This document discusses principles for classifying and treating ankle fractures. It describes two main classification systems - the Danis-Weber (AO) system and the Lauge-Hansen system. Key evaluation factors are the history, clinical exam, and radiographic views. Treatment may involve non-operative or operative approaches depending on the fracture displacement and stability. Surgical principles aim to restore stability and congruency of the ankle joint through techniques like open reduction and internal fixation of the medial, lateral, and posterior malleoli as needed.

1. AOTrauma Principles Course
Malleolar fractures
Peter PS KO, HK
Robert Vander Griend, US

2. Goal of this lecture
• Classification principles
• Patho-mechanics of injury
• Evaluation
• Treatment

3. Ankle fractures
• Intraarticular injuries
• Soft-tissue injury
- subcutaneous fracture
- soft tissues can be unforgiving

4. Ankle fractures
Injury: bone(s) and/or ligament(s)
1. medial malleolus—deltoid complex
2. lateral malleolus—lateral ligaments
3. anterior tubercle—anterior syndesmotic ligaments
4. posterior tubercle—post syndesmotic ligaments
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5. Classification: Danis-Weber (AO)
A fibula infrasyndesmotic
B fibula transsyndesmotic
C fibula suprasyndesmotic

6. Terminology used in Lauge-Hansen
classification
• Supination/pronation—position of foot as it rotates
around the subtalar joint
• Inversion (IR)/eversion (ER)—rotation of talus around
axis of tibia
• Adduction/abduction—rotation movements of talus
around its long axis

7. Classification: Lauge-Hansen
• Initial foot position
- supination vs pronation
→ tension failure
• Rotation of the talus
- transverse plane
(adduction vs abduction)
- external rotation to axis of tibia

8. Supination—Adduction/(A)
Lateral injury
• Ligamentous
• Avulsion fracture fibula
Medial injury
• Impaction fracture @ incisura!
• Vertical fracture medial malleolus
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9. Supination―External Rotation/ (B)
1. Anterior lateral ankle
2. Distal fibula
3. Posterior lateral ankle
4. Medial injury
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11. Pronation—Abduction (C1-2)
1. Medial injury
2. Disruption of inferior
syndesmosis
3. Axial/bending fracture of fibula
• Interosseous membrane injured
to the level of fibula fracture
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13. Pronation external rotation (C1 or C3)
1. Medial injury
1. Anterior syndesmosis
2. Rotational injury to fibula
3. ± posterior syndesmosis
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16. Assessment
• History
• Clinical examination
• Radiographic examination—AP, lateral, and mortise
views

17. Nonoperative treatment
• Nondisplaced fractures
• Stable fractures
• Patient or limb ≠ surgery
• Isolated lateral malleolus

18. Indications for surgery
• Failure of closed reduction
• Displaced fractures
• Unstable fractures

19. Preoperative planning
• Timing
- patient factors
- status of soft tissues

20. Preoperative planning
• Choice of implants
• Position of patient
• Approaches
• Sequence of reduction and fixation
• Pitfalls and hazards
• If you cannot plan it, you cannot do it

21. Patient position

22. Choice of incision
Sup.fibular nerve Saphenous nerve

23. Principles of fixation
• Medial malleolus
• Lateral malleolus
• Posterior malleolus
• Syndesmosis

24. Medial malleolus
• 4.0 mm distal, threaded cancellous bone screw
• perpendicular to fracture
• interfragmentary compression
tension band
small MM fragment
salvage

25. Medial malleolus
Vertically oriented fracture compression and buttress
Impaction fragment(s)

26. Lateral malleolus
• Anatomical reduction
- Length
- Rotation
- Mortise
• Fixation
- IFC & neutralization
- Bridging plate
- TSF
- IM ??
Case from R Teasdale

27. Lateral malleolus
Anti-glide
technique

28. Bimalleolar equivalent, SER 4, 44-B2.1
• Routine medial repair not needed
• Explore medial side if reduction not anatomical

29. Posterior malleolus
• > 25-30% of articular surface
• > 2 mm of displacement
• Posterior subluxation of talus
• To restore stability of syndesmosis

30. Transsyndesmotic fixation (TSF)
• Unstable syndesmosis
• Equivocal instability in “at risk” injury pattern
• Radiographic parameters
- medial clear space widened > 4 mm
- tib-fib clear space > 5 mm

31. Transsyndesmotic fixation (TSF)
• Intraoperative stress test
- hook or spreader
  mobility of fibula
- talar shift on external rotation stress films
• Equivocal?
- Nike test– “just do it”

32. Transsyndesmotic fixation (TSF)
• Ankle
• Fibula must be reduced
• Syndesmosis
• Holding screw(s) not
compression/lag screw
• Opinions vary use 1 or 2
screws, 3.5 mm vs 4.5 mm
screw, engage 3 or 4
cortices
• Remove TSF before WB
Image from Skeletal TraumaImage from Skeletal Trauma

33. After care
• Protected immobilization and elevation
- → Wound healed at 7–10 days
• Removable splint and early ROM
• Short leg cast
• Weight bearing based on injury pattern

34. Summary
• Intraarticular injuries (follow principles)
• Restore
- stability & congruency of joints
- normal function