The document discusses ankle fractures, providing information on ankle anatomy, classification systems, clinical features, imaging, treatment, and complications. It describes the ankle joint as composed of the tibia, fibula, and talus bones. Two common classification systems are described - the Weber system categorizes fractures by the location of the fibular fracture in relation to the syndesmosis, while the Lauge-Hansen system depends on the mechanism of injury. Clinical features may include pain, swelling, limited movement, and neurovascular issues. Imaging includes x-rays and sometimes CT or MRI to evaluate bone and soft tissue injuries. Treatment involves initial stabilization followed by casting or surgery to restore anatomy, with goals of preventing post-traumatic arthritis

1. ANKLE
FRACTURE

2. ANKLE ANATOMY
 Ankle is a three bone joint composed of the
tibia , fibula and talus
 Talus articulates with the tibial plafond
superiorly , posterior malleolus of the tibia
posteriorly and medial malleolus medially
 Lateral articulation is with malleolus of fibula

4. Anatomy: Lateral Side
Medial view of fibula
Articular surface
Malleolar fossa
Lateral Ridge
Lateral Ligamentous Complex

5. Ankle Fracture
 Ankle fractures are among the most common injuries and management of
these fractures depends upon careful identification of the extent of bony
injury as well as soft tissue and ligamentous damage.
 Once defined, the key to successful outcome following rotational ankle
fractures is anatomic restoration and healing of ankle mortise.
 The male-to-female ratio for ankle fracture is 2:1

6. Fracture Stability
•Isolated medial or lateral malleolar fracture •Usually stable
•Posterior malleolus fracture (refers to
the posterior tibia)
•Usually unstable, as often associated with other
malleolar fractures
•Bimalleolar fracture (both medial and lateral
malleolus)
•Mostly unstable
•Trimalleolar fracture (medial, lateral and posterior mall
leolus)
•Always unstable

7. CLASSIFICATION
 2 Common Classifications
1. Weber Classification
2. Lauge Hansen Classification
The Weber classification categorizes ankle fractures according to the level of the
fibular fracture in relation to the ankle syndesmosis .
(a) Below syndesmosis (b) Level of syndesmosis
(c) Above level of syndesmosis

8. Weber A: fracture of the lateral malleolus
below the syndesmosis (intact syndesmosis,)
Usually stable.
Weber B: fracture of the lateral malleolus at
the level of the syndesmosis (possible
syndesmotic injury)Variable stability.
Weber C: fracture of the lateral malleolus
above the syndesmosis (ruptured syndesmosis,
torn interosseous membrane), Unstable.
Maisonneuve fracture: proximal subcapital
Weber C fracture; rupture of the syndesmosis
(definite lesions in red); medial malleolus
fracture and/or deltoid ligament tear (possible
lesions in blue) , Unstable

9. Lauge-Hansen(Depends
on the mechanism of
Injury)
Types:
Supination External Rotation
Supination Adduction
Pronation External Rotation
Pronation Abduction
•based on foot position and force of applied
stress/force
•has been shown to predict the observed (via MRI)
ligamentous injury in less than 50% of operatively
treated fracture

10. Supination-External Rotation
Stage 1 Anterior tibio- fibular
ligament
Stage 2 Fibula fracture
Stage 3 Posterior malleolus
fracture or posterior tibio-fibular
ligament
Stage 4 Deltoid ligament tear or
medial malleolus fracture

11. Supination-External
Rotation
Stage 2: Stable
Lateral Injury: classic posterosuperioranteroinferior fibula fracture
Medial Injury: Stability maintained

12. • Stage 1: fibula fracture is transverse
below mortise.
• Stage 2: medial malleolus fracture is
classic vertical pattern.
Supination Adduction
1
2

13. Supination Adduction: Stage 2
Lateral Injury: transverse fibular fracture at/below level of mortise
Medial injury: vertical shear type medial malleolar fracture

14.  Stage 1 Deltoid
ligament tear or
medial malleolus
fracture
 Stage 2 Anterior
tibio-fibular
ligament and
interosseous
membrane
 Stage 3 Spiral,
proximal fibula
fracture
 Stage 4 Posterior
malleolus fracture
or posterior tibio-
fibular ligament
Pronation-External Rotation

15. Pronation External Rotation: Stage 4
Medial injury: deltoid ligament tear &/or transverse medial malleolar fracture
Lateral Injury: spiral proximal lateral malleolar fracture
HIGHLY UNSTABLE…SYNDESMOTIC INJURY COMMON

16.  Stage 1 Transverse
medial malleolus fracture
distal to mortise
 Stage 2 Posterior
malleolus fracture or
posterior tibio-fibular
ligament
 Stage 3 Fibula fracture,
typically proximal to
mortise, often with a
butterfly fragment
Pronation-Abduction

17. Pronation-Abduction
Medial injury: tranverse to short oblique medial malleolar fracture
Lateral Injury: comminuted impaction type distal lateral malleolar fracture

18. CLINICAL FEATURES
• Local pain, swelling and hematoma
• Tenderness, especially in the area of the malleoli,
the syndesmosis and the posterior aspect of the ankle
joint
• Restricted range of movement
• Skin abnormalities (lacerations, discolorations, tenting,
or blistering)
• In some cases, accompanying injury (e.g., fracture of
the proximal fibula, knee, or foot)
Parts of the distal tibia can be seen protruding
from an 8 cm long wound above the medial
ankle. The foot is in a slightly pronated position.
X-ray findings show a distal fibula fracture at the
level of the syndesmosis (Weber B fracture).

19. MEHANISM OF INJURY
 Pattern of ankle fracture depends on many factors;
Position of foot and direction of force,
Chronicity or recurrent trauma leading to ligament injury
or laxity and distorted ankle biomechanics.
Patients age,
Bone quality

20. CLINICAL EVALUATION
 Variable presentation (limp to nonambulatory with severe pain,
swelling and deformity)
 Extent of soft tissue injury must be evaluated.
 Neurovascular status should be carefully documented.
 Entire length of fibula should be palpated for tenderness.
 A dislocated ankle should be reduced and splinted immediately.

21. • Ottawa ankle rules: used to indicate whether x-ray for ankle and
midfoot injuries is necessary X-ray (plain) of the ankle is indicated
when the patient experiences pain in the malleolar region and has one
one of the following features
• Tenderness at the posterior border or tip of the lateral malleolus
• Tenderness at the posterior border or tip of the medial malleolus
• Inability to bear weight

22. RADIOGRAPHIC EXAMINATION
 Plain X-ray Films:
•Anterio-posterior view of ankle
•Lateral view of ankle
•Mortise view of ankle
•Stress views when required
•Image the entire tibia, ankle to knee joint,
•Foot films when tender to palpation.

23.  On the anteroposterior view:-
 -The distal tibia and fibula, including the medial and
lateral malleoli, are well demonstrated.
 -Important note is that the fibular (lateral) malleolus is
longer than the tibial (medial) malleolus.
 -This anatomic feature, important for maintaining
ankle stability, is crucial for reconstruction of the
fractured ankle joint.
 -Even minimal displacement or shortening of the
lateral malleolus allows lateral talar shift to occur and
may cause incongruity in the ankle joint, possibly
leading to posttraumatic arthritis.

24. ANTEROPOSTERIOR VIEW
 Tibiofibular overlap
<10mm is abnormal – implies syndesmotic injury.
 Tibiofibular clear space
>5mm is abnormal – implies syndesmotic injury.
•Talar tilt
>2mm is considered abnormal.

25. LATERALVIEW
 Posterior malleolar fractures
can be identified.
 AP Talar Subluxation : Dome
of the talus should be centered
under the tibia and congruous
with the tibial plafond
 Associated injuries to
: Talus
: Calcaneum

26. MORTISE X-RAY
 The mortise view is about 15 degree of Internal
rotation.
 Useful in evaluation of articular surface between
talar dome and mortise.
 Medial Clear Space
- Between lateral border of medial malleolus and
medial talus
< = 4mm is Normal
>4mm suggests lateral shift of talus

27. Ankle fracture with displacement
Lateral radiograph of the
ankle:
Ankle fracture with
displacement of the talus (Ta)
in relation to the tibia (Ti).
The shaded area represents
the physiological, anatomical
position of the talus: talus and
tibia usually form the
talocrural joint. Because of
the displacement of the talus
(green line), the joint cannot
function normally.

28. OTHER IMAGING MODALITIES
 CT views
- Joint involvement
- Posterior malleolar fracture pattern
- Pre-operative planning
- Evaluate hindfoot and midfoot it needed
 MRI
-Ligament and tendon injury
- Syndesmosis injuries

29. TREATMENT
• Initial management: rest, ice, compression, and elevation
• Conservative treatment
• Indications: stable fractures (isolated/nondisplaced malleolar fractures)
• Short leg cast for 4–6 weeks
• Surgical treatment: to ensure normal alignment of bone and cartilage to prevent ankle arthritis
and to regain functionality
• Indications: unstable/displaced fractures, open ankle fractures, and cases of neurovascular damage
• Technique: reposition and internal or external fixation with metal plates and/or screws
• Aim of the operation is to ensure anatomical reduction of the ankle-mortise.This means
ensuring anatomical reduction of medial and lateral malleoli,and reduction of the talus
accurately within the mortise
 Unstable fractures require surgery, most often an open reduction and internal
fixation (ORIF), which is usually performed with permanently implanted metal hardware
that holds the bones in place while the natural healing process occurs.
A cast or splint will be required to immobilize the ankle following surgery

30.  Fractures with displacement
Aim of the operation is to ensure anatomical reduction of the ankle-
mortise.This means ensuring anatomical reduction of medial and lateral
malleoli,and reduction of the talus accurately within the mortise

31. WEBER B FRACTURE OF THE UPPER RIGHT ANKLE AFTER SURGERY
Posteroanterior X-ray of the right upper ankle: The fibula
fracture was treated by internal fixation by plate
osteosynthesis. An adjusting screw is used to fix the position
of the joint until healing of the syndesmotic injury is
achieved.

32. WEBER B FRACTURE OF THE UPPER RIGHT ANKLE POST-SURGERY
X-ray of the upper right anke (lateral view):
internal fixation using plate osteosynthesis and
an adjusting screw

33. COMPLICATIONS
 General complications of Fracture
• Damage to the peroneal nerve or saphenous nerve
• Post-traumatic osteoarthritis

34. REFERENCE
 http://rad.desk.nl/en/p420a20ca7196b/ankle-fracture-weber-and-lauge-
hansen-classification.html
 https://www.physio-pedia.com/Ankle_and_Foot_Fractures
 https://www.orthobullets.com/trauma/1047/ankle-fractures
 https://app.pulsenotes.com/surgery/orthopaedics/notes/ankle-fractures
 https://www.hss.edu/condition-list_ankle-fractures.asp
 https://orthoinfo.aaos.org/en/diseases--conditions/ankle-fractures-broken-
ankle/

35. Thank you