Current review of ankle fracture management.

1. ANKLE FRACTURE
MANAGEMENT
DR ANKIT JOSE
MS (ORTHO), FAJR,
FELLOW IN ARTHROSCOPY AND SPORTS
MEDICINE

2. CONTENTS
• Approaches .
• Infrasyndesmotic fibular fractures.
• Transsyndesmotic fibular fractures.
• Suprasyndesmotic fibular fractures.
• Posterior Malleolar fracture.
• Postoperative management.
• Complications .

3. APPROACHES
Approaches to the Lateral side: A straight
incision is recommended slightly posterior
to the fibula.care not to damage either the
superficial fibular or the sural nerve.
Approaches to the Medial side:.
Care must be taken to avoid both
the saphenous vein and nerve

4. Infrasyndesmotic fibular fractures
(type A)
• Tension band wiring technique.
• Retrograde screw inserted when the lateral
failure is of the osseoligamentous type.
• Tibial plafond at the medial corner should be
inspected , impaction fracture is reduced and
supported by a bone graft.

5. 3
1
2

6. Transsyndesmotic fibular fractures
(type B)
• Protection plate
• Posterior buttress (antiglide) plate.

8. Suprasyndesmotic fibular fractures
(type C)
• Restore the length and rotation of the fibula.

10. HOW TO FIX MEDIAL MALLEOLAR
FRACTURE
• Screw or TBW fixation ?
• Screw fixation: which zone to insert ?
• Plate fixation - Vertical Fractures.

11. TBW - TRANSVERSE
FRACTURE
LAG SCREW-
OBLIQUE
FRACTURE
REVISION 5% 19%
COMPLICATIONS 16% 33%
RADIOLOGICAL
UNION
79% 71%
AOFAS 86 80

12. KNOTLESS TENSION BAND
KTB is comparable to the WTB while offering a hassle-free and irritation-
free reduction. Further prospective studies are needed to measure KTB
operating time of the procedure, direct patient costs, a validated scoring
system, and patient satisfaction without additional frustration of hardware
removal due to irritation.
TBW

13. Results: Screws placed in Zone 1 (the anterior colliculus) did not contact
the posterior tibial tendon in any specimens. Screws placed in Zone 2 (the
intercollicular groove) were, on the average, 2 mm from the posterior tibial
tendon. Screws placed in Zone 3 (the posterior colliculus) resulted in tendon
abutment in all ten specimens and in tendon injury in five of the ten
specimens.

14. Study demonstrated using LCP metaphyseal plate in patients associated with lateral
malleolar fracture could achieve significantly better AOFAS scores and less healing
time than using one-third tubular plate.

15. Weber A fracture Weber B fracture

16. SER IV injury surgically
created. One leg was
randomly allocated to fixation
with a fibular nail and the
other a lag screw and
neutralization plate.
Conclusions: This study demonstrated greater torque to failure and better
maintenance of the fibular construct for the intramedullary fibular nail
compared to standard plating.

17. Posterior Malleolar Fracture – When
to fix?
(1) Ankle fracture dislocations that could not be
reduced after closed reduction of the ankle joint
despite the size of the fragment.
(2) In patients with no ankle joint dislocation, if we
could not achieve reduction of the PM after
medial and/or lateral malleoli fixation.
(3) If the fracture was larger than 25% of the
articular surface.

18. APPROACHES

21. The direct reduction technique via a posterolateral approach and PA fixation
enables higher quality of reduction and better functional outcome in the
management of the posterior fragment compared with indirect
reduction and percutaneous AP fixation.
48 patients with trimalleolar fracture were enrolled in the study

22. open reduction and internal fixation of fractures of 40
patients of the posterior malleolus with a posterolateral
approach and compared the results of the 2 techniques
At the final follow-up, the mean AOFAS score of the patients regardless of fixation type was
94.1 (range, 85-100). The statistical results showed no significant difference between the
patients regardless of the fixation type of the posterior malleolus in terms of AOFAS
scores and ROM of the ankle .
Fixation of the PM provides 70% of the TFS stability in ankle
fractures that involve PM fractures, whereas TFSS provides
only 40%.

23. Group A
• Two parallel
placed 3.5
mm
partially
threaded
titanium
alloy screws
Group B
• Anatomical
plates were
used.
Conclusion: For a Haraguchi type I posterior malleolar fracture with an average
height of 19 mm, fixation with a posterior malleolar anatomical plate failed to
demonstrate a stronger strength than 2 parallel-placed 3.5-mm partially threaded
screws, which indicates that plates may not be absolutely necessary for standard
rehabilitation after posterior malleolar internal fixation.

24. Early WB
GROUP
• Early weight
bearing and
ROM at 2
weeks.
Late WB GROUP
• Late weight
bearing non
weightbearing
and cast
immobilization
for 6 weeks.
J Orthop Trauma Volume 30, Number 7, July 2016

25. There were no differences with regard to
wound complications or
infections and no cases of fixation failure or
loss of reduction. Patients
in the Late WB group had higher rates of
planned/performed hardware
removal due to plate irritation
Conclusions: Given the
convenience for the patient,
early improved functional
outcome, and the lack of an
increased complication rate,
we recommend early
postoperative weight bearing
and ROM in patients with
surgically treated ankle
fractures.

30. A total of 26 studies were included in the final analysis. All papers studied the
management of Weber C fractures using open reduction and internal fixation
(ORIF). Three main functional outcome scores were identified.
The mean rate of syndesmosis malreduction was 18.2%.

33. TAKE HOME MESSAGE
• Approach and fixation based on Fracture
pattern .
• Elderly >60 yrs and diabetes patients require
proper counselling .

34. THANK YOU