Ankle fractures are common injuries that require careful evaluation to identify bony and soft tissue damage. The ankle is a complex hinge joint supported by ligaments and the tibia, fibula, talus, and deltoid ligament. Classification systems like Lauge-Hansen and Weber are used to characterize fracture patterns and guide treatment, which may involve closed management or surgery to restore ankle anatomy and stability. Restoring length and rotation of the fibula as well as stabilizing potential syndesmotic injuries is important for successful outcomes.

1. Ankle FracturesAnkle Fractures
Dr. Anshu Sharma,Dr. Anshu Sharma,
Orthopaedic Resident,Orthopaedic Resident,
MGMC&H, Jaipur.MGMC&H, Jaipur.

2.  Ankle is a complex hinge jointAnkle is a complex hinge joint
composed of the tibia, fibula,composed of the tibia, fibula,
talus and complextalus and complex
ligamentous system.ligamentous system.
 Distal tibial surface is referredDistal tibial surface is referred
to as the “plafond” which,to as the “plafond” which,
together with the medial andtogether with the medial and
lateral malleoli, forms thelateral malleoli, forms the
mortise.mortise.
 Talus articulates with the tibialTalus articulates with the tibial
plafond superiorly , posteriorplafond superiorly , posterior
malleolus of the tibiamalleolus of the tibia
posteriorly and medialposteriorly and medial
malleolus medially.malleolus medially.
 Lateral articulation is withLateral articulation is with
malleolus of fibula.malleolus of fibula.

3. -The talar dome is trapezoidal, with the anterior aspect 2.5mm wider than
the posterior talus.
-The body of talus is almost entirely covered by articular cartilage.
- The medial malleolus articulates with the medial facet of the talus and
divide into an anterior colliculus and a posterior colliculus, which provides
attachment to superficial and deep deltoid ligaments respectively.
-The tibiotalar articulation is considered to be highly congruent such that 1
mm talar shift within the mortise decreases the contact area by 42 %.

4. ANKLE JOINT IS SUPPORTED BYANKLE JOINT IS SUPPORTED BY
 Fibrous capsuleFibrous capsule
 Deltoid ligamentDeltoid ligament
A. SuperficialA. Superficial
a. Anterior-a. Anterior-
Tibionavicular,Tibionavicular,
b. Middle-b. Middle-
Tibiocalcaneal,Tibiocalcaneal,
c. Posterior-c. Posterior-
SupreficialSupreficial
Tibiotalar.Tibiotalar.
B. Deep : DeepB. Deep : Deep
Tibiotalar.Tibiotalar.

5.  Lateral ligamentLateral ligament
• Anterior-Anterior-
Talofibular,Talofibular,
• Posterior-Posterior-
Talofibular,Talofibular,
• Calcaneofibular.Calcaneofibular.

6. SYNDESMOTIC LIGAMENTSSYNDESMOTIC LIGAMENTS
 Anterior inferiorAnterior inferior
tibiofibular ligament,tibiofibular ligament,
 Posterior inferiorPosterior inferior
tibiofibular ligament,tibiofibular ligament,
 TransverseTransverse
tibiofibular ligament,tibiofibular ligament,
 InterosseousInterosseous
ligament.ligament.

8. BiomechanicsBiomechanics
 The normal ROM of Ankle:The normal ROM of Ankle:
-Dorsiflexion: 30*,-Dorsiflexion: 30*,
-Planter flexion: 45*.-Planter flexion: 45*.
 Motion analysis studies reveal that aMotion analysis studies reveal that a
minimum of 10* of dorsiflexion and 20* ofminimum of 10* of dorsiflexion and 20* of
planter flexion are required for normalplanter flexion are required for normal
gait.gait.
 The axis of flexion of the ankle runsThe axis of flexion of the ankle runs
between the distal aspect of two malleoli,between the distal aspect of two malleoli,
which is externally rotated 20* comparedwhich is externally rotated 20* compared
with knee axis.with knee axis.

9. INTRODUCTION
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.
The key to successful outcome following ankle fractures is
anatomic restoration and healing of ankle mortise.

10. Mechanism of InjuryMechanism of Injury
 Pattern of ankle fracture depends onPattern of ankle fracture depends on
many factors:many factors:
-Position of foot and direction of-Position of foot and direction of
force,force,
-Chronicity or recurrent trauma-Chronicity or recurrent trauma
leading to ligament injury or laxityleading to ligament injury or laxity
and distorted ankle biomechanics.and distorted ankle biomechanics.
-Patients age,-Patients age,
-Bone quality.-Bone quality.

11. Clinical EvalutionClinical Evalution
 Variable presentation (limp toVariable presentation (limp to
nonambulatory with severe pain, swellingnonambulatory with severe pain, swelling
and deformity)and deformity)
 Extent of soft tissue injury must beExtent of soft tissue injury must be
evaluated.evaluated.
 Neurovascular status should be carefullyNeurovascular status should be carefully
documented.documented.
 Entire length of fibula should be palpatedEntire length of fibula should be palpated
for tenderness.for tenderness.
 A dislocated ankle should be reduced andA dislocated ankle should be reduced and
splinted immediately.splinted immediately.

12. Radiographic EvaluationRadiographic Evaluation
Plain X-ray FilmsPlain X-ray Films::
•Anterio-posterior view of ankle,Anterio-posterior view of ankle,
•Lateral view of ankle,Lateral view of ankle,
•Mortise view of ankle,Mortise view of ankle,
•Stress views when required,Stress views when required,
•Image the entire tibia, ankle to kneeImage the entire tibia, ankle to knee
joint,joint,
•Foot films when tender to palpation.Foot films when tender to palpation.

13. 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.

14. •Tibiofibular overlapTibiofibular overlap
<10mm<10mm is abnormal –is abnormal –
implies syndesmotic injury.implies syndesmotic injury.
•Tibiofibular clear spaceTibiofibular clear space
>5mm>5mm is abnormal –is abnormal –
implies syndesmotic injury.implies syndesmotic injury.
•Talar tiltTalar tilt >2mm>2mm isis
considered abnormal.considered abnormal.
Consider a comparison with
radiographs of the normal side if there
are unresolved concerns of injury.

16. •Posterior mallelolarPosterior mallelolar
fractures can befractures can be
identified.identified.
•AP Talar subluxation:AP Talar subluxation:
Dome of the talus shouldDome of the talus should
be centered under the tibiabe centered under the tibia
and congruous with theand congruous with the
tibial plafond.tibial plafond.
•Associated injuriesAssociated injuries
to:to:
–Talus,Talus,
–Calcaneum.Calcaneum.

17.  AP view takenAP view taken
with ankle in 15-with ankle in 15-
20degrees of20degrees of
internal rotation.internal rotation.
 Useful inUseful in
evaluation ofevaluation of
articular surfacearticular surface
between talarbetween talar
dome and mortise.dome and mortise.
10 degrees internal rotation of 5th
MT with respect to a vertical line

18.  Medial clear spaceMedial clear space
• Between lateralBetween lateral
border of medialborder of medial
malleous and medialmalleous and medial
talus.talus.
<= 4mm is normal,<= 4mm is normal,
>4mm suggests>4mm suggests
lateral shift of talus.lateral shift of talus.

19. Consider a comparison with radiographs of the normal side if
there are unresolved concerns of injury.

20. Shenton’s Line of the Ankle.

21. • Stress ViewsStress Views
– Gravity stress viewGravity stress view
– Manual stress viewsManual stress views
• CTCT
– Joint involvement,Joint involvement,
– Posterior malleolarPosterior malleolar
fracture pattern,fracture pattern,
– Pre-operativePre-operative
planning,planning,
– Evaluate hindfoot andEvaluate hindfoot and
midfoot if needed.midfoot if needed.
• MRIMRI
– Ligament and tendonLigament and tendon
injury,injury,
– Syndesmosis injuries.Syndesmosis injuries.

22.  The ankle is a ringThe ankle is a ring
• Tibial plafondTibial plafond
• Medial malleolusMedial malleolus
• Deltoid ligamentsDeltoid ligaments
• calcaneouscalcaneous
• Lateral collateral ligamentsLateral collateral ligaments
• Lateral malleolusLateral malleolus
• SyndesmosisSyndesmosis
 Fracture of single partFracture of single part
usually stableusually stable
 Fracture > 1 part =Fracture > 1 part =
unstableunstable

23. Classification SystemClassification System
 Classification systems:Classification systems:
•Lauge-Hansen,Lauge-Hansen,
•Weber,Weber,
•OTA.OTA.
 Additional Anatomic Evaluation:Additional Anatomic Evaluation:
•Posterior Malleolar Fractures,Posterior Malleolar Fractures,
•Syndesmotic Injuries,Syndesmotic Injuries,
•Common Eponyms.Common Eponyms.

24. Lauge-Hansen ClassificationLauge-Hansen Classification
 Four Patterns are recognized, based on PURE injury sequences, eachFour Patterns are recognized, based on PURE injury sequences, each
subdivided into stages of increasing severity.subdivided into stages of increasing severity.
 Based on Cadaveric studies.Based on Cadaveric studies.
 First word: Position of foot at time of injuryFirst word: Position of foot at time of injury
 Second word: Force applied to foot relative to tibia at time of injury.Second word: Force applied to foot relative to tibia at time of injury.
Types:
SER
SAd
PER
PAb

25.  Several stages per type with increasing severity.Several stages per type with increasing severity.
 Imperfect system:Imperfect system:
• Not every fracture fits exactly into one categoryNot every fracture fits exactly into one category
• Even mechanismEven mechanismspecific pattern has been questionedspecific pattern has been questioned
• Inter and intraobserver variation not idealInter and intraobserver variation not ideal
• Still useful and widely usedStill useful and widely used
Remember the injury starts on the tight side of the ankle.!
The lateral side is tight in supination, while the medial
side is tight in pronation.

26. Supination-External RotationSupination-External Rotation
Accounts for 40 to 75% of
Malleolar fractures.
Stage 1- AITFL disruption,
Stage 2- Spiral # of Fibula,
Stage 3- PITFL disruption or
PM #,
Stage 4-Deltoid Ligament
disruption or transverse #
of MM

27. Standard: Closed management
Lateral Injury: classic posterosuperioranteroinferior fibula fracture
Medial Injury: Stability maintained

28. Lateral Injury: classic posterosuperioranteroinferior fibula fracture
Medial Injury: medial malleolar fracture &*/or deltoid ligament injury
Standard: Surgical management

29. GOAL: TO EVALUATE DEEP DELTOID [i.e. INSTABILITY]
METHOD: MEDIAL TENDERNESS
MEDIAL SWELLING
MEDIAL ECCHYMOSIS
STRESS VIEWS- GRAVITY OR MANUAL

30. + Stress View
Widened Medial Clear
Space
SE-4SE-4

31. Supination AdductionSupination Adduction
 Accounts for 10-20% ofAccounts for 10-20% of
Malleolar fractures.Malleolar fractures.
 Stage 1: Transverse # of FibulaStage 1: Transverse # of Fibula
(Weber A or B),(Weber A or B),
 Stage 2: Vertical medialStage 2: Vertical medial
malleolus #.malleolus #.

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

33. Pronation-External RotationPronation-External Rotation
 Accounts for 5 to 20% ofAccounts for 5 to 20% of
malleolar fractures.malleolar fractures.
 Stage 1 – Deltoid disruptionStage 1 – Deltoid disruption
or transverse # medialor transverse # medial
malleolus.malleolus.
 Stage 2- AITFL disruption.Stage 2- AITFL disruption.
 Stage 3 –Spiral # of fibulaStage 3 –Spiral # of fibula
(Weber C).(Weber C).
 Stage 4 – PITFL disruptionStage 4 – PITFL disruption
or posterior malleolus #.or posterior malleolus #.

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

35. • Must x-ray knee to ankle toMust x-ray knee to ankle to
assess injury.assess injury.
• Syndesmosis is disrupted inSyndesmosis is disrupted in
most cases.most cases.
-Eponym: Maissoneuve-Eponym: Maissoneuve
FractureFracture
• Restore:Restore:
– Fibular length andFibular length and
rotation,rotation,
– Ankle mortise,Ankle mortise,
– Syndesmotic stability.Syndesmotic stability.

36. Pronation-AbductionPronation-Abduction
 Accounts for 5 to 20% ofAccounts for 5 to 20% of
malleolar fractures.malleolar fractures.
 Stage 1 – Transverse # of MMStage 1 – Transverse # of MM
or deltoid ligament disruption,or deltoid ligament disruption,
 Stage 2 – PITFL disruption orStage 2 – PITFL disruption or
PM fracture.PM fracture.
 Stage 3 – CompressionStage 3 – Compression
bending of fibula leads tobending of fibula leads to
transverse or short obliquetransverse or short oblique
communited fracture.communited fracture.

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

38. Based on location ofBased on location of
fibula fracture relative tofibula fracture relative to
mortise and appearance.mortise and appearance.
 Weber A fibula belowWeber A fibula below
to mortise.(SAD)to mortise.(SAD)
 Weber B fibula at levelWeber B fibula at level
of mortise.(SER)of mortise.(SER)
 Weber C fibula aboveWeber C fibula above
to mortise.(PER)to mortise.(PER)
Concept - The higher theConcept - The higher the
fibula # the more severefibula # the more severe
the injury in terms ofthe injury in terms of
syndesmosis disruption.syndesmosis disruption.

39.  Alpha-NumericAlpha-Numeric
CodeCode
Tibia =4
Malleolar segment =4
Infrasyndesmotic=44A
Suprasyndesmotic=44C
Transsyndesmotic=44B
+
AO classification divides the three Danis Weber types further
for associated medial injuries.

40.  Alpha-NumericAlpha-Numeric
CodeCode
Infrasyndesmotic=44A

41.  Alpha-NumericAlpha-Numeric
CodeCode
Transsyndesmotic=44B

42.  Alpha-NumericAlpha-Numeric
CodeCode
Suprasyndesmotic=44C

43. Function:
Stability- Prevents posterior translation of talus &
enhances syndesmotic stability,
Weight bearing- increases surface area of ankle joint.

44. • Fracture pattern:Fracture pattern:
–VariableVariable
–Difficult to assess on standard lateralDifficult to assess on standard lateral
radiograph, so require:radiograph, so require:
• External rotation lateral viewExternal rotation lateral view
• CT scanCT scan

45. Type I- posterolateral oblique type Type II- medial extension type
Type III- small shell type
67% 19%
14%

46. FUNCTION:
Stability- Resists external rotation,
axial, & lateral displacement of talus
Weight bearing- Allows for equal
loading of weight.

47. • Maisonneuve Fracture
– Fracture of proximal fibula
with syndesmotic disruption.
• Volkmann Fracture
– Fracture of tibial attachment
of PITFL.
– Posterior malleolar fracture.
• Tillaux-Chaput Fracture
– Fracture of tibial attachment
of AITFL

48. Pott fracture:
In the Pott fracture, the fibula is
fractured above the intact distal
tibiofibular syndesmosis, the
deltoid ligament is ruptured, and
the talus is subluxed laterally.

49. Dupuytren fracture:
(A) This fracture usually
occurs 2 to 7 cm above
the distal tibiofibular
syndesmosis, with
disruption of the medial
collateral ligament and,
typically, tear of the
syndesmosis leading to
ankle instability.
(B) In the low variant,
the fracture occurs more
distally and the
tibiofibular ligament
remains intact.

50. Wagstaffe-LeFort
fracture:
In the Wagstaffe-LeFort
fracture,on the
anteroposterior view, the
medial portion of the fibula is
avulsed at the insertion of
the anterior tibiofibular
ligament. The ligament,
however, remains intact.

51. •Collicular FracturesCollicular Fractures
–Avulsion fracture ofAvulsion fracture of
distal portion of medialdistal portion of medial
malleolusmalleolus
–Injury may continueInjury may continue
and rupture the deepand rupture the deep
deltoid ligamentdeltoid ligament
•Bosworth fractureBosworth fracture
dislocationdislocation
–Fibular fracture withFibular fracture with
posterior dislocation ofposterior dislocation of
proximal fibularproximal fibular
segment behind tibia.segment behind tibia.
POSTERIOR COLLICULUS ANTERIOR COLLICULUS
INTERCOLLICULAR GROOVE

52. Tibial Pilon Fractures
The terms tibial plafond fracture, pilon fracture, and distal tibial
explosion fracture all have been used to describe intraarticular fractures
of the distal tibia.
Accounts for 7 to 10% of all tibia fractures.
Most common in men of 30-40 years.
These terms encompass a spectrum of skeletal injury ranging from
fractures caused by low-energy rotational forces to fractures caused by
high-energy axial compression forces arising from motor vehicle
accidents or falls from a height.

53. Source:Rosen
Rotational variants typically have a more favorable
prognosis, whereas high-energy fractures frequently are
associated with open wounds or severe, closed, soft-
tissue trauma.

54. -Because of their high energy nature, these fractures can be expected to
have specific associated injuries to calcaneum, tibial plateau, pelvis and
vertebral fractures.
-Swelling is often massive and rapid, required serial assessment of skin
integrity, necrosis and fracture blisters.
-Meticulous assessment of soft tissue damage is of paramount
importance.
-Some advise waiting 7 to 10 days for soft tissue healing to occur before
planning surgery.

56.  Ruedi and AllgowerRuedi and Allgower
classification:classification:
-Based on the severity of-Based on the severity of
comminuation and displacement ofcomminuation and displacement of
the articular surface.the articular surface.
-Poor prognosis with increasing-Poor prognosis with increasing
grade.grade.
Type I- Nondisplaced cleavageType I- Nondisplaced cleavage
fracture of ankle joint.fracture of ankle joint.
Type II- Displaced fracture withType II- Displaced fracture with
minimal impaction or comminution.minimal impaction or comminution.
Type III- Displaced fracture withType III- Displaced fracture with
significant articular comminutionsignificant articular comminution
and metaphyseal impaction.and metaphyseal impaction.

57. CLASSIFICATION OF ANKLE FRACTURES IN CHILDREN
Salter-Harris anatomic classification as applied to injuries of the distal
tibial epiphysis.

58. Ankle Fracture in Children
(Dias-Tachdjian classification)

59. TreatmentTreatment
 In Emergency Room Rx:In Emergency Room Rx:
-Closed reduction for displaced #,-Closed reduction for displaced #,
-Dislocated ankle should be reduced,-Dislocated ankle should be reduced,
-Open wounds and abrasions should be-Open wounds and abrasions should be
cleansed and dressed,cleansed and dressed,
-Following fracture reduction a well padded-Following fracture reduction a well padded
posterior slab should be applied,posterior slab should be applied,
-Postreduction radiographs should be-Postreduction radiographs should be
obtained for fracture asessment.obtained for fracture asessment.
-Limb must be elevated for reducing-Limb must be elevated for reducing
swelling.swelling.

60. Non- operative RxNon- operative Rx
 Indications:Indications:
-Nondisplaced, stable fractures,-Nondisplaced, stable fractures,
-Displaced fracture for stable anatomic reduction-Displaced fracture for stable anatomic reduction
of ankle mortise is achieved.of ankle mortise is achieved.
-Patient not fit for surgery.-Patient not fit for surgery.
 Apply well padded posterior splint for first fewApply well padded posterior splint for first few
days while swelling subsides with limb elevation.days while swelling subsides with limb elevation.
 Then apply cast with good padding for 4 to 6Then apply cast with good padding for 4 to 6
weeks with serial radiographic evaluation toweeks with serial radiographic evaluation to
ensure maintenance of reduction and fractureensure maintenance of reduction and fracture
healing.healing.
 If adequate fracture healing is present patientIf adequate fracture healing is present patient
can be placed in a short leg cast.can be placed in a short leg cast.
 Weight bearing is restricted until fracture healingWeight bearing is restricted until fracture healing
is adequate.is adequate.

61. Operative RxOperative Rx
 Majority of unstable fracture are bestMajority of unstable fracture are best
treated operatively.treated operatively.
 ORIF is indicated for:ORIF is indicated for:
-Failure to achieve or maintain closed-Failure to achieve or maintain closed
reduction (may be due to soft tissue interreduction (may be due to soft tissue inter
position),position),
-Unstable fracture,-Unstable fracture,
-Fractures that require abnormal fot-Fractures that require abnormal fot
positioning to maintain reduction( extremepositioning to maintain reduction( extreme
planter flexion),planter flexion),
-Open fractures.-Open fractures.

62.  ORIF should be performed when patientsORIF should be performed when patients
general medical condition, swelling aroundgeneral medical condition, swelling around
ankle and soft tissue status allow.ankle and soft tissue status allow.
 Usually swelling, blisters and soft tissueUsually swelling, blisters and soft tissue
issues stabilize within 7 to 10 days.issues stabilize within 7 to 10 days.
 Occasionally , a closed fracture withOccasionally , a closed fracture with
severe soft tissue trauma and swellin maysevere soft tissue trauma and swellin may
require reduction and stabilization withrequire reduction and stabilization with
external fixation to allow soft tissueexternal fixation to allow soft tissue
management before definitive fixation.management before definitive fixation.

63.  Lateral malleolar fracturesLateral malleolar fractures
distal to syndesmosis: lagdistal to syndesmosis: lag
screw or k- wire withscrew or k- wire with
tension banding.tension banding.
 Lat. Malleolar fractures atLat. Malleolar fractures at
or above syndesmosisor above syndesmosis
require accurate reductionrequire accurate reduction
and restoration of fibularand restoration of fibular
length: combination of laglength: combination of lag
screws and plate.screws and plate.

64.  For Medial malleolar fracturesFor Medial malleolar fractures
ORIF indications are:ORIF indications are:
-Fracture with syndesmotic-Fracture with syndesmotic
injury,injury,
-Persistent widening of medial-Persistent widening of medial
clear space following fibulaclear space following fibula
reduction,reduction,
-Inability to obtain adequate-Inability to obtain adequate
fibular reduction,fibular reduction,
-Persistent medial fracture-Persistent medial fracture
displacement after fibulardisplacement after fibular
fixation.fixation.
Usually stabilized withUsually stabilized with
cancellous screw or a figure ofcancellous screw or a figure of
8 tension band.8 tension band.

65.  Indication for fixation of posteriorIndication for fixation of posterior
malleolar fracture are:malleolar fracture are:
-Involvement of >25% of articular surface,-Involvement of >25% of articular surface,
-> 2mm displacement,-> 2mm displacement,
-Persistent posterior subluxation of talus.-Persistent posterior subluxation of talus.
 Fixation is achieved by indirect reductionFixation is achieved by indirect reduction
and placement of an anterior to posteriorand placement of an anterior to posterior
lag screw or a posteriorly placed plate.lag screw or a posteriorly placed plate.

66. Posterior Malleolus Fracture:Posterior Malleolus Fracture:
FixationFixation
 ScrewsScrews
 PlatesPlates

67. Syndesmotic Injury RxSyndesmotic Injury Rx
 Fibular fractures above the plafond mayFibular fractures above the plafond may
require syndesmotic stabilization.require syndesmotic stabilization.
 After fixation of the medial and lateralAfter fixation of the medial and lateral
malleoli, the syndesmosis should bemalleoli, the syndesmosis should be
stressed intra-operatively by lateral pullstressed intra-operatively by lateral pull
on the fibula with a bone hook or byon the fibula with a bone hook or by
stressing the ankle in external rotation.stressing the ankle in external rotation.
 Syndesmotic instability can then beSyndesmotic instability can then be
recognised clinically and under C-arm.recognised clinically and under C-arm.

68.  Distal tibia-fibulaDistal tibia-fibula
joint reduction isjoint reduction is
held with a largeheld with a large
pointedpointed
reduction clamp.reduction clamp.
 Now aNow a
syndesmoticsyndesmotic
screw is placedscrew is placed
1.5 to 2.0 cm1.5 to 2.0 cm
above theabove the
plafond from theplafond from the
fibula to thefibula to the
tibia.tibia.

69. Syndesmotic Screw ControversySyndesmotic Screw Controversy
 3.5 mm vs 4.5 mm3.5 mm vs 4.5 mm
screw(s)screw(s)
 3 cortices vs 4 cortices3 cortices vs 4 cortices
 Retain vs RemovalRetain vs Removal
 Metallic vs BioabsorbableMetallic vs Bioabsorbable

70. TIBIAL PILON FRACTURE RxTIBIAL PILON FRACTURE Rx
1.1. Plaster immobilizationPlaster immobilization
2.2. TractionTraction
3.3. Lag screw fixationLag screw fixation
4.4. OR & IF with platesOR & IF with plates
5.5. External fixation with orExternal fixation with or
without limited internalwithout limited internal
fixation.fixation.
Wait for 7 to 10 days for soft
tissue healing to occur before
planning surgery.
If articularIf articular
incongruity <2 mmincongruity <2 mm
and reserved for lowand reserved for low
energy injuries .energy injuries .

72. ComplicationsComplications
 PerioperativePerioperative
• MalreductionMalreduction
• Inadequate fixationInadequate fixation
• Intra-articular hardware penetrationIntra-articular hardware penetration
 Early PostoperativeEarly Postoperative
• Wound edge dehiscence/necrosis,Wound edge dehiscence/necrosis,
• Infection,Infection,
 LateLate
• Stiffness,Stiffness,
• Persistent oedema,Persistent oedema,
• Malunion,Malunion,
• Nonunion,Nonunion,
• Post-traumatic arthritis,Post-traumatic arthritis,
• Hardware related complications.Hardware related complications.

73. COMPLICATIONSCOMPLICATIONS