The document discusses the evaluation and management of ankle fractures, including indications for imaging like x-rays, CT, and MRI to classify fracture patterns. Both non-operative and operative treatment options are covered, with operative fixation recommended for unstable or displaced fractures. Potential complications of ankle fractures such as malunion, nonunion, infection, and post-traumatic arthritis are also reviewed.

1. Presenter : Dr.sunil santhosh .g
Moderator :Dr.Y.Sivaprasad

2.  Radiography
 CT
 MRI

3.  Assists in ordering X-rays in pt.’s with ankle injury.
 Ankle X-rays needed only if there is pain near the
malleoli with one or more of following,
a) age >55
b) inability to bear wt
c) bone tenderness at posterior edge or tip of either
malleolus.
 Nearly 100% sensitivity.
 Useful in reducing no. of x-rays in trauma setting.

4.  Antero-posterior
 Mortise
 Lateral

5.  Identifies fractures of malleoli,

distal tibia/fibula,
talar dome,
body and lateral process of talus,

6.  Tibiofibular clear space:
<5mm
 Tibiofibular over lap:
>10mm
 Talar Tilt: difference in
width of med &lat aspect
of joint–
<2mm

7. Foot in 15-20
degrees internal
rotation
Evaluate articular
surface between talar
dome and mortise

8.  Medial clear space:
<4mm
 Tibiofibular overlap:
>1mm

9. •Posterior mallelolar fractures
•AP talar subluxation
•Distal fibular translation
&/or angulation
•Associated or occult injuries
–Lateral process talus
–Posterior process talus
–Anterior process calcaneus

10.  Talocrural angle :
Btn 8-15 degrees &
within 2-3 deg of opp
ankle
Talar tilt: angle formed
b/n line Drawn parallel
to articular surface &
Talar surface – they
should be parallel to
each other

11.  CT
 Articular involvement
 Joint involvement
 Posterior malleolar fracture pattern
 Pre-operative planning
 Evaluate hindfoot and midfoot if needed
 MRI
◦ Ligament and tendon injury
◦ Talar dome lesions
◦ Syndesmosis injuries

12.  Stability may be defined as the combination of
insufficient fracture displacement to compromise
long-term function and the ability of the injured
ankle to withstand routine physiologic forces
without further displacement
 In stable ankle # Talus is centered Does not shift
with stress
 Presence or absence of Medial injury is key to the
stability of Lateral malleolar #

13. Biomechanical studies in an axially loaded
ankle model indicate that
 despite fracture of the fibula and complete
disruption of the anterior and posterior
syndesmosis, in the absence of a medial side
injury, the talus remains stable and centered
in the mortise .

14.  Non-operative :
Indications
 Non displaced Stable # & intact Syndesmosis
 Displaced # if stable Anatomic mortise is
achieved
 Those not Surgically fit

15.  Patients with Stable # Pattern can be
maintained in short leg cast &allowed to
weight bear as tolerated
 Those with un-stable # pattern are placed in
long leg cast for 4-6 weeks to maintain
rotational control Once adequate healing is
demonstrable can be shifted to short leg cast
but they are best treated opreratively.

16. Open reduction & Internal fixation is indicated in :
 Failure to achieve or maintain Closed reduction
 Unstable # with talar displacement or
Widened Ankle mortise
 # that require abnormal foot position for
reduction
 Open fractures

17. Indications :
 If Fibular displacement is >3mm
 # Within 5cms of Ankle joint
 Talar displacement
 Complete deltoid ligament rupture
 Associated with Bi or trimalleolar #

18.  Fibula # is fixed first If associated with medial or
posterior malleolar # except when it is severely
communited.
 It is exposed by either Lateral longitudinal or
postero-lateral approach
 Care to be taken to avoid superficial peroneal
nerve injury

19.  IF # is below the
syndesmosis it is
stabilised by using
a lag screw or k-
wires with tension
banding
 If # above
syndesmosis is
fixed with 1/3
semitubular plate
& screw fixation

20.  If # is a long oblique
- fixed with two lag
screws in a-p
direction to achieve
compression & must
be engaged to post
cortex .
 If # is Transverse
Intramedullary device
like rush nail,
Intramedullary screw
can be used.

21. Indications :
 Associated syndesmotic injury
 Widening of medial clearspace after Fibular
fixation.
 Inability to attain fibular reduction
 Persistent Medial # displacement after fibular
fixation

22.  Approached through Antero-medial incision
 Usually fixed using Two 4 mm cancellous lag
screws perpendicular to # line

23.  Alternatively
Fixation can be
done by using
Tension Band wiring
if # fragment is
small
 If associated with
Proximalcommuniti
on then Butress
plate is used to
maintain reduction

24.  In this both Medial & Lateral stabilizing
Structures of the ankle joint are lost .
 Usually Treated with ORIF of Both malleoli as
there is more chance of non-union with
Closed reduction .

25.  In this Bimalleolar # is associated with # of
Posterior tibial lip
 Results are usually poor Compared to bi-
malleolar #

26. Indications :
 If Involment is> 25% of Articular surface
 > 2mm Displacement
 Persistent Posterior subluxation of talus
Reduction is achieved in this by using either by
direct or indirect technique

27.  In Indirect Approach ,
Screw is passed
Anterior to posterior &
inter fragmentary
compression is
achieved .
 In Direct approach
Screw or Plate fixation
is done posterior to
anterior direction
through postero lateral
incision .

28.  Syndesmotic injuries are most commonly caused
by prn–ext rotation, prn-abdc and
infrequently,supn–ext rotation mechanisms
(Danis-Weber type C and type B injuries).
 These forces cause talus to abduct or rotate
externally in the mortise, leading to disruption
of the syndesmotic ligaments.

29. Indications :
 syndesmotic injuries associated with
proximalfibular and that involve a medial
injury that cannot be stabilized and
 syndesmotic injuries extending more than 5
cm proximal to the plafond.
Integrity of syndesmosis is confirmed by
Extrernal rotation stress test & Cotton test

30.  screws or oblique pins inserted through the
lateral malleolus and into the distal tibia.
 The screw should be positioned 2 to 3 cm
proximal to the tibial plafond,
 Directed parallel to the joint surface, and
 angled 30 degrees anteriorly so that it is
perpendicular to the tibiofibular joint.

31.  Two screws have been found to provide more
stability than fixation with one screw
 Screws should engage both cortex of fibula &
one or two cortex of fibula

32.  Occurs supination -external rotation of the foot.
 X-ray AP view shows tilting of talus & Increased
medial clear space Under stress
 Accepted RX is ORIF of Fibula with ligament
repair to maintain ankle mortise.

33.  Through Ant-medial approach
 Deltoid ligament identified
 Deep part Identified by opening tibialis post
sheath
 Ligament repaired by suturing it to neck &
body of Talus Diagonally

34. ◦ Treat with appropriate antibiotics pre-op and 48
hr post-op
◦ I & D with immediate ORIF if clean wound
◦ ORIF and Ex Fix if severe soft tissue damage
present to allow for wound care
◦ Low grade open # results similar to closed
fractures

35. • Perioperative
– Malreduction
– Inadequate fixation
– Intra-articular hardware penetration
• Early Postoperative
– Wound edge dehiscence/necrosis
– Infection
– Compartment syndrome
• Late
– Stiffness
– Distal tibiofibular synostosis
– Malunion
– Nonunion
– Post-traumatic arthritis
– Hardware related complications
– Complex regional pain syndrome type 1

36. Malunion
◦Usually associated with
shortened or malrotated distal
fibula
◦Failure to reduce the
syndesmotic injury
◦Treated with fibular lengthening
and/or derotational osteotomy
+/- syndesmotic fixation
◦Ankle fusion for advanced
arthrosis or osteotomy failure

37.  Non-union
◦ Usually involving the medial malleolus due to
soft tissue (i.e. posterior tibial tendon)
interposition
◦ Treated with electrical stimulation, ORIF, bone
graft, or excision of fragment
◦ Patient may have co-morbidities such as
diabetes, peripheral vascular disease or smoking

38.  Wound problems
◦ Edge necrosis (3%)
◦ Dehiscence
 Risk is decreased by minimizing swelling, not
using a tourniquet, and careful atraumatic soft
tissue handling
 ORIF in the presence of fracture blisters and larger
abrasions have more than twice the average wound
complication rate.

39.  Infection
◦ Occurs in less than 2% of closed fractures
◦ Increased incidence in Diabetics, Age > 50, and
Alcoholics
◦ Treated with antibiotics
◦ Implants usually left in place to maintain stability for
optimal soft tissue perfusion
◦ May require serial debridements +/- VAC dressing
◦ Arthrodesis used as a salvage procedure

40.  Post traumatic
arthrosis
secondary either to
articular damage at
the
time of injury or
inadequate reduction
resulting in abnormal
mechanics.

41.  Tibiofibular synostosis
◦ associated with syndesmotic screw use and
is usually asymptomatic

42. Reference:
Campbell,
Rockwood,
Hand book of #,
Net.