This document discusses ankle fractures, including their classification, clinical assessment, treatment options, and outcomes. Ankle fractures represent 10% of all fractures and are typically caused by falls or sports injuries. Assessment involves history, exam, and imaging to classify the fracture. Treatment depends on the specific fracture but may involve immobilization, surgery, or a combination. Most patients recover well, though complications can include infection, loss of reduction, or post-traumatic osteoarthritis.

1. Ankle Fractures
Dr. Mohammad Mahdi Shater
Orthopedic Surgery Resident
Baqiyatallah University of Medical Sciences
‫الرحیم‬ ‫الرحمن‬ ‫اهلل‬ ‫بسم‬
Rockwood and Green's Fractures in Adults

2. Introduction
 Ankle fractures represent 10% of all fractures
 The second most common lower limb fractures after hip fractures
 typically low-energy injuries with the majority occurring due to simple falls or
sport
 Increase of Incidence
 Alcohol and Obesity

3. Pathoanatomy, Applied Anatomy, and
Biomechanics
 Anatomy(Bone,Symdesmosis,ATFL,PTFL)

4. Pathoanatomy, Applied Anatomy, and
Biomechanics
 Anatomy(Bone,Symdesmosis,ATFL,PTFL)

5. Pathoanatomy, Applied Anatomy, and
Biomechanics
 Anatomy(Capsule,ligament)

6. Pathoanatomy, Applied Anatomy, and
Biomechanics
 Anatomy(Muscle, Soft tissue)

7. Assessment (Classification )
 Pott Classification
unimalleolar, bimalleolar, or trimalleolar based on the combined fractures of the
lateral, medial, and posterior malleoli
 Danis–Weber Classifications
A, B, or C with a fracture below, at the level of, or above the syndesmosis
 OA/OTA Classifications

8. Assessment (Classification )

9. Assessment (Classification )

10. Assessment (Classification )

11. Assessment (Classification )

12. Assessment (Classification )
 Lauge–Hansen Classification
It employs two words and a number. The first word describes the position of the
foot at the time of fracture (supination or pronation), the second the deforming
force at the ankle (abduction, adduction, internal rotation, or external rotation).
There are four resulting classes of injury: supination external rotation (SER),
pronation external rotation (PER), supination adduction (SAD), and pronation
abduction (PAB)

13. Assessment (Classification )

14. Eponymous Terms
 Volkmann's fracture
 Maisonneuve fracture

15. Clinical Assessment
 detailed history
 physical examination
 radiographic imaging(anteroposterior (AP), a lateral, and a mortise, CT scan, MRI)
 Ottawa ankle rules

16. Clinical Assessment

17. Clinical Assessment

18. Clinical Assessment
 Ball sign

19. Clinical Assessment
 Instability criteria
lateral malleolus displacement of more than 2 mm, with Talus shift in radiography
Medial malleolus displacement
Deltoid rupture (medial clear space>5mm)
Syndesmosis rupture

20. Clinical Assessment
 Syndesmosis Repture
 AP :
tibial fibular clear space>5mm
tibial fibular overlap<10mm
 Mortise:
tibial fibular overlap<1mm
Lat:
Ant/post sublaxation

21. Treatment options
 Isolated Lateral Malleolar Fractures
Truly isolated lateral malleolar fractures are stable, do not result in tibiotalar incongruence, and can
be treated conservatively.
A number of methods have been shown to be satisfactory including below-knee weight-bearing
casts, elasticated bandaging, air stirrup devices ankle braces and stabilizing shoes.
No significant differences have been found in outcome beyond 3 months between these
treatment options.

22. Treatment options
 Author’s Preferred Management
Patients with an apparently isolated lateral malleolar fracture and a congruent mortise on their
initial radiographs are provided with a functional brace and allowed to mobilize fully weight
bearing regardless of the presence or absence of medialsided bruising or swelling.
They are reviewed at 1 and 6 weeks postinjury with AP and lateral radiographs.
Neither stress views nor MRI are used routinely.
If any talar shift is revealed, the patient is advised to undergo operative fixation of the fibula (but
not the deltoid ligament). Otherwise they are discharged to physiotherapy rehabilitation at 6
weeks.

23. Treatment options
 Isolated Medial Malleolar Fractures
isolated medial malleolar fractures can generally be managed nonoperatively Immobilization
consisted of a below-knee non–weightbearing cast for 6 weeks followed by progressive weight
bearing and physiotherapy.

24. Treatment options
 Isolated Medial Malleolar Fractures

25. Treatment options
 Posterior malleolar Fractures
Posterior talar subluxation is thought to occur due to the loss of the posterior malleolus as a
stabilizing structure.
Ankle fracture involving more than 25% of the posterior malleolus should be managed operatively.
The majority of cases are stabilized with percutaneous anterior to posterior screws.
Large or irreducible fragments are treated with posterior plating

26. Treatment options
 Syndesmotic Injurie
Diastasis requires the rupture of three strong ligaments and the interosseous Membrane Patients
at particular risk of persistent syndesmotic instability include the PER fracture with a deltoid
ligament rupture (i.e., the high AO/OTA type C fracture or Maisonneuve fracture).
have been suggested to correlate with syndesmotic rupture:
The most commonly used are a tibiofibular clear space (“syndesmosis A”) of greater than 5 mm
and a tibiofibular overlap (“syndesmosis B”) of less than 5 mm on the AP view or of less than 1 mm
on the mortise view.
The tibiofibular clear space is the most reliable of these parameters.

29. Outcomes
 most patients do well following an ankle fracture. Eighty-eight percent are pain free or have
only mild pain at 1 year, and 90% have no restrictions or only mild recreational limitations. A
substantial improvement is generally seen between 6 months and 1 year after injury

30. Adverse Outcomes and Unexpected
Complications
 Common Adverse Outcomes and Complications
 Wound infection/dehiscence
 Loss of reduction
 Thromboembolism
 Symptomatic hardware
 Osteoarthritis
 Nonunion
 Compartment syndrome
 Neuroma