and talus bones. Fractures are classified based on the location of the fibula fracture and force applied at injury. Imaging helps evaluate fracture pattern and stability while manual stress tests assess ligament integrity. Management depends on fracture and ligament involvement, with goals of anatomical reduction and stable fixation.

1. Ankle fracture
Aashish Yadav
Junior resident
Department of Orthopedics
JIPMER

2. Objective
• Introduction
• Anatomy
• Classification
• Imaging and diagnosis
• Management/controversies /Recent advances

3. Introduction
• Ankle fractures are very common injuries to the ankle which
generally occur due to a twisting mechanism.
• Diagnosis is made with orthogonal radiographs of the ankle.
• Treatment can be nonoperative or operative depending on fracture
displacement, ankle stability, syndesmosis injury, and patient
activity demands.

4.  Ankle is a three bone joint composed of the tibia , fibula an
talus.
 Talus articulates with the tibial plafond superiorly ,
posterior malleolus of the tibia posteriorly and medial
malleolus medially
 Lateral articulation is with malleolus of fibula
 Medial malleolus is shorter and anterior and thus axis of
the joint is 15 degrees of external rotation.

5. Stabilityof ankle:
(1) Static stabilizers
(a) Medial osteoligamentus complex:
• Superficial deltoid ligament – Posterior tibio talar, Tibiocalcaneal and Tibio navicular ligament
• Deep deltoid ligament – Anterior tibio talar ligamnet
(b) Lateral Osteoligamentus complex:
• Anterior talo fibular ligament (ATFL- weakest – most common to injury in ankle sprain)
• Posterior talo fibular ligament
• Calcaneo fibular ligament
(c) Syndesmosis:
• Anterior inferior tibio fibular ligament
• Posterior inferior tibio fibular ligament
• Interosseous ligament

8. (2) Dynamic stabilizers
(a) Axial loading:
The joint is considered saddle-shaped with the dome itself is wider
anteriorly than posteriorly, and as the ankle dorsiflexes, the fibula rotates
externally through the tibiofibular syndesmosis, to accommodate this
widened anterior surface of the talar dome. It forms a closed pack
position which provides stability to ankle
(b) Muscles around ankle joint

10. Based on location of fibula fracture
relative to mortise and appearance
• Weber A - fibula distal to
Syndesmosis
• Weber B - fibula at the level of
Syndesmosis
• Weber C - fibula above the level of
Syndesmosis
 Concept - the higher the fibula the
more severe the injury

11. Lauge-Hansen
• First word: position of foot at time of injury
• Second word: force applied to foot relative to tibia at time of injury
• Types: SER
SAd
PER
PAb

24. Gravity Stress Exam
Michelson et al. CORR 387: 178-82, 2001.

25. Manual Stress
Exam

46. How to simplify?
• Vertical medial malleolar fracture-SAD
• Horizontal/Oblique/No fracture
SER
PAB
PER

47. Step 1
Check the level of lateral malleolar fracture
Infrasyndesmotic
SAD
Transyndesmotic
Syndesmosis injury
Suprasyndesmotic
PER

48. STEP 2
• Nature of lateral malleoli fracture
1)If oblique:SER(lateral view # line -Antero inferior-posterosuperior)
2)If communited/transverse #:PAB
SER PAB

55. • Diastasis requires rupture of three strong ligaments and interosseous membrane,
hence suggesting a very substantial insult to ankle.
• Severe abduction forces causes  torsional movement of talus which  forces
the tibia and fibula causing  syndesmosis injury.
• Pronation type is frequently associated with syndesmosis injury than Supination
injuries.
• PER with deltoid rupture is particularly at high risk.

59. BARTONICEK AND HIS ASSOCIATES (2015)
• Type 1: extraincisural fragment with an intact
fibular notch.
• Type 2: posterolateral fragment extending into the
fibular notch.
• Type 3: posteromedial two-part fragment involving
the medial malleolus.
• Type 4: large posterolateral triangular fragment (in-
volving more than one-third of the notch).
• Type 5 :irregular, osteoporotic fragments.

60. Q: Why malleolar fractures usually need operative treatment?
1. It is an intraarticular fracture, so need anatomical reduction.
2. Usually there is interposition of periosteum which may lead to
nonunion.
3. It is an avulsion fracture which is gradually separated and
leads to nonunion.

61. •
•
•
Maisonneuve Fracture
– Fracture of proximal fibula with
syndesmotic disruption
Volkmann Fracture
– Fracture of tibial attachment of
PITFL
– Posterior malleolar fracture type
Tillaux-Chaput Fracture
– Fracture of tibial attachment of
AITFL

62. Wagstaffe-LeFort fracture.
In the Wagstaffe-LeFort
fracture, seen here
schematically on the
anteroposterior view, the
medial portion of the fibula is
avulsed at the insertion of the
anterior tibiofibular ligament.
The ligament, however,
remains intact.

63. Bosworth fracture(David M. Bosworth)
•
•
The Bosworth fracture is a rare
fracture of the distal fibula with an
associated fixed posterior
dislocation of the proximal fibular
fragment which becomes trapped
behind the posterior tibial tubercle.
MOI - severe external rotation of
the foot

64. Cotton fracture of ankle

65. Tillaux fracture

66. IMAGING

67. X-rays
At least 03 views needed:
1. Anteroposterior
2. Lateral
3. 10 degree oblique (mortise view):
Will reveal entire extent of the ankle joint space.
4.external rotation stress
• most appropriate stress radiograph to assess competency of deltoid ligament
• more sensitive to injury than medial tenderness, ecchymosis, or edema
• gravity stress radiograph is equivalent to manual stress radiograph
5.full-length tibia, or proximal tibia, to rule out Maisonneuve-type
fracture

68. ANTEROPOSTERIOR VIEW
Tibiofibular overlap
Measured 10 mm above joint line
<5 mm on ap view and
<1 mm on the mortise
view
◦Talar tilt
◦> 2mm is considered
abnormal

69. • Tibiofibular clear space
measure clear space 1 cm above joint
 >5mm is abnormal - implies
syndesmotic injury

70. 10degrees internal rotationof 5thMTwith respect toaverticalline

71. ⦁ Taken with ankle in
15-25 degrees of
internal rotation
⦁ Useful in
evaluation of
articular surface
between talar
dome and mortise

72. ⦁ Medial clear space
◦ Between lateral border of
medial malleous and
medial talus
◦ <4mm is normal
◦ >4mm suggests lateral
shift of talus

74. FIBULARLENGTH: 1. Shenton’s Lineof theankle
2. Thedimetest

75. •Posterior mallelolar
fractures
•AP talar subluxation
•Distal fibular translation
&/or angulation
•Syndesmotic relationship
•Associated or occult
injuries
–Lateral process talus
–Posterior process talus
–Anterior process calcaneus

76. • Stress Views
– Gravity stress view
– Manual stress views
• CT
Joint involvement
Posterior malleolar fracture
pattern
Pre-operative planning
–
–
–
– Evaluate hindfoot and
midfoot if needed
• MRI
Ligament and tendon
–
–
–
injury
Talar dome lesions
Syndesmosis injuries

77. Gravity Stress Exam
Michelson et al. CORR 387: 178-82, 2001.

78. Manual Stress Exam

79. Management of
Ankle Fractures

80. Nonoperative
• 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
• bimalleolar fracture if elderly or unable to undergo surgical
intervention
• posterior malleolar fracture (type 1) or < 2mm step-off
•

81. Operative
• 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 (type 2,3,4 and 5) or > 2mm step-off
• Bosworth fracture-dislocations
• open fractures
• malleolar nonunions

82. PRINCIPLE OF FIXATION
• Medial malleolus
• Lateral malleolus
• Posterior malleolus
• Syndesmosis

83. Isolated lateral malleolus fracture:
(with no instability)
- Truly isolated lateral malleolus #- stable
- SER 2 and SAD 1 type
- No tibiotalar incongruence
- Can be managed conservatively with
weight bearing cast, ankle brace, elastic
bandaging, stabilizing shoes, air stirrup
devices.

84. Isolated medial malleolus fracture:
• This includes
- anterior colliculus # with/without deep deltoid injuty
- posterio colliculus #
- supracollicular #
- chip avulsion fractures
Undisplaced fractures can be treated conservatively but
fractures with below knee cast for 6 weeks f/b
progressive ewight bearing and phyiotherapy
Fractures with significant displacement require fixation.

86. In assessing the accuracy of reduction 04 objective must be
met:
1. Fibula must be restored to it’s full length
2. Talus sits squarely in the mortis, with the talar & tibial articular
surfaces parallel.
3. The medial joint space must be restored to it’s normal width, i.e,
the same width as the tibiotalar space (about 4mm).
4. Oblique view must show there is no tibiofibular diastasis.

87. Approaches to the ankle joint for fixation of
bimalleolar fracture:
(A) Approaches to lateral malleolus:
1. Anterolateral
2. Midlateral
3. Posterolateral/ posterior
(B) Approaches to medial malleolus:
A. Anteromedial / Oblique (Koenig & Schaefer)
B. Posteromedial / Posterior convex (Broom head)
C. Medial (Colona & Ralston) /Anterior convex (Colona & Ralston)

89. MEDIAL MALLEOLAR #
FIXATION
Vertical fracture
(SAD 2)
2 transverse screws
Or
Antiglide plate
Oblique fracture
Two 4.5 mm partially
threaded cancellous
screws perpendicular
to the fracture line
Transverse fracture
Tension band wire

90. MEDIAL MALLEOLUS FRACTURE
• ORIF
• Indications
• 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
• fixation of medial malleolus fracture
• for transverse pattern, lag by technique using 3.5 fully-threaded screw

91. Rx of medial malleolus #

92. • The use of fully
threaded 3.5mm
screws for
fixation of medial
malleolar
fractures has
been reported
with good results
and less
complication

93. • The antiglide plate construct was stiffer (P < 0.05) than each of the
other three constructs, and the bicortical screw construct was
stiffer (P < 0.05) than both unicortical screw constructs.

95. • There was no statistical difference in the
complication rate between medial malleolar
fracture fixation with hook plate versus 2 lag
screws in this study
• Hook plate fixation is an acceptable alternative to
medial malleolar fracture fixation, especially in
patients at high risk for poor bone healing.

96. Should you repair the medial collateral
ligament?
• Routine medial repair not
needed
• Explore medial side if reduction
is not anatomical

97. lateral malleolus #
fixation
Fixation of lateral malleolu
Simple oblique
fracture
(SER 3,4)
Inter frag screw
+/- neutralization plate
Or
Malleolar screw
Simple transverse
fracture
(PER 3,4)
Compression plate
Comminuted fracture
(PAB 3)
Bridge platting
Or
IM nailing

98. Rx of lateral malleolus #

99. Rx of lateral malleolus #
1. Maximal acceptable displacement of the fibula reported literally
from 0 to 05mm.
2. In most pt. 02 to 03mm of displacement is accepted, depending of
the functional demand.

100. • ORIF
• Indications
• if talar shift or > 3 mm of displacement
• can be treated operatively if also treating an ipsilateral syndesmosis injury
• Technique
• open reduction and plating
• plate placement
• lateral
• lag screw fixation with neutralization plating
• bridge plate technique
• posterior
• antiglide technique
• lag screw fixation with neutralization plating
• most common disadvantage of using posterior antiglide plating is peroneal irritation if
the plate is placed too distally
• posterior antiglide plating is biomechanically superior to lateral plate placement

101. • intramedullary retrograde screw placement
• isolated lag screw fixation
• possible if fibula is a spiral pattern and screws can be placed at least 1 cm apart
• the stiffest fixation construct for the fibula is a locking plate
• In highly comminuted fractures, patients with osteoporotic bone, or short
metaphyseal segments, locking plates are often advocated.

102. Locking v/s Non-locking plate
• Although locking plates have been found to provide superior fixation
strength in osteoporotic fractures
• Davis et al evaluated the biomechanical properties of locking and
nonlocking plates in Weber B fibula fractures in a cadaver model.
Evaluation of torsion, load to failure, and axial stiffness demonstrated
no differences between two groups.
• Lyle et al found no difference in the complication rate or revision
surgery rate at 2-year follow-up between the two groups
• Distal fibular locking plates had a mean cost greater than six times
that of a one-third tubular plate

103. Intramedullary fixation
• In patients with poor soft-tissue envelopes or high risk for wound-
healing complications
• Fibular intramedullary nailing demonstrates greater resistance to
torque to failure than traditional fibular plating with a lag screw and is
a low-profile surgical implant (Smith G et al)
• A prospective, randomized controlled trial of 100 patients elder than
65 years with ankle demonstrated markedly fewer wound infections
in the fibular nail group, with similar functional outcomes and union
rates as compared to one-third tubular plating

106. Isolated syndesmotic Injury
• less frequent
• In simple syndesmotic sprains without diastasis of the syndesmotic
region - non-operative management with a non-weight bearing cast
for 6 weeks
• Displaced and widened mortise needs operative fixation of the
syndesmosis

107. Syndesmotic injury fixation
Indications
• widening of medial clear space
• tibiofibular clear space (AP) greater than 5 mm
• tibiofibular overlap (mortise) narrowed

108. Intra operative stress testing:
• Lateral force to heel to displace the fibula laterally (cotton’s test)
• Pulling the fibula laterally with a hook (hook test) – most popular by
the surgeons
• Fibular translation test is performed by drawing the fibula forward
and backward with the tibia stabilised
• External rotation stress test

109. Cotton’s test

110. Hook test

111. Fibular translation test

112. Method to fix
syndesmosis:
1. Screw or oblique pin (insert through lateral malleolus & distal tibia)
2. 3.5mm-4.5mm neutralizing screw.
3. Screw is inserted 2.1 to 4 cm above the ankle joint line & parallel to the
ankle joint beginning postero-laterally to the fibula proceeding
anteromedially to the tibia.
4. 30 degree anteriorly angled.

113. Goal
• Primary goal is to restore ankle stability and to maintain correct
alignment of tibia and fibula to allow sufficient healing of the
syndesmotic ligaments
• Fibula length must be restored with normal ankle mortise
• "Dime sign"/Shentons line to determine length of fibula

114. SYNDESMOSIS FIXATION
• One 3.5 screw
• Two 3.5 screw
• 4.5 screw
• 3 cortices
• 4 cortices
• TightRope device
• Bioabsorbable screw

115. 3.5mm v/s 4.5mm
• Currently, there is no gold standard for the appropriate size of the screw for
ankle diastasis, and commonly either 3.5 or 4.5 mm cortical screws are used
• In Europe most surgeons use one single 3.5-mm tricortical diastasis screw for
stabilization of the syndesmosis in Weber B or C fractures
• Two syndesmotic screws are commonly used in Maisonneuve fractures (Tim
schepers et al )
• In biomechanical studies, 3.5 and 4.5 mm cortical screws showed
comparable biomechanical characteristics (Thompson MC et al)
• There is evidence that two screws provide a better construct
biomechanically compared to one diastasis screw alone.

117. 3 cortices v/s 4 cortices
• showed that there is no
difference in clinical outcome
comparing the engagement of
three vs four cortices.

119. Bioabsorbable screws v/s metallic screw
• Comparable with respect to the incidence of
complications and range of motion.
• the absolute number of complications was
greater with bioabsorbable screws
(23.4% vs 5.7%).
• Most frequent complications of
bioabsorbable screws were wound-related
complications in 19.7% of the patients.

121. Tightrope fixation
• Rate of malreduction using screw fixation was
39% compared with 15% using TightRope
fixation
• One major advantage of this method
compared to screws is that there is no need
to remove the knot routinely
• Early returning to work

123. Management of posterior malleolar fracture
• Indications
• Type 2,3,4 and 5
• > 2 mm articular stepoff
• syndesmosis injury
• technique
Approach
• Percutaneous
• posterolateral approach
• posteromedial approach
• decision of approach will depend on fracture lines and need for
fibular fixation
• Fixation technique
• anterior to posterior lag screws to capture fragment (if nondisplaced)
• posterior to anterior lag screw and buttress plate
• antiglide plate

125. Posterior malleolus # fixation

129. References
• Rockwood and Green(Fracture in adults 8th edition)
• Orthopedic Trauma Association
• AO/OTA
• Orthobullets