This document discusses surgical techniques for fixing ankle fractures. It describes the anatomy of the ankle joint and surrounding ligaments. Common fracture patterns are described using the Weber classification system. Surgical approaches and fixation methods are outlined, including lateral plating, lag screws, and posterior plating. The principles of fixation aim for stability, articular congruity, and restoration of the fibula. Factors such as the position of the foot, deforming forces, and stability tests are important to consider when determining appropriate treatment.

1. Ankle fracture fixation
Derek Park
Consultant Trauma & Orthopaedic Surgeon
Barnet & Chase Farm Hospitals

2. Outline
• Surgical anatomy and
approaches
• Surgical fixation techniques

3. Ankle fractures
• Why does this ankle
fracture…

4. Ankle fractures
• End up like this?

5. Ankle fractures
• And why do Orthopaedic
surgeons do things like
this?

6. Ankle fractures
• Or this?

7. Ankle fractures
• Or even this?

8. Why do people get it wrong?
• Underestimation of the fracture
• Lack of understanding of ankle
fracture patterns
• Lack of understanding of the
basic principles of fracture
reduction & stabilisation

9. Surgical and functional anatomy of
the ankle joint
• Ankle joint = 3 bone articulation
between tibia, fibula and talus
• 80% load transmitted through
the tibial plafond of the talar
dome in single leg stance
• Talar dome is wider anteriorly
than posteriorly = section of a
cone, with apex medial, fully
congruous

10. Surgical and functional anatomy of
the ankle joint
• Strong ligaments support
the ankle Medially:
• superficial deltoid ligament
• deep deltoid ligament
• Deep deltoid acts as a
check-rein to abnormal
talar movement
• Draws in and stabilizes the
talus on axial loading

11. Surgical and functional anatomy of
the ankle joint
• Lateral ligament complex
comprises the:
• anterior talofibular ligament - ATFL
• calcaneofibular ligament- CFL
• posterior talofibular ligament - PTFL

12. Syndesmosis complex
• Fibrous connection comprising:
• anterior & posterior tibiofibular
ligaments (AITFL & PITFL)
• interosseous ligament

13. Surgical approaches
• Direct lateral
• Posterolateral approach
• Peroneus & FHL

14. Surgical fixation techniques
• Lateral plating
• Interfragmentary lag screw
• at least 2x bicortical screws
proximal and 2x unicortical
screws distal

15. Surgical fixation techniques

16. Surgical fixation techniques
• Posterior (antiglide) plating

17. Surgical fixation techniques
• Distal fibular locked plating
• decreased bone stock
• severely comminuted fx

18. Treatment rationale
• What is stable and what
isn’t?
• How do you assess
stability?

19. Weber classification
• Level of fibular fracture
relative to the syndesmosis
• A = below syndesmosis
• B = level of syndesmosis
• C = above level of
syndesmosis

20. 1. Position of the foot
2. Deforming force

21. Assessment of stability
• the difference between
SER II and SER IV (40-
75% ankle #s)
• because SER II injuries do
well whether treated
operatively or otherwise
• whereas most SER IV #s
do better with an ORIF

22. Supination/Adduction

23. Pronation/External rotation
• Is it a PER injury?
• If “high” fibular fracture (Weber
C) = Yes
• ORIF

24. Principles of fixation
• Key goals are:
• stability
• articular congruity
• restoration of fibular length
and rotation
• Fix LM #
• interfragmentary lag screw +
neutralisation (1/3rd tubular)
plate
• bridging plate DCP/LCP
• Fix MM #
• 2x screws
• tension band wire
• Fix PM #

25. Diastasis screw - how
• Primary issues
• clamp reduction
• position 2-3cm above joint line
• position screw not compression
screw
• through plate if low enough
• Secondary issues
• 1 vs 2 screws
• 3.5mm vs 4.5mm screws
• 3 vs 4 cortices
• ankle position at time of
insertion
• post-op regimen

31. In Summary
• Isolated Weber B LM #s, no talar shift, no medial
signs = (probably) Stable
• Isolated Weber B LM #s, no talar shift, +ve medial
signs = Assess for stability
• Bimalleolar #s = ORIF
• Isolated Weber B LM #s with talar shift = ORIF
• Weber C LM #s = ORIF