Ankle Fractures Lecture · Ankle Fractures Posterolateral approach 4/19/2016 34 Maissoneuve Fracture Fracture of proximal fibula +/- medial malleolar fracture Pronation-external rotation

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Orthopaedic Trauma Association

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Ankle Fractures

Resident Comprehensive Fracture Course

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Introduction

Ankle fractures are extremely commonTreated by a wide

variety of surgeonsComplex injuryNot just “intern’s case”

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Introduction

Ankle Fractures

High-Energy Pilon Fractures

Low-Energy Pilon Fractures

Atypical Ankle

Fractures

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Physical Examination

Swelling/ecchymosis

Pain over syndesmosis

Neurovascular exam pulses

neuropathy

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Anatomy

Bony Structures

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Anatomy

Ligamentous structures Lateral ligaments ATFL

PTFL

CFL

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Anatomy

Ligamentous structures Medial ligaments Deltoid

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Imaging – What’s Normal

• Symmetric mortise

• Fibular length

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Imaging – What’s Normal

• Tibiofibular clear space (AP & mortise)– <6mm

• Tibiofibular overlap– > 6mm or ~40%

fibular width (AP)

– > 1mm (mortise)

• Medial clear space

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Classifcation

Weber

Lauge-Hansen

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Imaging

Radiographs

Ankle 3 views

Need Tib-fib films

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Imaging

Stress radiographs?

Tornetta JBJS 2004

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ImagingWeight Bearing radiographs

Is the fracture unstable under physiologic loads?

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Initial Treatment

Need to reduce dislocations!

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Advanced Imaging CT

Good for posterior malleolar fractures

MRI?

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Instability

Loss of normal anatomical relationships at rest or under physiologic loading

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Decision Making

Stable

Conservative Tx4/19/2016 18

Medial Malleolar Fractures

Nondisplaced fractures may be treated nonoperatively

Displaced fractures Isolated ?? ORIF

Part of bimalleolar pattern ORIF Horizontal (tension) compression

Vertical (shear) antiglide plate

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Medial Malleolus

Screw Fixation Standard 2 screws Solid

Cannulated

Fully threaded

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Other compression options for medial side

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Medial Malleolus Plate Fixation Vertical fracture patterns

Additional stability

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Lateral Malleolus Fractures Nonoperative management

2-3 mm displacement NO medial widening or

syndesmotic injury Cast or boot

immobilization 6 wks WBAT Follow closely!

Stress view to ensure no medial injury ???

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Lateral Malleolus Traditional Lateral Approach Relatively safe (sup. peroneal n.)

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Implant ConsiderationsLateral Side

One-third tubular “neutralization” plate

laterally “antiglide” plate posteriorly

3.5 LCDCP on shaft

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Other options forlateral side

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Posterior Malleolar Fractures

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Posterior Malleolus

> 25% rule

Based on nothing Fix if ANY posterior

subluxation

A P or P A

Prone position very helpful

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Posterior Malleolus Controversial topic

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Methods of Fixation

Screws Antegrade

Retrograde

Plate

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Ankle Fractures Posteromedial approach Through floor of PT, FDL

Supine or prone

Symptomatic HWR

Allows for fixation of medial malleolus

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Ankle Fractures Posteromedial approach

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Ankle Fractures Posterolateral approach Prone Also allows for ORIF medial

malleolus

Larger fragments

ORIF fibula through same approach

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Ankle Fractures Posterolateral approach

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Maissoneuve Fracture

Fracture of proximal fibula

+/- medial malleolar fracture

Pronation-external rotation

Requires reduction and stabilization of syndesmosis

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Maissoneuve Fracture

Fracture of proximal fibula

+/- medial malleolarfracture

Pronation-external rotation

Requires reduction and stabilization of syndesmosis

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Anatomy Fibula relation to tibia

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Anatomy

Ligamentous structures Syndesmotic ligament AITFL

PITFL

ITL

IOM

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Syndesmosis Fixation

MUST test for Syndesmoticinstability after fixation of lateral malleolus

Have bone hook on table to check stability, Cotton Test

Syndesmosis Controversies

1 vs. 2 screws

3.5 vs. 4.5 screws

4 cortices vs. 3

Two hole plate

Tightrope

No Difference!

The key is the REDUCTION !!

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Special Considerations

Diabetics/Neuropathy Need more & bigger fixation

Prolonged NWB

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Diabetics/Neuropathy

Diabetics/Neuropathy Alternative Treatments

Increased risk of complications

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Aftercare

Splint x 2weeks

Boot at 2wks to allow ROM

Weightbearing a 6-8 wks in Boot May consider brace for simpler patterns

Brace and therapy at 10 weeks May consider therapy sooner for stiffness

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Summary

Mutliple factors play into determining ORIF

Select best technique/incision for fixation on an individual basis

Goal is to provide stability and articular reduction

Be respectful and humble