ANKLE FRACTURES

Shammas B.M,Calicut
Medical College
Ankle Anatomy
 Facts
• Most frequently injured joint in the body
• Works to maintain balance
• 26 bones in the ankle
• Toes numbered 1-5 starting at the “’big
toe” great toe
 Ankle Ligaments
• Note – Most of the names of the ankle
ligaments, give the attachment point.
 Lateral Ankle Ligaments
• Commonly injured
with ankle inversion
• Talofibular – connects
the talus and fibula
• Calcaneofibular –
connects the
calcaneus and fibula
Medial Ankle Ligaments
• Deltoid ligaments are
four strong ligaments
maintaining stability
during eversion
• Talotibial – connects
the talus and tibia
• calcaneotibial –
connects the tibia and
calcaneus
 Ankle Injuries
• type I — Only a few
fibers are stretched or
torn, so ankle is mildly
tender and painful,
but muscle strength is
normal.
Ankle Injuries
Type II — A greater
number fibers are
torn, so there is more
severe pain and
tenderness, together
with mild swelling,
noticeable loss of
strength and
sometimes bruising
 Ankle Injuries

• Type III — The

ligaments tears all the
way through. it rips
into two separate
parts .there will be
considerable pain,
swelling, tenderness
and discoloration.
 Ankle Injuries
• Sprains / Strains –
80% of sprains are
caused by ankle
inversion.
• Inversion sprains
cause damage to the
lateral ligaments
Ankle Injuries
• Ankle Fracture –
commonly caused by
eversion. The fibula
is often broken.
Classifications
Lauge-Hansen
• Cadaveric study which relates the fracture
pattern to an injury mechanism
• The first word in the designation refers to
the foot’s position at the time of injury; the
second word refers to the direction of the
deforming force.
• ‘‘eversion’’ is a misnomer; it more correctly
should be ‘‘external’’ or ‘‘lateral’’ rotation
Type of injury (foot Pathology
position/direction of
force)
Supination/Adduction Transverse # of
fibula/tear of collateral
ligaments ± vertical #
medial malleolus
Type of injury Pathology
(foot position
/direction of force)
Supination/ 1.Disruption of the anterior
Eversion tibiofibular ligament
(External 2.Spiral oblique fracture of
rotation) the distal fibula
3.Disruption of the posterior
tibiofibular ligament or
fracture of the posterior
malleolus
4.Fracture of the medial
malleolus or rupture of the
deltoid ligament
Type of injury Pathology
(foot position
/direction of
force)
Pronation/ 1.Transverse fracture of the medial
Abduction malleolus or rupture of the deltoid
ligament
2.Rupture of the syndesmotic
ligaments or avulsion fracture of their
insertion(s)
3.Short, horizontal, oblique fracture
of the fibula above the level of the
joint
Type of injury (foot position Pathology
/direction of force)

Pronation/ 1.Transverse fracture of the

medial malleolus or
Eversion disruption of the deltoid
ligament
2.Disruption of the anterior
tibiofibular ligament
3.Short oblique fracture of the
fibula above the level of the
joint
4.Rupture of posterior
tibiofibular ligament or
avulsion fracture of the
posterolateral tibia
Type of injury (foot Pathology
position /direction of
force)

Pronation/ 1.Fracture of the medial

Dorsiflexion malleolus
2.Fracture of the anterior
margin of the tibia
3.Supramalleolar
fracture of the fibula
4.Transverse fracture of
the posterior tibial
surface
 AO/ Danis-Weber
Type Pathology

A Avulsion # fibula ± shear # of med

malleolus
B Fibula # at level of syndesmosis ± # med
malleolus/ tear of deltoid ligament
C Fibula # above level of syndesmosis ±
medial injury + tear of ITFL and
interosseous membrane
• Maissoneuve’s fracture
• Spiral fracture of proximal fibula associated with very unstable ankle
injury
• Bosworth Fracture
• A lesion described by Bosworth may be the cause of failure to
reduce a posterior fracture-dislocation of the ankle.
• The distal end of the proximal fragment of the fibula may be
displaced posterior to the tibia and locked by the tibia’s
posterolateral ridge; the bone cannot be released
by manipulation because of the pull of the intact interosseous
membrane.
• In these cases the fibula is exposed, and a periosteal elevator is
used to release the bone; considerable force may be necessary.
The fibular fracture then is fixed.
• Bosworth fracture with entrapment of fibular behind tibia.
A, Anteroposterior view. B and C, Lateral views.
 Rationale behind ORIF of ankle
fractures
• Tibiotalar congruency
• Ramsey and Hamilton (JBJS (B) 1976) showed that a
1mm lateral shift of the talus in the ankle mortice
reduces the contact area by 42%
• Posterior malleolus fracture >33% leads to a significant
loss of tibiotalar contact
• DeSouza (JBJS (A) 1985) showed 90% satisfactory
results could be obtained even if up to 2mm of lateral
displacement was present
• Generally
– Young ORIF if >1mm displacement or >2º talar tilt
– Old can accept up to 2mm of displacement
– Always take into account the ambulatory needs of the patient
and judge treatment accordingly
 Surgical technique
• Standard AO fixation
• Interfragmentary screw and 1/3 tubular neutralisation plate for fibula
and lag screw fixation for medial malleolus
• Syndesmosis screw is required if fibula is unstable at end of fixation
(engage 3 cortices and ensure the ankle is at 90º when inserting
screw, and that the screw is not lagged) Screw needs to be
removed before weight bearing can be commenced
• Alternative fixation for Type B fractures of the fibula is the anti-glide
plate which has been shown to be biomechanically superior to a
lateral plate
• Posterior malleolus fractures need to be fixed if there is > 25% of
the articular surface involved. This is often underestimated on lateral
radiographs
 Post-operative management
• In studies comparing the effect of early
movement vs immobilisation and weight
bearing vs non-weight bearing, the
conclusion is that there is no difference in
the final result whichever regime is used.
 Arthritis
• Incidence increases with severity of injury
• Degenerative changes in
• 10% of anatomically fixed
• 85% if not adequately reduced - changes
apparent within 18 months
• Klossner "Late results of operative and
non-operative treatment of severe ankle
fractures" Acta Chir Scand Suppl. 293: 1-
93, 1962
 Prognosis
• There is a reduction in the incidence of
arthrosis in patients where an anatomical
reduction has been achieved (Phillips et al
JBJS 67A: 67-78, 1985)
• Prospective trial shows higher total ankle
scores in those that are operatively
treated- especially so in those pts more
than 50 yrs old
 PILON / PLAFOND
FRACTURES (Pilon = Hammer
/ Plafond = Ceiling)
Reudi & Allgower Classification

Type Pathology
1 Undisplaced

2 Displaced with joint incongruity

3 Marked comminution with

crushing of the subchondral
cancellous bone
 Initial treatment
• Reduction of any dislocation and covering
of exposed wounds if present
• Assess neurovascular status
• Check for evidence of compartment
syndrome
• Splint fracture which may require
temporary skeletal traction
• Investigations
• X-ray plus CT
• Timing of surgery
• Type II and III - goal is to keep talus centred under the tibia while soft tissue
heal over 7 to 21 days
• Study by M.Sirkin et al 1999, a series of pilon fractures underwent
immediate external fixation and ORIF of the fibula, and formal ORIF of the
tibial articular surface was performed on a delayed basis (avg. delay 12-13
days); - using this protocol, no patient that presented with a closed injury
developed a full thickness skin necrosis and none required secondary soft
tissue coverage
• The historically high rate of infection and skin necrosis following ORIF of
these injuries is most related to operative timing - in the study by MJ
Patterson and JD Cole (JTO 1999), all patients underwent a two staged
technique for the treatment of complex pilon fracture - initially all patients
underwent immediate fibular fixation and placement of a medial fixator
 Surgical options
• 1. ORIF
• Medial and anterior incisions with full thickness flaps
developed at level of the periosteum. These incisions
must be at least 7 cm apart to protect the viability of the
intervening skin bridge
• Steps
– Fibula # brought out to length and fixed with plate (DCP)
– Tibial # exposed and reduced, held with temporary K-wires –
usually 4 main fragments
– K-wires replaced with interfragmentary screws and fixed with
buttress plate
– Closure of wounds – tension must be avoided and if present
close deep layers and return later for delayed 1º closure of skin
2. Fine wire fixation with circular frames
• Using either the Ilizarov or hybrid external
fixators
• This can be combined with limited internal
fixation of the tibia using interfragmentary
screws and fixation of the fibula
3. Trans-articular external fixation
• Will align the tibia but will not address the central
depression of the joint surface.
• Useful as first part of 2 -stage procedure (to
allow soft tissue management & CT & planning)
 Outcomes
• Operative treatment of high-energy pilon fractures will
take an average of 4 months to heal
• 75% of patients that do not develop wound complications
may expect a good result
• Subsequent arthrodesis rate ~ 10%
• Bourne et al " Pilon fractures of the distal tibia" CORR
240:42-46, 1989
– 36% satisfactory results in intra artic fracture treated with closed
means
– 76% satisfactory for operative treatment
– 32% at 4.5 yrs had undergone ankle arthrodesis for failed result