injuries around ankle

1. ANKLE
INJURIES
MODERATOR : DR SHESHAGIRI
PRESENTER : DR HISHAM
JSS MEDICAL COLLEGE, MYSORE

2. INTRODUCTION
Ankle injuries apart from road traffic accidents can also result
from a slip while walking or getting down from stairs or a
twisting injury in sports and fall from a height.
Ankle injuries can occur when one attempts to turn violently
over a fixed foot or the foot being used as lever to produce
twist at the ankle
Great majority of ankle injuries are caused by indirect violence.

3. If not treated properly the ankle injuries are a source of disability in the form of pain, instability and early
degenerative arthritis of the ankle.
Ankle fractures represent 10% of all fractures
Incidence of 130/1 lakh/ year – 2nd MC lower limb fracture
67%- isolated malleolar fracture
25% - bimalleolar fracture
8% - trimalleolar fracture
Mean age at injury is 45 years ( bimodal distribution)

4. ANATOMY
Ankle joint is a synovial joint of
hinge variety
Ankle is a three bone joint composed
of tibia, fibula and talus
Talus articulates with the tibial
plafond superiorly , posterior
malleolus posteriorly and medial
malleolus medially, Lateral
articulation is with malleolus of
fibula

5. ■ The joint is considered saddle shaped with dome itself is wider anteriorly than
posteriorly and as the ankle dorsiflexes, fibula rotates externally to accommodate
this widened anterior surface of talar dome
■ Inferior tibiofibular joint is at syndesmosis joint

6. TIBIA

7. MEDIAL AND
LATERAL
MALLEOLUS

8. TALUS

9. ANKLE MORTISE
■ The bony arch formed by the tibial plafond and
two malleoli is referred as the ankle "mortise"
■ Tenon (talus) made to fit in arch.
MORTISE JOINT
■ A joint made by a mortise and tenon.
■ MORTISE - tibia and fibula
■ TENON - talus

10. LlGAMENTS
OFTHE
JOINT
CAPSULAR LlGAMENT WITH SYNOVlAL
MEMBRANE
• Thin in front & behind.
• Thick on either side where it blends with collateral
ligaments.
• It surrounds the joint and is attached all around the
articular margin
 SYNDESMOTIC LlGAMENT COMPLEX
• Between distal tibia & fibula.
• Resist axial, rotational, & translational forces to
maintain the structural integrity of mortise

11. LlGAMENTS -
syndesmosis
(a) ANTERIOR TlBIOFIBULAR LIGAMENT
(b) POSTERIOR TlBIOFIBULAR LIGAMENT
(C) TRANSEVERSE TlBIOFIBULAR
LIGAMENT
(d) lNTEROSSEOUS LIGAMENT

12. LATERAL LIGAMENTS
Talofibular ligaments:
1) Anterior Talofibular Ligaments: It prevents anterior subluxation of
talus when ankle is in plantar flexion.
2)Posterior Talofibular Ligament: It prevents posterior and rotatory
subluxation of the talus.
Calcaneofibular ligament :
■ connecting lateral malleolus to calcaneus.
■ It acts primarily to stabilize sub-talar joint and
limit inversion

13. MEDIAL
LIGAMENT
DELTOID LIGAMENTS
supports the medial side
triangular shaped
apex at tip of medial malleolus
base at talus, navicular, calcaneus
Assist spring ligament in holding up the head of talus and maintain the medial
longitudinal arch of foot.
1) Superficial deltoid ligament
2) Deep deltoid ligament

14. ■ Originates primarily
from anterior colliculus
of medial malleolus.
■ Tibiotalar portion.
■ Tibionavicular portion
prevents inward
displacement of talus.
■ Tibiocalcaneal portion
prevents valgus
displacement of
calcaneous.
SUPERICIAL DELTOID LIGAMENT

15. Deep deltoid ligament
(deep portion of tibio talar ligament)(intra-articular portion)
• Originates from posterior border of the anterior colliculus,
intercollicular groove and posterior colliculus.
• Inserts into medial surface of the talus.
• Primary medial stabilizer of ankle, prevents lateral displacement
and external rotation of talus.

16. BLOOD SUPPLY OF ANKLE JOINT
■ The ankle joint receives its blood supply form malleolar
branches of the anterior and posterior tibial and peroneal
arteries.
NERVE SUPPLY TO ANKLE JOINT
■ The ankle joint receives its nerve supply from deep
peroneal and tibial nerves. Occasionally, the superficial
peroneal nerve also supplies the ankle joint.
■ In calcaneal fractures chance of sural nerve and tibial
nerve injury is more.

17. ANKLE BIOMECHANICS
Locking and unlocking of the ankle joint:
During dorsiflexion, the wide anterior part of the talus is lodged into the narrow
posterior part of the superior articular surface .ln this position; the ankle joint is
locked as the foot cannot be moved from side to side.
During plantar flexion, the narrow posterior part of talus is lodged in the wide
anterior part of the socket. In this position, the ankle joint is unlocked as the foot
can be moved slightly from side to side.

19. AXIS
■ In neutral position , axis passes
through the lateral malleoli-body
of talus- medial malleoli
■ Lateral malleoli extends more
distally and lie posteriorly
compared to medial malleoli
■ Therefore axis of ankle is
rotated laterally 20 – 30 degree
in transverse plane

20. ANKLE
STABILISERS
Shape of talus
lnterosseous membrane
Ant. and post. talofibular ligaments
Calcaneofibular ligament
Deltoid ligament
Ankle joint capsule

21. CLINICAL
EVALUATION
Patients presents with
a limp , significant pain
and discomfort, with
swelling, tenderness,
and variable deformity.
Neurovascular status
should be checked
The extent of soft
tissue injury should be
evaluated - blistering.
The entire length of
the fibula should be
palpated for
tenderness
A dislocated ankle
should be reduced and
splinted immediately.

22. MOVEMENTS - ANKLE
TRUE JOINT- Dorsiflexion & Plantarflexion (Active,Passive)
Dorsiflexion - 15 to 30°
Plantarflexion - 30 to 50°
Critical angle - 15° Plantar flexion to 15° Dorsiflexion from 0° position
15° Plantar flexion is the minimum angle required for Push-off phase of gait
15° Dorsiflexion minimum angle require for deceleration to heel strike and squatting

23. ANKLE SPRAIN
■ Most common acute sports injury
■ Mechanism of injury is inversion and
plantar flexion of the foot
■ Injury to Anterior talofibular ligament
and calcaneofibular ligaments

24. CLASSIFICATION
Type
Type I — Only a few
fibers are stretched
or torn, so ankle is
mildly tender and
painful, but muscle
strength is normal.
Type
Type II — A greater
number of fibers
are torn, so there is
severe pain and
tenderness,
together with mild
swelling, noticeable
loss of strength and
sometimes bruising
with laxity of the
joint.
Type
Type III —The
ligaments are torn
into two separate
parts, there will be
considerable pain,
swelling,
tenderness and
discoloration with
gross instability of
the joint.

25. Management 1) CONSERVATIVE - Initial
choice of treatment
■ Protection
■ Rest
■ Ice
■ Compression
■ elevation

26. 2) SURGICAL
■ Indication - large bony avulsion
- severe ligament damage
- severe recurrent injuries
Surgical Methods
■ Repair of acute rupture of deltoid ligament
■ Repair of acute rupture of the ligaments of the distal tibiofibular joint
■ Repair of acute rupture of the lateral ligaments
■ Post op care – cast for 2 weeks with non weight bearing crutch walking – suture
removal and boot cast conversion with partial weight bearing – at 6 weeks full weight
bearing without crutches followed by ankle ROM exercises

27. • Common complication of acute ligament injury
• About 1/3 rd patients with grade 3 injury will have
symptoms upto 3 years
• Patients should be first treated conservatively if
symptomatic by brace, ankle tape and muscle
strengthening program.
• Surgical reconstruction indicated for failed
conservative program for 3-6 months
• If the injury is less than 6 months old –
MODIFIED BROSTROM REPAIR
CHRONIC INSTABILITY
OF ANKLE AFTER
INJURY

28. MODIFIED BROSTROM REPAIR
• Curvilinear skin incision
• Identify lateral portion of extensor retinaculum
• Dissect capsular tissue over ankle joint and peroneal sheath to
visualise the attenuated ligaments ( calcaneofibular and anterior
talofibular ligament)
• With ankle in valgus and foot in eversion-abduction , both the
ligaments are trimmed and end to end repair is done with permanent
suture
• Intraop Stability of ligament visualised
• Suture back the retinaculum- subtalar stability

29. RADIOLOGY

30. RADIOGRAPHIC
MEASUREMENTS OF
ALIGNMENT AND
STABILITY
1. TALOCRURALANGLE
■ The talocrural angle is a line drawn parallel to
the articular surface of the distal tibia and one
connecting the tips of both malleoli. Normally
between 8° and 15°. Difference of greater than
2° - 3° is abnormal and indicates fibular
shortening.
2. TALAR TILT
■ A line drawn parallel to the articular surface of
the distal tibia and second line drawn parallel to
the talar surface should be parallel to each other.
The difference between these 2 angles is talar
tilt. Normal tilt angle is 0 degree(-1.5 to +1.5)

31. 3. MEDIAL CLEAR SPACE
■ On the mortise view, the distance between the
lateral border of the medial malleolus and the
medial border of the talus (medial clear
space)should be equal to the superior clear space
between the talus and distal tibia . A space of
greater than 4mm is abnormal and indicated lateral
shift of the talus
4. TIBIOFIBULAR LINE
■ On the mortise view, a line formed by the
subchondral bone of the distal tibia and the medial
aspect of the fibula should be continuous.
Disruption of this line indicates shortening,
rotation, or lateral displacement of the fibula.

32. 5. SYNDESMOTIC INTEGRITY
■ On the AP view, tibiofibular overlap is measured between the
lateral border of the anterior tibial prominence(C) and the medial
border of the fibula(B) .
■ An overlap of less than 10 mm is abnormal and indicates a
syndesmotic injury, resulting in separation of the tibia and fibula.
■ The tibiofibular clear space (interosseous clear space) is the
distance between the groove formed by the anterior and posterior
tubercles of the tibia and the fibula.
■ On AP view, the distance between the lateral border of the
posterior tibial malleolus(A) and the medial border of the fibula(B)
should be less than 5 mm. A wider space indicates a syndesmotic
injury

33. OTTAWAANKLE RULES
■ To manage the large volume of ankle injuries of patients
who presented to emergency certain criteria has been
established for requiring, ankle radiographs.
 Age > 55 yrs old
 Inability to bear weight
 Bone tenderness over the posterior edge or tip of either
malleolus
■ An initial evaluation of the
radiograph should 1st focus on
 Tibiotalar articulation
 fibular shortening
 Widening of joint space
 Malrotation of fibula
 Talar tilt
X-RAY

34. ■ AP VIEW
■ MORTISE VIEW
■ LATERAL VIEW
■ In acute trauma settings, non-weight bearing views are taken .Once
the patient is able to stand, weight-bearing views are taken to
Check alignment and stability.
ANTERO-POSTERIOR VIEW
Used to evaluate:
■ Fractures of medial or lateral malleolus
■ Anterolateral tibia ,Proximal fibula
■ Osteochondral fractures of distal tibia or talus
■ Articular congruity
■ Relative malleolar length
■ Syndesmotic integrity , Talar shift
ANKLE X-RAYS : 3VIEWS

35. AB – Tibio fibular clear space > 5mm –
syndesmotic injury
BC - Tibio fibular overlap < 10mm –
syndesmotic injury
A. The ball or dime sign is an unbroken
curve connecting the recess in the
distal tip of the fibula and lateral
process of the talus when the fibula is
out to length
B. Fibula malreduced in a shortened
position - ball sign absent

36. MORTISE VIEW
■ Taken with the leg internally rotated 15° to
20° so that the x-ray beam is perpendicular to
the transmalleolar axis.
Used to evaluate
■ Fibular length
■ Talar tilt
■ Talar shift
■ Talocrural angle
■ Medial clear space
■ Tibiofibular overlap
■ Tibiofibular clear space
■ Small osteochondral lesions

37. LATERALVIEW
Taken with foot perpendicular to the long axis of the tibia with beam
centered on talus
The dome of the talus should be centered under tibia and congruous
with the distal tibial articular surface.
Used to evaluate:
Displacement of the talus in anterior or posterior direction
Fractures of posterior or anterior tibial margins
Fractures of the talar neck
Calcaneus fractures

38. SPECIALIZED EVALUATION
STRESS x- RAYS VIEWS
• Used to confirm suspected ligamentous instability. Stress views
of the opposite ankle must be obtained for comparison.
• For Lateral Ligaments - AP and mortise view is taken with an
inversion (supination) stress on the ankle.
• For Anterior Talofibular And Calcaneofibular Ligaments –
Talar tilt Stress views with the foot in plantarflexion and neutral.
• For Syndesmotic Integrity - External rotation stress view
• For Subluxation Of The Talus - Lateral view during an anterior
or posterior drawer stress

39. OTHER IMAGING MODALITIES
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

40. CLASSIFICATION SYSTEMS
OF ANKLE FRACTURES
1)Pott classification
2)Dennis-weber
Classification
3) AO/OTA classifications
4)Lauge-hansen
classification

41. DANIS-WEBER
CLASSIFICATION
Based on location and appearance of
fibula fracture
Type A
Below
syndesmosis
Internal rotation
and adduction
Type B
At level of
syndesmosis
External rotation
leads to oblique
fracture
Type C
Above
syndesmosis
Syndesmotic
injury

43. AO
classification
■ AO classification divides the three
DanisWeber types further for associated
medial injuries
■ Infrasyndesmotic=44A
■ Transsyndesmotic=44B
■ Suprasyndesmotic=44C

44. Infrasyndesmotic=44A

45. Transsyndesmotic=44B

46. Suprasyndesmotic=44C

47. LAUGE —HANSEN
CLASSIFICATION
• Based on cadaveric study
• First word: position of foot at time of injury —
SUPINATION or PRONATION
• Second word: force applied to foot relative to tibia at
time of injury — ABDUCTION or ADDUCTION or
EXTERNAL ROTATION.
Types:
• Supination External Rotation
• Supination Adduction
• Pronation External Rotation
• Pronation Abduction

48. Supination-adduction
■ It occurs in about 20-25% of all ankle fractures.
■ The foot is fixed on the ground in supination when an adduction force is applied to the
talus.
2 stages
■ Stage 1-Supination results in a tear of the lateral collateral ligament or an avulsion
fracture of the lateral malleolus below the level of the tibial plafond
■ Stage 2-More talar tilt results in the medial malleolus being pushed off in a vertical or
oblique way.

50. ■ This is the most common type and occurs in about 60-70% of all
ankle fractures.
■ The foot is fixed on the ground in supination and an external
rotation force is applied to the talus.
■ The events take place in a clockwise manner
■ Stage 1: Rupture of anterior inferior tibiofibular ligament.
■ Stage 2: Oblique fracture or spiral fracture of the lateral
malleolus.
■ Stage 3: Rupture of post tibiofibular ligament or fracture of
posterior malleolus of tibia.
■ Stage 4: Transverse (sometimes oblique) fracture of Medial
malleolus.
SUPINATION EXTERNAL
ROTATION

52. This is seen in approximately
20%of ankle fractures
Stage 1: transverse fracture of
medial malleoli/ disruption of
deltoid ligament
Stage 2: disruption of anterior
tibio fibular ligament
Stage 3: short oblique fracture of
fibula above the level of joint
Stage 4: rupture of posterior
tibio fibular ligament or avulsion
fracture of postero-lateral tibia.
PRONATION EXTERNAL
ROTATION

54. Stage 1:Transverse medial
malleolus fracture distal to
mortise
Stage 2: Posterior malleolus
fracture or posterior tibio-fibular
ligament rupture
Stage 3: Fibula fracture, typically
proximal to mortise, often
transverse or comminuted.
PRONATION
ABDUCTION

57. SER SAD PER PAB
How to identify ?

58. 1) ANTERIOR DRAWER TEST
■ Integrity of anterior tibio fibular ligament.
■ First the patient relaxed with knee flexed.
■ Then stabilize the leg with one hand grasping the
heel with the other hand and applying the
anterior force to affect anterior talar translation.
■ Perform in both plantar flexion (tests ATFL) &
dorsiflexion (tests CFL).
■ A few mm of movement is normal.
■ Compare with other leg
STABILITYTESTS

59. 2) TALAR TILT TEST:
■ It primarily examine the CFL instead of the
ATFL.
■ With the patient relaxed affected knee flexed,
stabilize the leg with one hand and grasp the
heel with other.
■ Then with foot first dorsiflexed (for CFL) and
plantar flexed (for ATFL), invert the hind foot.
■ Excessive motion may indicate instability of
the tibio talar joint, subtalar joint or both.

60. 3) EXTERNAL ROTATION STRESS TEST:
■ The single best physical examination test for
syndesmotic injury.
■ The patient is seated, with knee flexed at 90
degree.
■ The examiner stabilizes the patients leg &
externally rotates the foot.
■ If this reproduces pain at the syndesmosis, the
test is positive.

61. 4) COTTON TEST /LATERAL STRESS TEST
■ Manual stress test used to identify the amount
of lateral translation of the talus within the ankle
mortise.
■ Proximal ankle is stabilised and talus is shifted
laterally
■ Positive test – increased motion
■ Indicated syndesmotic injury

62. 5) HOOK TEST
■ Force is applied to the
lateral malleoli with a
bone bone hook, the
syndesmosis is assessed
under fluoroscopy in both
AP and lateral view .
■ More than 2mm of lateral
movement of the lateral
malleolus suggest
positive result

63. SURGICAL
APPROACHES OFTHE
ANKLE

64. GATELLIER
AND
CHASTANG
for LATERAL
MALLEOLUS
Begin the incision about 12 cm proximal to the tip of the lateral
malleolus and extend it distallyBegin
Curve the incision anteriorly for 2.5 to 4 cm in the line of the
peroneal tendonsCurve
Expose the fibula, including the lateral malleolus
subperiosteally, and incise the sheaths of the peroneal
retinaculum and tendons are moved anteriorly
Expose
If the fibula is not fractured, divide it 10 cm proximal to the tip
of the lateral malleolusDivide

65. • Carefully preserve the
calcaneofibular and
talofibular ligaments to
serve as a hinge and to
maintain the integrity of
the ankle after operation.
• Expose the lateral and
posterior aspects of the
distal tibia and the lateral
aspect of the ankle joint.

66. ■ When closing the incision, replace the fibula and secure it with a screw extending
transversely from the proximal part of the lateral malleolus through the tibiofibular
syndesmosis into the tibia just proximal and parallel to the ankle joint.
■ Overdrill the hole made in the fibula
■ Failure to overdrill the fibula can result in widening of the syndesmosis
■ Replace the tendons, repair the tendon sheaths and retinaculum, and close the
incision.
■ After the fracture has healed, remove the screw to prevent its becoming loose or
breaking

67. KOENIGANDSCHAEFER FOR MEDIAL
APPROACHTOANKLE
■ Curve the incision just proximal to the medial malleolus and divide the malleolus with
an osteotome or small power saw; preserve the attachment of the deltoid ligament.
■ Subluxate the talus and malleolus laterally to reach the joint surfaces.
■ Later replace the malleolus and fix it with one or two cancellous screws.
■ To make replacement easier, drill the holes for the screws before the osteotomy, insert
the screw, and then remove it.
■ At the end of the operation, reinsert the screws and close the wound.

68. COLONNAAND RALSTON FOR POSTERO-
MEDIALAPPROACHTOANKLE
■ Begin the incision at a point about 10 cm proximal and 2.5 cm posterior to the medial malleolus and
curve it anteriorly and inferiorly across the center of the medial malleolus.
■ Expose the medial malleolus by reflecting the periosteum, but preserve the deltoid ligament.
■ Divide the flexor retinaculum and retract the flexor halluces longus tendon and the neurovascular
bundle posteriorly and laterally.
■ Retract the tibialis posterior and flexor digitorum longus tendons medially and anteriorly to expose
the posterior tibial fracture.

70. POSTERIORAPPROACHTOTHEANKLE

71. LATERAL MALLEOLUS FRACTURES
Nonoperative managmement
2-3 mm displacement
No medial widening or syndesmotic injury
Below knee cast immobilization 6 wks
Surgical indications
Bimalleolar / trimalleolar fractures
Syndesmotic disruption
Talar subluxation
joint incongruity / articular stepoff

72. SURGICAL
TECHNIQUE
Fibula # is fixed first If associated with
medial or posterior malleolar # except
when it is severely communited.
It is exposed by either Lateral
longitudinal or postero- lateral
approach
Care to be taken to avoid superficial
peroneal nerve injury

73. IF # is below the syndesmosis it is stabilised by
using a lag screw or k- wires with tension
banding
If # above syndesmosis is fixed with 1/3
semitubular plate & screw fixation. If the plate is
placed posterolaterally it acts as a antiglide plate.

74. If # is a long oblique - fixed with two lag
screws in a-p direction to achieve
compression & must be engaged to post
cortex .
If # is Transverse - Intramedullary device
like rush nail, Intramedullary screw can
be used.

75. Operative Tips
• Isolated fracture gives suspicion of proximal fibula #
• Open reduction
• Remove interposed soft tissue and intraarticular
fragments
• Anti-glide plate for vertical fractures
Indications :
• Associated syndesmotic injury
• Widening of medial clear space after Fibular
fixation.
• Inability to attain fibular reduction
MEDIAL MALLEOLAR
FRACTURE

76. Surgical
technique
Approached
through Antero-
medial incision
Usually fixed
usingTwo 4 mm
cancellous lag
screws
perpendicular to
# line

77. Fixation can be done by using Tension
Band wiring if # fragment is small
Smaller fragments require one lag screw
and a k-wire to prevent rotation
If associated with Proximal comminution
then Buttress plate is used to maintain
reduction
Vertically oriented fracture requires
horizontally placed screws

78. POSTERIOR MALLEOLUS FRACTURE
Function:
■ Stability— prevents posterior translation of talus & enhances syndesmotic stability
■ Weight bearing- increases surface area of ankle joint
■ Fracture pattern:
Variable
Difficult to assess on standard lateral radiograph
■ Haraguchi et al classified posterior malleolus fractures as posterolateral oblique
type, medial extension type, and small shell type based on CT imaging

79. TYPES OF POSTERIOR MALLEOLUS #
■ Type I - posterolateral oblique type (67%)
■ Type II - medial extension type (19%)
■ Type lll - small shell type (14%)

80. INDICATIONS
■ If Involment is> 25% of Articular surface
■ > 2mm Displacement
■ Persistent Posterior subluxation of talus
■ Reduction is achieved in this by using either by direct or
indirect technique
 In Indirect Approach , Screw is passed Anterior to posterior &
inter fragmentary compression is achieved .
 In Direct approach Screw or Plate fixation is done posterior to
anterior direction through postero lateral incision .

81. SYNDESMOTIC INJURY
■ Also known as “High ankle sprains”
■ Injury to the ligamentous complex stabilizing the interconnection between the distal
fibula and tibia.
■ Syndesmotic injury are most commonly caused by pronation ext.rotation, pronation
abduction, and infrequently supination external rotation mechanisms.
■ Anatomical restoration of the distal tibiofibular syndesmosis is essential.
■ If the fibular fracture is above the level of DTFJ, this joint is assumed to be distrupted
and therefore must be anatomically reduced.

82. Ligaments that get involved
in syndesmotic injury
• Anterior inferior
tibiofibular ligament
(AITFL)
• Posterior inferior
tibiofibular ligament
(PITFL)
• Interosseous ligament
and membrane
• Inferior transverse
ligament

83. Provocative tests
• Squeeze test (Hopkin's):compression of tibia and fibula at midcalf level causes pain
at syndesmosis
• External rotation stress test: pain over syndesmosis is elicited with external
rotation/dorsiflexion of the foot with knee and hip flexed to 90 degrees
Syndesmosis Fixation Indications
• Syndesmotic injuries associated with proximal fibular fracture
• Syndesmotic injuries extending more than 5 cm proximal to the plafond.
• Intraop instability noted with a bone hook

84. Surgical
technique
■ Fixation of syndesmosis is either with oblique pins or
screws inserted through the lateral malleolus into the
distal tibia.
■ The screw should be positioned 2 to 3 cm proximal to the
tibial plafond,
■ Directed parallel to the joint surface, and angled 30
degrees anteriorly so that it is perpendicular to the
tibiofibular joint.
■ Two screws have been found to provide more stability
than fixation with one screw
■ Screws should engage both cortex of fibula & one or two

85. COMPLICATION

86. MAL UNlON
■ Can occur with lateral malleolus, medial malleolus or the posterior malleolus.
■ Degenerative changes and pain can occur.
Treatment-
■ # Lat mall - osteotomy through the # site, fixation with plate & screws and bone grafting.
■ # Medial mall - osteotomy through # site & fixation with malleolar screw & k wire.
■ # Post mall - if >25% of articular surface involved, osteotomy through # site, reduction& fixation with
k wire & malleolar screws.
NON UNION
■ In conservatively treated patients.
■ Non union of lat. malleolus < med.malleolus.
Treatment-
■ non union site exposed & ends are freshened , rigidly fixed with a malleolar screw & k wire

87. WOUND HEALING
■ Plate application over lateral malleolus interferes with wound healing.
■ Prevented by meticulous closure of subcutaneous layer to cover the implant &
constant elevation of the limb for first 5-7 days.
INFECTION
■ Associated with poor closure ,failure to elevate the limb postoperatively
■ Treatment - leave the implant in situ, dressing to be done regularly. when the fracture
has united, implant to be removed, debridement under antibiotic coverage
FIXATION FAILURE
■ Loosening or backing out of screws usually seen in distal fibula.
■ Treatment – if screw loosens prior to healing of syndesmotic ligament it should be
replaced

88. SUDECKS DYSTROPHY
■ Characterised by pain, edema, shiny skin with reduced ROM.
■ Prevented by early ROM exercises, elevation of the affected limb.
■ Once the condition has developed — intensive physiotherapy, prolonged
elevation & use of sympathetic blocking agents.
DEGENERATIVE ARTHRITIS
■ Due to imperfect reduction.
■ Treatment - if malunion is the cause correct it.
■ If advanced arthritis present - arthrodesis.

89. EPONYMOUS
FRACTURE

90. MAISONNEUVE FRACTURE
■ Fracture of proximal 1/3 of fibula
■ +/- medial malleolar fracture
■ Pronation-external rotation mechanism
■ Requires reduction and stabilization of syndesmosis
VOLKMANN FRACTURE
■ Fracture of tibial attachment of PITFL
■ Posterior malleolar fracture type

91. WAGSTAFFE-LEFORT FRACTURE
■ The medial portion of the fibula is avulsed at the
insertion of the anterior tibiofibular ligament.
■ The ligament remains intact.
TlLLAUX-CHAPUT FRACTURE
■ Fracture of tibial attachment of AITFL
■ External rotational force across the ankle
■ Commonly seen in adolescents
■ Treatment: ORlF

92. POTTS FRACTURE
■ Common term of bimalleolar fracture
■ In the Pott fracture, the Fibula is fractured above the
intact distal tibiofibular syndesmosis, the deltoid
ligament is ruptured and the talus is subluxed
laterally
DUPUYTREN FRACTURE
■ This fracture usually occurs 2 to 7 cm above the
distal tibiofibular syndesmosis, with disruption of
the medial collateral ligament and typically, tear of
the syndesmosis leading to ankle instability

93. COLLICULAR FRACTURES
■ Avulsion fracture of distal portion of medial malleolus
■ lnjury may continue and rupture the deep deltoid
ligament
BOSWORTH FRACTURE DISLOCATION
■ Fracture of the distal fibula with an associated fixed
posterior dislocation of the proximal fragment which
becomes trapped behind the posterior tibial tubercle.
■ Severe external rotation of the ankle

94. RECENT ADVANCES

95. Arthroscopy –Assisted ORIF
■ Ankle arthroscopy has been increasingly used to direct visualization and evaluation of
intra-articular pathology and ligamentous injury
■ Diagnostic arthroscopy is performed before fracture fixation to evaluate the ankle
cartilage and also remove intraarticular hematoma.

96. ■ Ability to perform dynamic ligamentous stress examinations
■ Intra-articular fracture fragments and loose bodies can also be identified and
removed
■ literature suggests that ankle arthroscopy has added benefit during ankle
fracture fixation in cases of suspected intra-articular loose bodies, OCLs, and
acute ligamentous instability

97. ■ (C) Intraoperative arthroscopy prior to fracture fixation shows a large full-
thickness talar osteochondral lesion (OCL), (D) cartilaginous loose bodies
from the OCL, and (E) syndesmotic disruption (yellow arrow) not seen on
preoperative radiographs.

98. Deltoid Ligament
Complex Repair
a small curved incision over the anteromedial
aspect of the ankle centered over the medial
gutter.
The deltoid ligament complex is removed from
the medial gutter, the medial malleolar bone is
freshened and the ligament is fixed to the medial
malleolus using one to two 3.0-3.5-mm suture
anchors.
The ligament is repaired with multiple horizontal
mattress sutures at the end of the case after fibula
and syndesmotic fixation is complete

99. Expanded Indications for Posterior Malleolus
Fixation
■ Controversy persists regarding operative indications and fixation of posterior
malleolus fractures
■ Recent studies showed no association between fragment size and long-term
outcomes
■ Instead, relatively large isolated posterior malleolar fractures with adequate
articular congruity can be treated nonoperatively.
■ Associated bimalleolar, syndesmotic, or ankle fracture variant injuries, fractures
involving as little as 10% of the articular surface should be treated more
aggressively with surgery.

100. Limited-Incision Fibular Nailing
■ Limited-incision intramedullary nail
fixation of the distal fibula is emerging
as an alternative to conventional lateral
plate construct.
■ Patients who require decreased soft
tissue dissection and/or early weight
bearing.

101. Dynamic Syndesmotic Fixation
■ Recent studies demonstrate a
significant trend toward increased use
and improved radiographic and clinical
outcomes associated with suture button
fixation for syndesmotic injuries
compared with traditional syndesmotic
screws.

102. REFERENCES
Campbell operative orthopaedics
Rockwood and green
McRae – orthopaedic trauma
Foot and ankle journal 2019 - Advances in the
Surgical Management of Ankle Fractures

103. THANKYOU