Ankle (malleolar) fractures

Outline
1. Problem of the ankle joint
2. Anatomy
3. Evaluation
4. Classification
5. Initial management
6. Definitive management
7. Outcomes & complication
The problem of the ankle joint
 Most common significant lower extremity fracture
 Routinely exposed to 1.25 - 5.5x body weight
 Most congruent weight-bearing joint. 1mm lateral shift of
talus - 42% decrease in joint contact area (Ramsey JBJS 1976
- carbon black transference technique w 23 cadaver ankles)
 Not intrinsically stable in flexion or extension, depends on
ligaments, muscles
 Tenuous soft tissue coverage
 Anatomy

Deep deltoid is primary medial stabilizer.

Restrains external rotation.

Syndesmosis - AITFL + PITFL + ITL + IOL. If fails, fibula and talus go lateral

ATFL = true LCL in plantarflexion. FCL = true LCL in dorsiflexion.

Evaluation
 High energy (soft tissue compromise?) vs. low
energy (osteoporosis?)
 Weight bearing on fracture (suggests diabetic
neuropathy, schizophrenia)
 Systemic illness interfering w wound healing?
(smoker, diabetes)
 Small open wounds easily communicate w
bone or joint
 Xrays: AP, lateral, mortise, stress view, proximal
fibula
 Anterior drawer lateral view, 3mm ant.
Displacement of talus = ATFL rupture
Classification

Pott (anatomic/descriptive)

Weber
Classification
Niels Lauge-Hansen (1899-
 Lauge-Hansen: 1976). Danish radiologist.

Position of foot,
force applied
 Pronation worse
than supination
 External rotation
worse than
ad/abduction
 Reverse injury force
to reduce
Classification
SAD 10-20% - Usually syndesmosis
stable. Plafond impaction 50%
SER 40-75% - IV can look like a II if
deltoid fails. II is nonop but IV is
surgical. Stress to differentiate.
PAB 5-21% - Comminuted fibula
difficult to fix, syndesmosis often
unstable
PER 7-19% - Unstable syndesmosis
(Weber C), Maisonneuve
In general, unstable at stage III
Radiographic parameters
 <5mm
 Symmetrical
 Continuous
 Congruent
Closed reduction
• Why? Improve perfusion.
Opportunity for definitive
treatment may be missed.
• Goal: Centered talus under tibia
• Rotation: first web space aligned
w patella.
• Reverse force of injury
Surgery
Indications
Clinical deformity: deformed/dislocated on inspection
Radiographic deformity: talar shift, incongruent mortise
Unstable pattern: bimal, trimal, high fibula
Goals
Secure restoration of normal tibiotalar relationship
Lateral mal: out to length
Medial mal: reduced
Posterior mal: fix if >25%
Syndesmosis: anatomic position of fibula in incisura
Timing
When soft tissues recovered. Within 2 weeks, outcome same. (Konrath 1995,
Fogel 1987)
Operative treatment

1/3 tubular 3.5mm DCP

Postoperative care
• Splint 2 weeks, then functional brace w ROM exercises
• Non-weightbearing for 6 weeks (controversial)
• No driving for 9 weeks (or 6 weeks after weight bearing)
Postoperative care
 Outcomes
2005: Improved functional outcome at mean 1.5yr follow
follow up w anatomic syndesmosis reduction.

2006: 90% minimal pain/functional limitation at 1 year. 1985: ORIF improves outcomes. Talocrural angle predicts
Male, young, absence diabetes predict good outcome prognosis.

2011: 80% good-excellent at mean 5.1 yrs. No diff. between weber A and B.
Complications