2. Epidemiology
• Most common weight-bearing skeletal injury
• Incidence of ankle fractures has doubled since the
1960’s
• Highest incidence in elderly women
• Unimalleolar 68%
• Bimalleolar 25%
• Trimalleolar 7%
• Open 2%
3. Ankle Anatomy
• Complex joint comprising the articulation of the tibia
and fibula with the foot at the talus
• Talar dome tibial plafond are trapezoidal (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 thin soft tissue envelope
8. Ankle Biomechanics
• Tri-plane motion
• The load bearing force in stance phase of gait is
4 times the body weight
• Normal ROM:
~20 degrees of extension
~40 degrees of flexion
• At least 10 degrees of dorsiflexion (extension)
is needed for normal gait
• 1 mm of lateral talar shift decreases tibio/talar
surface contact up to as much as 40%
9. History
Consider the relevant factors of the injury
• Mechanism of injury
• Time elapsed since the injury
• Soft-tissue injury
• Has the patient ambulated on the ankle?
• Patient’s age / bone quality
• Associated injuries
• Comorbidities
10. Physical Exam
• Neurovascular exam
• Note obvious deformities
• Pain over the medial or lateral malleoli
• Palpation of ligaments about the ankle
• Palpation along course of the entire fibula
• Pain at the ankle with side to side compression
of the tibia and fibula (5cm or more above the
joint) may indicate a syndesmotic injury
• Examine the hindfoot and forefoot
11. Radiographic Evaluation
• Plain Films
AP, Mortise, Oblique views of the
ankle
Image the entire tibia to knee joint
Foot films when tender to palpation
Common associated fracture are:
5th metatarsal base fracture
Calcaneal fracture
12. Anteroposterior View
Quantitative analysis
Tibiofibular overlap
<10mm is abnormal - implies syndesmotic injury
Tibiofibular clear space
>5mm is abnormal - implies syndesmotic injury
Talar tiltTalar tilt
>2mm is considered abnormal
Consider a comparison with
radiographs of the normal side if there
are unresolved concerns of injury
13. Mortise View
•Foot is internally rotated
and AP projection is
performed
•Abnormal findings:
medial joint space widening
talocural angle <8 or >15
degrees (comparison to normal
side is helpful)
tibia/fibula overlap <1mm
15. Lateral View
•Posterior mallelolar fractures
•Anterior/posterior
subluxation of the talus under
the tibia
•Angulation of distal fibula
•Talus fractures
•Associated injuries
16. 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 dome
lesions
Syndesmosis injuries
18. Lauge-Hansen
Based on cadaveric study
First word refers to position of foot at time of 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.
19. Lauge-Hansen
In each type of fracture there are several stages of
injury.
Not every fracture fits exactly into one category.
20. Supination-External Rotation
1
23
4
Stage 1 Anterior
tibio- fibular
ligament
Stage 2 Fibula fx
Stage 3 Posterior
malleolus fx or
posterior tibio-
fibular ligament
Stage 4 Deltoid
ligament tear or
medial malleolus
fx
21. SER Fractures
Classic short oblique fibula fracture. Begins at the mortise
anteriorly and extends posterior-proximal. The SER fibula
fracture is ideal for a posterior lateral antiglide plate.
The medial injury can be a fracture or a deltoid ligament
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.
23. SER-2 vs. SER-4 How To Decide?
SER-2
Negative Stress view
External rotation of foot with
ankle in neutral flexion (00
)
Stable Treatment FWBAT
+ Stress View
Widened Medial Clear Space
SE-4SE-4
24. A Comparison of Physical Findings
(Swelling, Tenderness, Ecchymosis) and
Stress X-ray
Swelling and Ecchymosis Scale
None
Mild
Moderate
Severe
Tornetta et al
26. Performed if mortise reduced on initial films
No talar subluxation
Medial clear space 4mm or less
Ankle in neutral dorsiflexion
External rotation stress
@ 8 lbs
Ankle positioned in Mortise view for stress
radiograph
Stress Radiograph
28. Instability = SE 4
3 mm3 mm
6 mm6 mm
Medial clear space >
4mm
At least 1mm more than
superior joint space
Any talar subluxation
29. Medial Tenderness – No Correlation with
Instability
Mild Moderate Severe
SE 2 67% 20% 13%
Stress (+) SE 4 50% 22% 28%
SE 4 50% 12% 38%
Bimalleolar 23% 41% 36%
0%
10%
20%
30%
40%
50%
60%
70%
SE 2 Se 4
Mild Moderate Severe
30. Medial Swelling – No Correlation to
Instability
Mild Moderate Severe
SE 2 38% 37% 25%
Stress (+) SE 4 21% 44% 35%
SE 4 13% 31% 56%
Bimalleolar 36% 50% 14%
0%
10%
20%
30%
40%
50%
60%
SE 2 Stress (+) SE 4 SE 4 Bimalleolar
Mild Moderate Severe
31. Stress Examination
Effective method of diagnosing Stable SER-2
67 SE2…all healed without displacement
Medial tenderness
NO!!
Ecchymosis
NO!!
`
Tornetta et al
32. Supination Adduction
1
Stage 1 Fibula fracture is
transverse below mortise.
Stage 2 Medial malleolus
fracture is classic vertical
pattern.
Marginal impaction is
common at the medial
edge of the plafond.
2
33. SAD
Only 2 injury 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.
34. Pronation-External Rotation
Stage 1 Deltoid
ligament 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
34
1 2
35. PER
Proximal spiral fibula fracture
Must x-ray knee to ankle to assess injury
Syndesmosis is disrupted in most cases
Epiponym Maisoneuve Fracture
Restoration of the mortise and syndesmosis are the
keys to treatment
The fibula must be have length and rotation restored
36. Pronation-Abduction
Stage 1 Transverse medial
malleolus fx distal to
mortise
Stage 2 Posterior malleolus
fx or posterior tibio-
fibular ligament
Stage 3 Fibula fracture,
typically proximal to
mortise, often with a
butterfly fragment
1
2 3
37. PAB
Fibula fracture typically in distal 1/2 of fibula.
Plating of fibula may be helpful.
Medial malleolus fx can be difficult to purchase with
standard screws. Tension band fixation may be
helpful.
38. 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
41. Common Names of Fracture
Variants
• Maisonneuve Fracture
Fracture at the proximal 1/3 of the fibula - PER IV
• Volkmann Fracture
Posterior malleolus fracture
• Wagstaffe Fracture
Anterior fibular tubercle avulsion fracture by the anterior inferior
tibiofibular ligament (AITF)
• Tillaux-Chaput Fracture
Avulsion of the anterior lateral tibia due to the AITF
• Collicular Fractures
Avulsion fracture of distal portion of medial malleolus
Injury may continue and rupture the deep deltoid ligament
42. 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
43. Nonoperative Treatment
• Indications:
Nondisplaced stable fracture with intact
syndesmosis
Patient whose overall condition is unstable and
would not tolerate an operative procedure
• Management:
Below the knee cast for 4-6 weeks
Follow with serial x-rays and transition to
walking boot or short-leg walking cast
44. Nonoperative Treatment
•Clinical example
SER injury
Treated in walker boot WBAT
Films 4 months post injury show
healed stable mortise
Less than 3 mm displacement of
the isolated fibula fracture with a
reduced ankle mortise do not
require surgery
49. Operative Fixation
In general when a bimalleolar ankle fracture
is operated it is helpful to open the medial
side prior to lateral fixation. This allows
better visualization of the mortise to assess
cartilage damage and remove osteochondral
fragments.
50. Case Example
20 yo male falls while running - sustains ankle injury
Diagnosis SER Stage 4
52. Medial Approach
Initial approach to medial malleolus allows better inspection of
talus and tibial plafond. The fibula is still unstable allowing
improved visualization to the joint.
Chondral defect on talar domeChondral defect on talar dome
Tibial Plafond
Medial Malleolus
53. Lateral Plating
Fracture reduced with plate in this exampleFracture reduced with plate in this example
or with screws alone into plate proximallyor with screws alone into plate proximally
Drill Screw HoleDrill Screw Hole
54.
55. 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 syndesmosis.
56. 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 plafond prior to reduction of
the fibula is difficult because the posterior
malleolus is often attached to the distal fibula.
Generally reducing the fibula and dorsiflexing the
ankle are the first steps in reduction. Occasionally
a posterior approach may be necessary for
reduction.
62. Antiglide Plating
Fracture Reduced With Clamp in this exampleFracture Reduced With Clamp in this example
or with screws alone into plate proximallyor with screws alone into plate proximally
Fill Screw HolesFill Screw Holes
Lag ScrewLag Screw
66. Screw Only Fixation
Over 100 cases
No hardware failure
2% lateral irritation
Incisional
Compares favorably with direct lateral
plating
Tornetta et al
74. Before Fixation After Fixation
4343°
42°42°
Cadaveric Study of Syndesmodic
Screws Compressing Mortise
75. Syndesmotic Fixation
It has been traditionally taught to dorsiflexion when
inserting a syndesmodic screw to prevent malreduction of
the mortise by over tightening the joint
However Dorsiflexion is not necessary
Cannot Overtighten when the syndesmosis is reduced!
Make sure syndesmosis is anatomic!
Tornetta et al
76. Syndesmodic Screws
Contoversies
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 in literature on these points!
77. 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 porer
overall outcomes
78. Soft Tissue Problems
• Dislocation with skin 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
79. Diabetic Ankle Fractures
• Neuropathy, nephropathy, retinopathy and PVD
increase the risk of complications (Marsh, OTA, 2003)
• Significant risk 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 rehabilitation time may be as much as
double the non-diabetic patient
80. 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
81. Postoperative Care
•Casting vs. Removable Boot with early ROM
May have some wound problems with boot
No study shows a significant
difference between the treatments
In general early return of motion
is prefered when the fixation
is stable and the patient can comply
with post-operative recomendations
82. 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 screws and
has maximal mechanical stability
•Consider an intramedullary screw if there is
not adequate distal bone
83. Outcome
Position of the mortise at union and stabiltiy of
talus are critical factors!
Obtain an anatomic reduction
Hold to union
If loss of position is noticed,
re-reduce if possible
84. Results
• Stable ankle fractures without lateral talar shift
treated conservatively have 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 dorsiflexion ( Lindsjo, Clin Orthop, 1985)
85. Results
Predictors of poorer results
Bimalleolar fracture
Anterolateral impaction injuries of
the tibial plafond
Large posterior malleolar
fragments
Talar dome injuries
Talus fractures
Associated foot/ankle injuries
Delay in fixation
Age > 50 yr
Diabetes Mellitus
86. Complications
•Malunion
Usually associated with shortened
or malrotated distal fibula
Failure to reduce the syndesmotic
injury
Treated with fibular lengthening
and/or derotational osteotomy +/-
syndesmotic fixation
Good results with fibular
osteotomy to prevent arthrosis
Ankle fusion for advanced
arthrosis or osteotomy failure
87. 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 vascular disease or smoking
Noncompliance and premature weight bearing
88. 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
89. 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 salvage procedure
90. 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 or ankle
implant
91. Complications
• Compartment Syndrome
Can occur in immediate postoperative period.
Treated with fasciotomies followed by delayed
closure or skin graft
• Complex Regional Pain Syndrome Type I
(RSD)
minimized by appropriate reduction and early
return to function
• Tibiofibular synostosis
associated with syndesmotic screw use and is
usually asymptomatic
92. Summary
• Careful clinical and radiographic evaluation
• Restoration of ankle joint 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
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Lower Extremity
Index
