ankle fractures

1. MANAGEMENT OF ACUTE ANKLE FRACTURES
Dr UDAY KUMAR
MS(Orth) DNB(Orth)
SAGAR HOSPITALS
SINDHI HOSPITAL
CHINMAYA HOSPITAL
BANGALORE
Jan 9, 2015

2. - ankle fractures ----- between 107 and 187 per 100,000 persons
per year
-Unimalleolar fractures-- most common -- 70%
-most common mechanism is---- supination injury
foll by pronation
-more common in --- young men aged 15–24 yrs
-- older women
INCIDENCE

3. Clinical features
-H/O severe twisting, abduction or adduction
injuries.
-Severe pain.
-Inability to stand on the affected limb.
-Swelling and deformity.
-Tenderness on one or both malleoli.

4. Skin-soft tissue injury—closed/open
Nerves
Vasculature
Co-morbidities---diabetes
smoking
alcohol
Evaluate

5. Initial Management
-Pain control
-RICE
-Rest
-Immobilise---splint
-Compression bandage
-Elevation

6. X rays
-Ankle Series
AP
mortise
lateral
AP
Lateral
Mortise

7. - fractures of malleoli
- distal tibia/fibula
- talar dome
- body and lateral process of
talus
Antero-posterior view

8. • Tibiofibular clear space:
<5mm
• Tibiofibular over lap:
>10mm
• Talar Tilt: difference in
width of med &lat aspect of
joint–
<2mm
Measurements in AP view

9. -Foot in 15-20 degrees
internal rotation
-Evaluate articular surface
between talar dome and
mortise
Mortise view
-Medial clear space:
<4mm

10. •Posterior malleolar fractures
•AP talar subluxation
•Distal fibular translation &/or
angulation
•Associated or occult injuries
–Lateral process talus
–Posterior process talus
–Anterior process calcaneus
Lateral View

11. Evaluation: Radiographic
Other Imaging Modalities
• Stress Views
– Gravity
– Manual
• CT
– Articular involvement
– Posterior malleolus
• MRI
– Ligament and tendon injury
– Talar dome lesions
– Syndesmosis injuries

12. Weber/AO classification
based on level of
fibula fracture
A – Below syndesmosis
B – At syndesmosis
C – Above syndesmosis

13. Classification: Lauge-Hansen meets Danis-Weber

14. Simple Classification
Stable Unstable
• Stable fractures
– Most commonly involve
medial or lateral side
only
– Talus remains anatomic
relative to tibia

15. Unstable fractures
– Disruption of 2 or more
aspects of the mortise --
bone and/or ligament
– Talus may sublux or be
dislocated from tibia

16. Stable Examples

17. Unstable Examples

18. Management
-Stable Ankle fracture
--- short leg cast for 6 weeks
- Cast patients
reduced hospital stay
lower cost of treatment
Non-operative

19. Surgical Indications
• Bimalleolar / trimalleolar fractures
• Syndesmotic disruption
• Talar subluxation
• Open fractures

20. Soft tissue injury
• Debridement
• External fixator and delayed ORIF

21. Basic Set-Up
• Supine position most common
– Occasionally prone for direct approach to posterior
malleolus
• Bump beneath ipsilateral buttocks (allows easier
approach to fibula)
• Tourniquet
• Prep / drape to above knee
• Pre-op antibiotics
• Fluoroscopy or X-ray

22. Instrumentation
• Small fragment set
• Cannulated screws
• K-wires
• Cerclage wire
• Power
• Have mini-frag
available

23. Ankle Fracture
ORIF PLAN

24. Uni malleolar fracture
Fix with
-- Two 4 mm
cancellous screws
--TB wire
--plate

25. Bimalleolar fracture
Plate fibula
Two 4 mm cancellous screws
in medial malleolus

26. Tri-malleolar fracture
Plate fibula
Two 4 mm cancellous
screws in med malleolus
fix posterior malleolus if
>20 - 25% articular
surface involved

27. Fixation techniques

28. Lateral Malleolus
• One-third tubular plate &
3.5 mm cortex screws
– Lateral
– Posterior
• 3.5mm compression plate
for unstable fractures
-avoid superficial peroneal nerve injury

29. Lateral Malleolus
• Locking plates -- lateral or posterolateral
• Osteoporotic bone
• Unstable fractures
• Distal fractures

30. Lateral Malleolus
in very distal fibula fractures
• Hook Plate
• K wire with
cerclage wire
. Lag screw/Rush pin

31. Medial Malleolus
• Two partially threaded 4.0
mm cancellous screws
• K-wires with cerclage wire
• Buttress plate

32. Posterior Malleolus fixation
If involvement is
> 25% of Articular surface
> 2mm Displacement
Persistent Posterior subluxation of talus
Anterior to posterior

33. Posterior to anterior
Posterior Malleolus

34. Syndesmosis Fixation
• Syndesmotic instability checked
after fixation of malleolus
• Consider if fibula fracture > 4 cm
above joint line
• Have bone hook on back table to
check stability

35. Syndesmosis
• large or small fragment fully threaded
screws, one or two
• Not inserted as lag screw, but as a
positioning screw
• May be removed in 6 - 12 weeks
• Bioresorbable screws/Tight rope

36. Postoperative Care
• Well padded splint immobilization
for a few days
• Ice and elevation
• Non weight bearing for 6 weeks
• Early conversion to brace and ROM