This document provides an overview of ankle fracture patterns, classifications, radiographic evaluation, treatment approaches, and postoperative management. Key points include that ankle fractures can be classified anatomically or using the Lauge-Hansen system, radiographs include stress views to assess ligament injuries, treatment depends on fracture displacement and stability, and goals are anatomic reduction and fixation to restore the ankle mortise. Complications include wound issues, infection, and post-traumatic arthritis.

3. • Injury patterns
 Isolated medial malleolus fracture
 Isolated lateral malleolus fracture
 Bimalleolar fracture
 Posterior malleolus fractures
 Bosworth fracture-dislocations
 Open ankle fractures
 Associated/Isolated syndesmosis injuries

4. • Radiographs
 AP, Lateral and Obliques
 External rotation stress radiograph
 Most appropriate stress radiograph to assess competency of
deltoid ligament
 A medial clear space of >5mm with external rotation stress
applied to a dorsiflexed ankle is predictive of deep deltoid
disruption
 More sensitive to injury than medial tenderness, ecchymosis, or
edema

5. • Radiographic measurements
 Talocrural angle
 measured by bisection of line through tibial anatomical axis and
another line through the tips of the malleoli
 shortening of lateral malleoli fractures can lead to increased
talocrural angle
 Talocrural angle is not 100% reliable for estimating restoration of
fibular length

7. • Classification
 Anatomic / Descriptive
 Isolated medial malleolar
 Isolated lateral malleolar
 Bimalleolar
 Trimalleolar
 Bosworth fracture-dislocation
(posterior dislocation of the fibula behind incisura fibularis)

8.  Lauge-Hansen
 Based on foot position and force of applied stress/force
 Shown to predict the observed (via MRI) ligamentous
injury in less than 50% of operatively treated fractures

9. Supination - Adduction
(SAD)
• Talofibular sprain or distal fibular avulsion
• Vertical medial malleolus and impaction of
anteromedial distal tibia

10. Supination external rotation
(SER)
• Anterior tibiofibular ligament sprain
• Lateral short oblique fibula fracture
(anteroinferior to posterosuperior)
• Posterior tibiofibular ligament rupture
or avulsion of posterior malleolus
• Medial malleolus transverse fracture
or disruption of deltoid ligament

11. Pronation external rotation
(PER)
• Medial malleolus transverse fracture or
disruption of deltoid ligament
• Anterior tibiofibular ligament disruption
• Lateral short oblique or spiral fracture of
fibula (anterosuperior to posteroinferior)
above the level of the joint
• Posterior tibiofibular ligament rupture or
avulsion of posterior malleolus

12. Pronation Abduction
(PAB)
• Medial malleolus transverse fracture or disruption
of deltoid ligament
• Anterior tibiofibular ligament sprain
• Transverse comminuted fracture of the fibula
above the level of the syndesmosis

13.  Denis-Weber (location of fibular fracture)
 A - infrasyndesmotic (generally not associated with ankle instability)
 B - transsyndesmotic
 C – suprasyndesmotic

14.  AO classification

15. • General Treatment
 Nonoperative
 Short-leg walking cast/boot
 Isolated nondisplaced medial malleolus fracture or tip avulsions
 Isolated lateral malleolus fracture with < 3mm displacement
and no talar shift
 Posterior malleolar fracture with < 25% joint involvement
or < 2mm step-off

16.  Operative (Open reduction internal fixation)
 Any talar displacement
 Displaced isolated medial malleolar fracture
 Displaced isolated lateral malleolar fracture
 Bimalleolar fracture and bimalleolar-equivalent fracture
 Posterior malleolar fracture with > 25% or > 2mm step-off
 Bosworth fracture-dislocations
 Open fractures
 Goal of treatment
 stable anatomic reduction of talus in the ankle mortise
 1 mm shift of talus leads to 42% decrease in tibiotalar contact area

17.  Outcomes
 overall success rate is high
 prolonged recovery expected (2 years to obtain final functional result)
 significant functional impairment often noted
 worse outcomes with: smoking, decreased education, alcohol use,
increased age, presence of medial malleolar fracture
 ORIF superior to closed treatment of bimalleolar fractures
 In Lauge-Hansen supination-adduction fractures, restoration of marginal
impaction of the anteromedial tibial plafond leads to optimal functional
results after surgery

18. • ISOLATED MEDIAL MALLEOLUS FRACTURE
 Nonoperative (short leg walking cast or cast boot)
 Nondisplaced fracture and tip avulsions
 Operative (ORIF)
 Any displacement or talar shift
 Lag screw fixation (stronger if placed perpendicular to fr line)
 Antiglide plate with lag screw (Best for vertical shear fr)
 Tension band fixation

20. • ISOLATED LATERAL MALLEOLUS FRACTURE
 Nonoperative (short leg walking cast vs cast boot)
 intact mortise
 no talar shift
 < 3mm displacement
 Classically fractures with more than 4-5 mm of medial clear space
widening on stress radiographs have been considered unstable and
need to be treated surgically
 Recent studies have shown the deep deltoid may be intact with up
to 8-10 mm of widening on stress radiographs
 if the mortise is well reduced, results from operative and non-
operative treatment are similar

21.  Operative (ORIF)
 if talar shift or > 3 mm of displacement
 can be treated operatively if also treating an ipsilateral syndesmosis
injury
 Open reduction and plating
 plate placement
 lateral
 lag screw fixation with neutralization plating
 bridge plate technique

22.  posterior
 antiglide technique
 lag screw fixation with neutralization plating
o most common disadvantage of using posterior antiglide plating
is peroneal irritation if the plate is placed too distally
o posterior antiglide plating is biomechanically superior to lateral
plate placement
 intramedullary retrograde screw placement

24.  Post-operative care
 period of immobilization usually 4-6 weeks after ORIF
 duration of immobilization should be doubled in Diabetic patients

25. • MEDIAL AND LATERAL (BIMALLEOLAR) FRACTURE
 Operative (ORIF)
 any lateral talar shift
 Technique:
 Fibula (fixed as previously)
 medial malleolus
 cancellous lag screws
 bicortical screws
 tension band wiring
 antiglide plate to treat a vertical medial malleolus
fracture (screws parallel to joint)

26. • FUNCTIONAL BIMALLEOLAR FRACTURE
(deltoid ligament tear with fibular fracture)
 Operative (ORIF of lateral malleolus)
 can see significant lateral translation of the talus in this pattern
 not necessary to repair medial deltoid ligament
 only need to explore medially if you are unable to reduce the
mortise

28. • POSTERIOR MALLEOLAR FRACTURE
 Nonoperative (short leg walking cast vs boot)
 < 25% of articular surface involved
(CT rather than Xrays “unreliable”)
 < 2 mm articular stepoff
 syndesmotic stability
 Operative (ORIF)
 > 25% of articular surface involved
 > 2 mm articular stepoff
 syndesmosis injury

29.  Approach
 posterolateral approach
 posteromedial approach
 Fixation
 anterior to posterior lag screws to capture fragment (if
nondisplaced)
 posterior to anterior lag screw and buttress plate
 antiglide plate

30.  Syndesmosis injury
 stress examination of syndesmosis still required after posterior
malleolar fixation
 posteroinferior tibiofibular ligament may remain attached to
posterior malleolus and syndesmotic stability may be restored
with isolated posterior malleolar fixation

31. • BOSWORTH FRACTURE-DISLOCATION
 rare fracture-dislocation of the ankle where the fibula becomes
entrapped behind the tibia and becomes irreducible
 posterolateral ridge of the distal tibia hinders reduction of the fibula
 Operative (ORIF of the fibula in the incisura fibularis)
 indicated in most cases

33. • OPEN ANKLE FRACTURE
 Operative
 Emergent operative debridement and ORIF
 indicated if soft tissue conditions allow
 External fixation
 According to soft tissue and overall patient conditions.

34. • ASSOCIATED SYNDESMOTIC INJURY
 suspect injury in all ankle fractures
 most common in Weber C fracture patterns
 up to 25% of tibial shaft fractures will have ankle injury

35.  Evaluation:
 measure clear space 1 cm above joint
 it has also been reported that there is no actual correlation
between syndesmotic injury and tibiofibular clear space or
overlap measurements
 best option is to assess stability intraoperatively with
abduction/external rotation stress of dorsiflexed foot
 instability of the syndesmosis is greatest in the anterior-
posterior direction
 lateral stress radiograph has more interobserver reliability than
an AP/mortise stress film

36.  Treatment (operative: syndesmotic screw fixation)
 widening of medial clear space
 tibiofibular clear space (AP) greater than 5 mm
 tibiofibular overlap (mortise) narrowed
 any postreduction malalignment or widening should be treated with
open debridement, reduction, and fixation

37.  Technique
 length and rotation of fibula must be accurately restored.
 one or two cortical screw(s) 2-4 cm above joint, angled posterior
to anterior 20-30 degrees
 lag technique not desired
 maximum dorsiflexion of ankle not required during screw placement
(can't overtighten a properly reduced syndesmosis)

40.  Postoperative
 screws should be maintained in place for at least 8-12 weeks
 must remain non-weight bearing, as screws are not biomechanically
strong enough to withstand forces of ambulation
 Controversies
 number of screws
o 1 or 2 no difference
 number of cortices
o 3 or 4 no difference
 size of screws
o 3.5 mm or 4.5 mm screws
 implant material
o (stainless steel screws, titanium screws, suture, bioabsorbable
materials)
 need for hardware removal
o no difference in outcomes seen with hardware maintenance
(breakage or loosening) or removal at 1 year

41. • Complications
 Wound problems (4-5%)
 Deep infections (1-2%)
 up to 20% in diabetic patients
 largest risk factor for diabetic patients is presence of peripheral
neuropathy
 Post-traumatic arthritis
 rare with anatomic reduction and fixation