This document discusses controversies in the management of ankle fractures. It summarizes two studies on the treatment of syndesmotic ankle fractures and medial malleolar fractures. For syndesmotic fractures, the optimal diagnosis and treatment is unclear. While displaced injuries require surgery, evidence is sparse on whether stabilizing nondisplaced fractures improves outcomes. For medial malleolar fractures, a randomized study found no difference in outcomes between using single screw fixation versus double screw fixation, suggesting single screw fixation is sufficient.

1. Controversies in the
Management of
Ankle Fractures
Prepared By Dr MADAN MOHAN

2. 1

3. Syndesmotic Ankle Fractures:
State of the Art
J Orthop Trauma ,Volume 32, Number 1, January 2018
James D. Michelson, MD, Department of Orthopaedics and
Rehabilitation, University of Vermont College of Medicine

4. •The diagnosis and treatment of syndesmotic
ankle fractures is controversial
•This is the current understanding addressing
several clinical questions that arise in the
treatment of such injuries.
•Disagreements exist indicates that the
optimal diagnosis or treatment paradigmhas
not been discovered

5. Notwithstanding an extensive
literature on the diagnosis and
treatment of syndesmotic
fractures, the availability of reliable
evidence is relatively sparse

6. Diagnosis of Syndesmotic Injury
• There was no evidence that fixation of a
nondisplaced, but unstable syndesmosis by “stress-
test,” resulted in improved outcomes
• It should be emphasized that this is not true for
displaced syndesmotic injuries, where
restoration of the mortise does improve the clinical
outcome.

7. • It is reasonable to surgically stabilize a nondisplaced unstable
syndesmosis, recognizing that it is not clear if this improves the
clinical outcome.
•All displaced syndesmotic injuries should
undergo surgical stabilization.

8. Assessment of Accuracy of the Reduction
Although every effort should be
made to accurately reduce the
syndesmosis, subtle rotary
malreduction may be difficult to
detect but may not affect the clinical
outcome.

9. Choice of Hardware
• The number of screws used and cortices engaged in
stabilization screws is at the surgeon’s discretion.
• Alternative fixation methods (bioabsorbable screws,
endobuttons, and direct ligament reconstruction) may
have the same clinical results, although the
supporting data for these are weak

10. Postoperative Treatment Regimen
Trans-syndesmotic screws do not have to
be removed after fracture healing.

11. Outcomes
Syndesmotic ankle fractures have worse
clinical outcomes than other bimalleolar
ankle fractures

12. 2

13. Single-Screw Fixation Compared
With Double Screw
Fixation for Treatment of Medial
Malleolar Fractures:
A Prospective Randomized Trial
Richard Buckley, MD, FRCSC,
From the Section of Orthopedics, Department of Surgery, University of Calgary,
Calgary, AB, Canada
J Orthop Trauma Volume 32, Number 11, November 2018

14. • Traditional teaching is to use two 4.0-mm screws instead of
1 for medial malleolar fixation to ensure rotational control.
• However, the medial malleolus usually fails in tension or
compression, and it is questionable if significant torsional
forces exist, which might require 2 screws for stable
fixation

15. Classified according to the Herscovici
classification.
• type-A fractures are avulsions of the tip of the malleolus,
• type-B occur between the tip and the level of the plafond,
• type-C are located at the level of the plafond and
• type-D extends vertically above this level

16. •A large randomized study was necessary to
determine whether DS fixation had any
clinical advantage over SS fixation for medial
malleolar fractures
•Samples size was 127

18. • The primary outcome, the SF-36, and the secondary
outcome, AHS, at baseline, 3, and 24 months did not show
a single point of statistical difference in any of the 8
categories between groups.
• This lack of difference points to SS fixation being an
equivalent fracture care method in terms of the 8 general
health categories of the SF-36

19. • The analysis of secondary objectives showed that there
was no difference in the OR time, days in hospital
postsurgery, or need for syndesmotic fixation between
groups.
• Importantly, the fracture classification or complexity did
not influence the overall trends in functional assessment or
secondary objectives.

20. • Perhaps the most notable and important finding from the study was
the patient crossover.
• Fourteen patients, almost 25% of those randomized to receive 2
screws, received only 1 screw
•A 2-year follow-up proved that clinical and
functional outcome was no different regardless
of the number of screws used

21. There are multiple strengths with this study. This
prospectively designed and powered study with a large
sample size (n = 140) provides results that are
applicable to a wide demographic. In addition, the
crossover between groups occurred only in 1
direction, from the DS to the SS group, strengthening
the notion that an SS can be as effective as 2
screws. This study will also be generalizable because it
was conducted by 4 experienced trauma
surgeons on a fracture that is common worldwide and
treated regularly every day

22. • In conclusion, SS fixation seems to be an efficacious
treatment for most medial malleolar fractures.
• After medial malleolar fixation with either 1 or 2
screws, no significant difference with specific or
general outcome scores, operating time, or
complications was found, indicating that single screw
and DS fixation provide equivalent medium-term
patient outcomes.