1) A malleolar fracture is a break in the bony prominence on the lateral or medial side of the ankle. 2) The majority are unimalleolar or bimalleolar fractures, most commonly caused by a twisting injury of the ankle. 3) Classification systems like the Weber system categorize fractures based on their location and relationship to the ankle joint. Displaced or unstable fractures often require open reduction and internal fixation to heal properly.

1. Malleolar Fracture of Ankle
By: Alhassan Mahdi Al Salem

2. Definition:
A break the continuity of the cortex of the bony
prominence situated at the lateral or medial aspect
of the ankle known as the lateral or medial
malleolus fracture.

3. Epidemiology:
The incidence is about 187 fractures per 100,000 each
year.
In athletics and the elderly .
The majority of ankle fractures are malleolar fractures:
• 60 to 70 % occur as unimalleolar fractures
• 15 to 20 % as bimalleolar fractures
• Male-to-female ratio is 2:1
• Men have a higher rate as young adults,
while women have higher rates in the 50 to 70-year age.

4. Mechanism of injury
• The patient stumbles and falls.
• The ankle is twisted and the talus tilts and/or
rotates causing a low-energy fracture of one
or both malleoli, with or without associated
injuries of the ligaments.
• If a malleolus is pushed off, it usually fractures
obliquely.
• if it is pulled off, it fractures transversely.

5. Classification
• The Weber ankle fracture
classification (or Danis-Weber classification)
is a simple system for classification of lateral
malleolar fractures, relating to the level of the
fracture in relation to the ankle joint. It has a
role in determining treatment.

6. Syndesmosis
• There are several ligaments/membranes
referring to the syndesmosis or structures
which hold the tibia and fibula in position.
These are:
• the interosseous membrane
• the syndesmotic ligaments
- posterior tibio-fibular ligament
- anterior tibio-fibular ligament

8. type A:
• is a transverse fracture of the
fibula below the tibiofibular
syndesmosis, perhaps
associated with an oblique or
vertical fracture of the medial
malleolus; this is almost
certainly an adduction (or
adduction and internal
rotation) injury.

9. • type B
• is an oblique fracture of the
fibula in the sagittal plane
(and therefore better seen
in the lateral xray) at the
level of the syndesmosis;
often there is also an
avulsion injury on the
medial side (a torn deltoid
ligament or fracture of the
medial malleolus). This is
probably an external
rotation injury and it may be
associated with a tear of the
anterior tibiofibular
ligament.

10. • Type C:
• is a more severe
injury, above the level
of the syndesmosis,
which means that the
tibiofibular ligament
and part of the
interosseous
membrane must have
been torn. This is due
to severe abduction or
a combination of
abduction and
external rotation.

11. Clinical features
• history of severe twisting injury.
• Severe pain.
• Swelling .
• Deformity.
• And if both the medial and lateral sides are
tender, a double injury (bony or ligamentous)
must be suspected.

12. Investigation
• History and clinical examination.
• X ray:
At least three views:
1- anterior posterior view.
2- Lateral view.
3- 30-degree oblique ‘mortise’ view.

13. Treatment
1st undisplaced fractures:
A- Type A:
Minimal splintage.
B- Type B:
below-knee cast is applied with the ankle in the
neutral (anatomical position).
C- Type C:
fracture may displaces in a cast therefore, type
C fractures are better fixed from the outset.

14. • 2nd displaced fractures:
A- Type A:
Open reduction and internal fixation.
B- Type B:
Close reduction with traction if succeed cast is
applied and if fail internal fixation.
C- Type C:
Almost all type C fractures are unstable and will
need open reduction and internal fixation.

15. complications
• Early:
Vascular injury
Wound breakdown and infection.
• Late:
Incomplete reduction.
Nonunion.
Joint stiffness.
Osteoarthritis.