Shammas B.M,Calicut Medical College

Ankle Anatomy

• • • • Most frequently injured joint in the body Works to maintain balance 26 bones in the ankle Toes numbered 1-5 starting at the “’big toe” great toe

Ankle Ligaments
• Note – Most of the names of the ankle ligaments, give the attachment point.

Lateral Ankle Ligaments
• Commonly injured with ankle inversion • Talofibular – connects the talus and fibula • Calcaneofibular – connects the calcaneus and fibula

Medial Ankle Ligaments
• Deltoid ligaments are four strong ligaments maintaining stability during eversion • Talotibial – connects the talus and tibia • calcaneotibial – connects the tibia and calcaneus

Ankle Injuries
• type I — Only a few fibers are stretched or torn, so ankle is mildly tender and painful, but muscle strength is normal.

Ankle Injuries
Type II — A greater number fibers are torn, so there is more severe pain and tenderness, together with mild swelling, noticeable loss of strength and sometimes bruising

Ankle Injuries
• Type III — The ligaments tears all the way through. it rips into two separate parts .there will be considerable pain, swelling, tenderness and discoloration.

Ankle Injuries
• Sprains / Strains – 80% of sprains are caused by ankle inversion. • Inversion sprains cause damage to the lateral ligaments

Ankle Injuries
• Ankle Fracture – commonly caused by eversion. The fibula is often broken.


• Cadaveric study which relates the fracture pattern to an injury mechanism • The first word in the designation refers to the foot’s position at the time of injury; the second word refers to the direction of the deforming force. • ‘‘eversion’’ is a misnomer; it more correctly should be ‘‘external’’ or ‘‘lateral’’ rotation

Type of injury (foot position/direction of force) Supination/Adduction


Transverse # of fibula/tear of collateral ligaments ± vertical # medial malleolus

Type of injury Pathology (foot position /direction of force)

Supination/ Eversion (External rotation)

1.Disruption of the anterior tibiofibular ligament 2.Spiral oblique fracture of the distal fibula 3.Disruption of the posterior tibiofibular ligament or fracture of the posterior malleolus 4.Fracture of the medial malleolus or rupture of the deltoid ligament

Type of injury (foot position /direction of force)


Pronation/ Abduction

1.Transverse fracture of the medial malleolus or rupture of the deltoid ligament 2.Rupture of the syndesmotic ligaments or avulsion fracture of their insertion(s) 3.Short, horizontal, oblique fracture of the fibula above the level of the joint

Type of injury (foot position Pathology /direction of force)

Pronation/ Eversion

1.Transverse fracture of the medial malleolus or disruption of the deltoid ligament 2.Disruption of the anterior tibiofibular ligament 3.Short oblique fracture of the fibula above the level of the joint 4.Rupture of posterior tibiofibular ligament or avulsion fracture of the posterolateral tibia

Type of injury (foot position /direction of force)


Pronation/ Dorsiflexion

1.Fracture of the medial malleolus 2.Fracture of the anterior margin of the tibia 3.Supramalleolar fracture of the fibula 4.Transverse fracture of the posterior tibial surface

AO/ Danis-Weber
Type A B C Pathology Avulsion # fibula ± shear # of med malleolus Fibula # at level of syndesmosis ± # med malleolus/ tear of deltoid ligament Fibula # above level of syndesmosis ± medial injury + tear of ITFL and interosseous membrane

• • • • •

Maissoneuve’s fracture Spiral fracture of proximal fibula associated with very unstable ankle injury Bosworth Fracture A lesion described by Bosworth may be the cause of failure to reduce a posterior fracture-dislocation of the ankle. The distal end of the proximal fragment of the fibula may be displaced posterior to the tibia and locked by the tibia’s posterolateral ridge; the bone cannot be released by manipulation because of the pull of the intact interosseous membrane. In these cases the fibula is exposed, and a periosteal elevator is used to release the bone; considerable force may be necessary. The fibular fracture then is fixed.

• Bosworth fracture with entrapment of fibular behind tibia. A, Anteroposterior view. B and C, Lateral views.

Rationale behind ORIF of ankle fractures
• Tibiotalar congruency • Ramsey and Hamilton (JBJS (B) 1976) showed that a 1mm lateral shift of the talus in the ankle mortice reduces the contact area by 42% • Posterior malleolus fracture >33% leads to a significant loss of tibiotalar contact • DeSouza (JBJS (A) 1985) showed 90% satisfactory results could be obtained even if up to 2mm of lateral displacement was present • Generally
– Young ORIF if >1mm displacement or >2º talar tilt – Old can accept up to 2mm of displacement – Always take into account the ambulatory needs of the patient and judge treatment accordingly

Surgical technique
• • Standard AO fixation Interfragmentary screw and 1/3 tubular neutralisation plate for fibula and lag screw fixation for medial malleolus • Syndesmosis screw is required if fibula is unstable at end of fixation (engage 3 cortices and ensure the ankle is at 90º when inserting screw, and that the screw is not lagged) Screw needs to be removed before weight bearing can be commenced • Alternative fixation for Type B fractures of the fibula is the anti-glide plate which has been shown to be biomechanically superior to a lateral plate • Posterior malleolus fractures need to be fixed if there is > 25% of the articular surface involved. This is often underestimated on lateral radiographs

Post-operative management
• In studies comparing the effect of early movement vs immobilisation and weight bearing vs non-weight bearing, the conclusion is that there is no difference in the final result whichever regime is used.

• • • • Incidence increases with severity of injury Degenerative changes in 10% of anatomically fixed 85% if not adequately reduced - changes apparent within 18 months • Klossner "Late results of operative and non-operative treatment of severe ankle fractures" Acta Chir Scand Suppl. 293: 193, 1962

• There is a reduction in the incidence of arthrosis in patients where an anatomical reduction has been achieved (Phillips et al JBJS 67A: 67-78, 1985) • Prospective trial shows higher total ankle scores in those that are operatively treated- especially so in those pts more than 50 yrs old

PILON / PLAFOND FRACTURES (Pilon = Hammer / Plafond = Ceiling)

Reudi & Allgower Classification
Type 1 2 3 Pathology Undisplaced Displaced with joint incongruity Marked comminution with crushing of the subchondral cancellous bone

Initial treatment
• Reduction of any dislocation and covering of exposed wounds if present • Assess neurovascular status • Check for evidence of compartment syndrome • Splint fracture which may require temporary skeletal traction

• • • • •

Investigations X-ray plus CT Timing of surgery Type II and III - goal is to keep talus centred under the tibia while soft tissue heal over 7 to 21 days Study by M.Sirkin et al 1999, a series of pilon fractures underwent immediate external fixation and ORIF of the fibula, and formal ORIF of the tibial articular surface was performed on a delayed basis (avg. delay 12-13 days); - using this protocol, no patient that presented with a closed injury developed a full thickness skin necrosis and none required secondary soft tissue coverage The historically high rate of infection and skin necrosis following ORIF of these injuries is most related to operative timing - in the study by MJ Patterson and JD Cole (JTO 1999), all patients underwent a two staged technique for the treatment of complex pilon fracture - initially all patients underwent immediate fibular fixation and placement of a medial fixator

Surgical options
• 1. ORIF • Medial and anterior incisions with full thickness flaps developed at level of the periosteum. These incisions must be at least 7 cm apart to protect the viability of the intervening skin bridge • Steps
– Fibula # brought out to length and fixed with plate (DCP) – Tibial # exposed and reduced, held with temporary K-wires – usually 4 main fragments – K-wires replaced with interfragmentary screws and fixed with buttress plate – Closure of wounds – tension must be avoided and if present close deep layers and return later for delayed 1º closure of skin

2. Fine wire fixation with circular frames • Using either the Ilizarov or hybrid external fixators • This can be combined with limited internal fixation of the tibia using interfragmentary screws and fixation of the fibula 3. Trans-articular external fixation • Will align the tibia but will not address the central depression of the joint surface. • Useful as first part of 2 -stage procedure (to allow soft tissue management & CT & planning)

• Operative treatment of high-energy pilon fractures will take an average of 4 months to heal • 75% of patients that do not develop wound complications may expect a good result • Subsequent arthrodesis rate ~ 10% • Bourne et al " Pilon fractures of the distal tibia" CORR 240:42-46, 1989
– 36% satisfactory results in intra artic fracture treated with closed means – 76% satisfactory for operative treatment – 32% at 4.5 yrs had undergone ankle arthrodesis for failed result

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