Chapter 59 – Malleolar Fractures and Soft Tissue

Injuries of the Ankle

James B. Carr, M.D.

No unequivocal boundary marks the proximal or distal limits of the ankle region. Structure, function, and injuries have
no borders here and often require that the leg and foot be included in any regional assessment or treatment. This
chapter considers malleolar fractures, related ligament injuries, and other soft tissue injuries of the ankle region. Pilon
fractures are discussed in Chapter 58 . Talar injuries are reviewed in Chapter 60 .

The ankle is a complex hinge in which both bones and ligaments play important and inseparable parts.[127] Satisfactory
function depends significantly on its precise structural integrity. As a weight-bearing joint, the ankle is exposed to
forces that transiently exceed 1.25 times body weight with normal gait and that may exceed 5.5 times body weight with
vigorous activities. Normal gait requires adequate dorsiflexion and plantar flexion. Inversion and eversion, as well as
accommodation to rotational stresses, are provided by the subtalar joint, whose function is linked closely with that of
the ankle.[112][159] The ankle is not intrinsically stable in any position and requires support from the muscles that cross it.

The overlying skin is thin, with a tenuous blood supply.[251] Tendons rather than muscle bellies cross the joint and
provide no coverage for it. After severe injuries, ankle wounds, both traumatic and surgical, may have problems
healing. An injury of the ankle region can affect—in addition to bone, articular surface, and ligament—any of the
tendons, nerves, or blood vessels that cross it.

Management of ankle injuries requires a thorough evaluation identifying both the anatomic structures involved and the
severity of the damage.[96][248] Once the injuries have been defined, optimal treatment generally entails as anatomic a
repair as possible while avoiding any additional compromise to the region.

ANATOMY AND BIOMECHANICS

Anatomy
Ankle anatomy has been thoroughly reviewed by several investigators.[96][238] Distally, the tibial shaft flares and the
bone changes from tubular cortical to metaphyseal and cancellous ( Fig. 59-1 ). In the young, active adult, the distal
tibia may be exceptionally dense. The AO/Association for the Study of Internal Fixation (AO/ASIF) has contributed to
our awareness of the distinction between malleolar fractures, which may have associated involvement of the plafond,
and pilon fractures, in which the focus of the injury is primarily supramalleolar.[235] The latter are discussed in the
previous chapter.

Figure 59-1 Normal anteroposterior (A), lateral (B), and mortise (C) views of the ankle. The tibiotalar joint demonstrates congruent articular
surfaces, normal subchondral bone outline, and uniform width of cartilage space. The overlap of the tibia and the fibula at the incisural notch is
evident. D, Computed tomographic scan through another patient's ankle shows that the medial and lateral joint spaces are not necessarily parallel.
Note again the congruent fit of the talus in mortise.
The anteromedial aspect of the distal tibia is notable for the prominent medial malleolus, which carries the medial
articular surface of the ankle mortise. It is smaller than the lateral malleolus and can be divided into an anterior
colliculus, covered laterally with articular cartilage, and a posterior colliculus. The superficial deltoid (medial collateral)
ligament is attached at the anterior colliculus and distally goes to the talus, calcaneus, and navicular, but it provides
little stability to the ankle joint itself. The primary medial stabilizer is the deep portion of the deltoid ligament, which is
attached to the posterior colliculus, the somewhat shorter posterior part of the malleolus. This nearly transverse,
synovium-covered, essentially intraarticular ligament is not accessible from outside the joint unless the talus is
displaced laterally or the medial malleolus can be turned distally through a fracture or osteotomy ( Fig. 59-2 ). Any
repair of the deltoid ligament that does not include this structure does not restore ligamentous stability.

Figure 59-2 The medial collateral ligament of the ankle. A, The superficial fibers connecting the medial malleolus to the talus, calcaneus, and
navicular have a roughly triangular appearance and suggest the name deltoid. B, The much more important deep fibers run nearly transversely
from the posterior colliculus to the talus posterior to its medial articular facet.

The articular surface of the distal tibia is concave, with the anterior and, especially, posterior lips projecting more
distally. The posterior lip of the plafond is the anchorage for the posterior part of the inferior tibiofibular syndesmotic
ligaments. It does not limit movement of the talus as the medial and lateral malleoli do. However, it is not uncommonly
injured along with the lateral and medial malleoli, becoming the "third malleolus." This injury is the basis for the term
trimalleolar fracture to describe injuries involving both the medial and the lateral malleoli along with the posterior lip.[96]

Because of the clinical observation that trimalleolar fractures with a large postmalleolar component tend to heal with
posterolateral talar subluxation, it has been assumed that the posterior malleolus is a restraint to posterior translation
of the talus.[292] It is unclear to what extent fibular malunion contributed to this finding. Using cadaver specimens,
Harper[99] and Raasch and colleagues[216] noted no posterior talar instability with fractures involving up to 40% of the
tibial surface. Somewhat contradictory findings were noted by Scheidt and co-workers.[244] Using an axially loaded
experimental model, they noted increased posterior drawer and internal rotation with posterior malleolar fractures
involving 25% of the distal tibial articular surface. The posterior malleolus also contributes to the weight-bearing
surface, with a loss of 35% of contact pressure seen with a fracture involving half of the joint surface.[216] Thus, the
posterior malleolus fracture must be evaluated regarding its effect on articular congruity. Although the posterior tibia's
contribution to posterior talar stability is less clear, a sizable (>25%) posterior malleolar fracture demands careful
assessment regarding whether it should be repaired.

The tibial joint surface has a central prominence oriented in the sagittal plane. The size of this ridge is variable. The
articular surface contour of the talar dome very closely matches the curved plafond and sagittal ridge. Slight lateral
displacement of the talus results in a considerable reduction of the contact area between the two bones. According to
Ramsey and Hamilton,[218] a 1-mm lateral shift produces a 42% decrease in joint contact area. It is presumed that
increased joint pressure, caused by the same amount of force being borne by a smaller area, results in degenerative
changes of the articular cartilage, a common problem after severe injuries in which loss of the congruent relationship
between talus and tibia occurs. Other studies have utilized contact pressure film technology to investigate alterations in
joint contact pressures.[41][155][285] Although they failed to replicate the dramatic results of Ramsey and Hamilton, these
studies demonstrated increased stresses with lateral talar shift and large posterior malleolar fragments. Despite these
findings, the primary cause of post-traumatic arthrosis remains unknown.

Laterally, the distal tibia is indented by a shallow groove or incisura for the fibula ( Fig. 59-3 ). This groove is formed by
a larger anterior tubercle (Chaput or Tillaux-Chaput) and a significantly smaller posterior tubercle.

Figure 59-3 Computed tomographic scan just above the ankle shows the prominent anterior tubercle, which overlaps the more posterior fibula
and helps form the incisural notch.

The most significant ligamentous complex of the ankle is that which unites the distal tibia and fibula. This so-called
syndesmosis comprises four distinct portions ( Fig. 59-4 ). Anteriorly, the anterior inferior tibiofibular ligament (AITFL)
runs obliquely slightly distally from the anterolateral tubercle of the tibia (Chaput's) to the anterior portion of the lateral
malleolus, where its attachment is occasionally referred to as Wagstaffe's tubercle. The posterior inferior tibiofibular
ligament (PITFL) runs obliquely distally from the posterior tubercle (Volkmann's or third or posterior malleolus). It is
distinguished from a fibrocartilaginous but otherwise similar connection between the tibia and the fibula that lies just
distally and is called the inferior transverse tibiofibular ligament. A short and variable distance above the ankle, the
tibiofibular interosseous membrane thickens and becomes the interosseous ligament. These four structures collectively
make up the syndesmosis and are largely responsible for the structural integrity of the ankle mortise. If they fail and the
fibular malleolus displaces laterally, the talus follows it and loses its normal relationship with the weight-bearing surface
of the tibial plafond.[140][211][292] This lateral talar shift is not reliably prevented by an apparently intact deltoid ligament
and forms the basis for the now well-appreciated need to reestablish the anatomic relationship of the lateral malleolus
to the distal tibia when it has been disrupted in a malleolar injury.
Figure 59-4 The ligaments of the distal tibiofibular syndesmosis. The lower part of the interosseous membrane thickens to form the
interosseous ligament (IOL). Just above the plafond lie the anterior inferior tibiofibular ligament (AITFL) and the posterior inferior tibiofibular
ligament (PITFL), with more distal fibers called the inferior transverse ligament (ITL). (Redrawn from Hamilton, C.C. Traumatic Disorders of the
Ankle. New York, Springer-Verlag, 1984, Fig. 1-7.)

The lateral collateral ligament (LCL) complex is made up of three portions ( Fig. 59-5 ). The anterior talofibular ligament
is directed anteromedially to the lateral neck of the talus. The bulky and stout posterior talofibular ligament is
posteromedially attached to the posterior process of the talus. Both of these are essentially thickenings, along with the
superficial deltoid ligament medially, in an otherwise structurally unimpressive and redundant ankle joint capsule. The
middle part of the ankle's LCL complex is the fibulocalcaneal ligament. It runs obliquely posteriorly and distally deep to
the peroneal tendons, more or less perpendicularly across the posterior facet of the subtalar joint, and attaches to the
calcaneus just posterior to the proximal extent of its peroneal tubercle. An additional, inconstant, posterolateral
extracapsular ligamentous structure is the so-called fibulotalocalcaneal ligament, a local thickening of the deep
aponeurosis of the leg that resists extreme foot dorsiflexion.[238]

Figure 59-5 The three components of the lateral collateral ligament are the anterior and posterior talofibular ligaments and, between them, the
fibulocalcaneal ligament, which crosses the talus. The orientation of anterior talofibular and fibulocalcaneal ligaments is demonstrated in Figure
54-14 .
A number of important structures cross the ankle joint and must be considered with any approach to diagnosis and
treatment of ankle injuries.

Superficially and posteriorly, the powerful plantar flexor of the ankle, the tendo calcaneus or Achilles tendon, is
prominent, with a thin tendon sheath and little subcutaneous tissue between it and the overlying skin. Just lateral to the
Achilles tendon lies the sural nerve, which supplies the skin of the lateral heel and midfoot and is at risk of painful
entrapment in a surgical scar. The plantaris tendon runs along the medial border of the Achilles tendon and attaches to
the calcaneus just medial to it. This slender tendon may be used for tendon or ligament repairs in the ankle region and
elsewhere.

On the lateral side of the ankle, the peroneus brevis and peroneus longus tendons, the latter more posteriorly, course
around the posterior surface of the lateral malleolus ( Fig. 59-6 ). They are tethered there by the superior peroneal
retinaculum, which, with its fibrocartilaginous attachment, may be avulsed from the fibula, permitting anterior
dislocation of the tendons. Such a dislocation is not prevented by the more anteriorly located inferior peroneal
retinaculum, a prolongation of the inferior extensor retinaculum. The peroneal tendons are superficial to the
fibulocalcaneal ligament. As they reach the lateral border of the foot, the peroneus longus crosses plantarward under
the peroneus brevis and traverses the foot under the long plantar ligament to insert on the proximal first metatarsal and
first cuneiform. The peroneus brevis inserts on the base of the fifth metatarsal, from which, with an inversion injury, it
may be avulsed with a small bone fragment.

Figure 59-6 The lateral ankle is crossed posteriorly by the peroneus brevis and peroneus longus tendons, restrained primarily by the superior
retinaculum posterior to the distal part of the lateral malleolus. The Achilles tendon is most posterior. The peroneus tertius and toe extensors are
anterior.

On the medial side of the ankle, several important structures lie posterior to the medial malleolus, anchored there by
the flexor retinaculum, which runs from the posteroinferior surface of the malleolus to the medial surface of the
tuberosity of the calcaneus. Its malleolar attachment is a fibrocartilaginous pulley for the most anterior of the flexor
tendons, the tibialis posterior, behind which lie, in order, the flexor digitorum longus; the posterior tibial artery and
associated veins with the tibial nerve; and most posteriorly, crossing the posterior surface of the ankle joint, the flexor
hallucis longus ( Fig. 59-7 ). Each tendon lies in a well-developed tunnel. Should a flexor tendon rupture or be
lacerated, it may retract beyond the surgeon's view, with the result that the injury is not recognized. Posterior tibial
tendon laceration occurs frequently enough with medial malleolus fractures that the surgeon should identify this tendon
when the fracture exposes its tunnel.
Figure 59-7 The structures crossing the medial ankle anteriorly include the tibialis anterior tendon, saphenous vein, and saphenous nerve.
Behind the medial malleolus lie the important tibialis posterior, the flexor digitorum longus, the posterior tibial artery and veins, the tibial nerve, and
the posteriorly located flexor hallucis longus.

A centimeter or two anterior to the medial malleolus lies the saphenous vein with its accompanying saphenous nerve
(usually two or more small branches). The vein is valuable for fluid administration, as it is rapidly available by cutdown
regardless of whether a patient is in shock. It is also important for venous drainage of an injured foot and should be
spared in such situations whenever possible. The saphenous nerves are at risk of entrapment in a local surgical or
traumatic scar, with resultant formation of painful neuromas. They should be identified and preserved or resected in a
manner that allows the proximal end to retract well away from any wound.

On the anterior aspect of the ankle, the extensor retinacula restrain the extensor tendons, anterior tibial vessels, and
deep peroneal nerve as they leave the anterior compartment of the leg and cross onto the dorsum of the foot ( Fig. 59-
8 ). Proximal to the ankle, the transverse fibers of the superior extensor retinaculum run from the anteromedial
subcutaneous surface of the tibia to the anterolateral surface of the distal fibula. The inferior extensor retinaculum is Y
shaped. Its base attaches to the calcaneus laterally. The proximal medial limb attaches to the medial malleolus and the
distal limb to the deep fascia medial to the navicular. The inferior extensor retinaculum thus lies over the anterior ankle
joint capsule. Under it, from lateral to medial, are the peroneus tertius, the extensor digitorum longus tendon, the deep
peroneal nerve, the anterior tibial artery (becoming the dorsalis pedis), the extensor hallucis longus tendon, and the
tibialis anterior tendon. The last runs somewhat obliquely to insert on the medial surface of the first cuneiform and the
base of the first metatarsal.
Figure 59-8 The anterior ankle is crossed by the dorsiflexors: tibialis anterior, extensor hallucis longus, extensor digitorum longus, and the
occasionally absent peroneus tertius tendons. The anterior tibial vessels and deep peroneal nerve are just lateral to the extensor hallucis longus.
The superior (transverse) and inferior (cruciate) retinacula provide pulleys for the dorsiflexors. The origin of the short extensors is from the
anterolateral calcaneus beneath the long toe extensor tendons.

The cutaneous blood supply of the ankle comes from the three major lower extremity arteries.[236] Each delivers
segmental branches that perforate the overlying fascia, branch superficial to it, and supply the skin[95] ( Fig. 59-9 ).
Anastomotic vessels link the segmental perforators. Each of these three arteries has a "zone of distribution" termed an
angiosome. Ideally, incisions should follow the approximate borders of these angiosomes. In addition, dissection
should be done below the enveloping deep fascia to avoid damage to the cutaneous vessels, which inevitably occurs
when subcutaneous flaps are created. These two principles are most important when treating high-energy fractures
with damaged soft tissues. Finally, if wound breakdown occurs, fasciocutaneous flaps based on these angisomes may
offer a solution.[95]
Figure 59-9 The angiosomes of the foot and ankle. Cutaneous blood flow is in the direction indicated by the arrows. Surgical incisions should
not interrupt cutaneous blood flow to the distal portion of an angiosome. The cutaneous arterial territories are supplied by the following arteries:
A.T., anterior tibial; D.P., dorsalis pedis; P.T., posterior tibial; Per, peroneal; M.P., medial plantar; and L.P., lateral plantar. (Redrawn from
Salmon, N. Arteries of the Skin. New York, Churchill Livingstone, 1988.)

Significant individual variation in ankle joint anatomy and mechanics should be recognized and considered in attempts
to define normality and to treat injuries. The use of the opposite ankle as a control is helpful, but it is important to
recognize the normal range of asymmetry that may account for some differences. For example, 3% of normal
individuals have a 10° difference between ankles in talar tilt measured on inversion stress radiographs.[96]

Biomechanics

ANKLE JOINT MECHANICS

The "empirical" ankle axis can be estimated by palpating the tips of the medial and lateral malleoli.[112][159] It passes just
below these, directed both posteriorly and inferiorly from the medial side ( Fig. 59-10 ). In 80%of ankles, normal motion
is simple rotation around this axis.

Figure 59-10 A line joining the tips of the medial and lateral malleoli is a close approximation of the axis of the ankle joint. Inman (1976) called
this the empirical axis of the ankle.

The obliquity of the empirical ankle joint axis varies from person to person. Its angle with the midline of the tibia in the
coronal plane averages 82° (i.e., 8° varus angulation). This angle varies from 74° to 94°, with a standard deviation of
3.6°. External tibial torsion in the transverse plane increases during childhood. In the adult, it measures approximately
22° relative to the midpoints of the proximal tibial condyles, ranging from 4° to 56°, with a standard deviation of 10°.[112]

The "actual" axis of the ankle joint is more oblique than the joint surface. The joint surface of the tibial plafond is also
angled in the coronal plane relative to the midline of the tibia but in the opposite direction to the ankle joint axis. Its
average is 3° of valgus angulation, ranging from 2° to 10°. The angle between the two, the talocrural angle, is an
indicator of normal lateral malleolar alignment. It measures83° ± 4°and is normally within 2° of the angle in the opposite
ankle ( Fig. 59-11 ).
 Figure 59-11 The tibiotalar articular surface (plafond) usually
has a slight lateral tilt, averaging 3 degrees. The empirical axis
is in a relatively varus position, as indicated by the talocrural
angle, formed by the intersection of a line perpendicular to the
plafond with the empirical axis. This averages83 ± 4 degrees
and is a reliable radiographic indicator of the relationship
among malleoli and plafond. It should be similar to that of the
opposite ankle.

The fit of talus in mortise is precise, making it the most congruent of the weight-bearing joints.[112] Both mortise and
talar trochlea are narrower posteriorly. Both this diminution of width and the degree of parallelism of the malleolar
articular surfaces vary among individuals. The fit of talus in mortise remains congruent throughout the ankle's range of
motion, as Inman[112] demonstrated, because the joint surface is a portion of a frustum of a cone, the axis of which is
the ankle's axis of rotation ( Fig. 59-12 ). Therefore, there is little if any change in mortise width during ankle motion (0
to 2 mm, according to Inman).[112] The effect of the ankle's oblique axis is an obligatory internal and external rotation of
the foot with plantar flexion and dorsiflexion, respectively ( Fig. 59-13 ).

Figure 59-12 The puzzling shape of the talus and mortise, which maintain a congruent fit throughout the
range of ankle motion, is explained by Inman's demonstration that the joint surface is a segment (frustum) of
a cone, the axis of which lies on the ankle's empirical axis. The smaller fibular facet is elliptical because of
its obliquity. The larger medial articular facet is round because it is perpendicular to the axis of the cone.
Figure 59-13 The obliquity of the ankle axis produces relative medial deviation of the foot (internal rotation) with plantar flexion and relative
lateral deviation of the foot (external rotation) with dorsiflexion. (Redrawn from Mann, R., ed. Surgery of the Foot, 5th ed. St. Louis, C.V. Mosby,
1986, Fig. 1-12.)

Lindsjö and associates[151] measured motion of the loaded ankle, noting, with hip and knee flexed and the foot on a 30-
cm-high stool, a mean of 32° dorsiflexion and 45° plantar flexion. They stated that, although normal gait required at
least 10° dorsiflexion, athletic activities were limited if loaded dorsiflexion was less than 20° to 30°.

Because the medial and lateral facets of the ankle mortise vary in their relationship to each other and to the ankle joint
axis, a mortise view radiograph does not necessarily show symmetric width of the ankle joint's "cartilage space."

Average in vivo subtalar motion is approximately 40°, ranging from 20° to 62°.[111] The orientation of the subtalar joint
is23° ± 11° (range 4° to 47°), internally rotated relative to the long axis of the foot in the transverse plane and elevated
anteriorly from the horizontal by42° ± 9°(range 20.5° to 68.5°) relative to the horizontal in the sagittal plane.[112] During
walking on level ground, average subtalar motion for a normal foot is 6°.[159]

ANKLE LIGAMENT MECHANICS

Medial Collateral Ligament

The deltoid ligament lies near the apex of the cone on which the surface of the ankle joint lies. It is thus able to
accommodate to the relatively smaller distance the talus travels on this side of the joint.[112][159][222]

The deltoid ligament functions to restrain external rotation of the talus in the mortise. On the basis of biomechanical
studies, it may provide up to 57% of this function.[259] As discussed later in this chapter, the presence of a deltoid
ligament tear in the setting of other malleolar lesions demands particular care in assessing talar stability.

Lateral Collateral Ligament

Because the lateral side of the joint has a greater radius of curvature, a larger distance is traveled on this side during
the same arc of rotation. The LCL is thus more complex, comprising three portions.[220] The anterior part, the anterior
talofibular ligament, lines up with the fibula during plantar flexion and, in this position, functions as a true collateral
ligament, resisting inversion of the talus in the mortise. With dorsiflexion, the fibulocalcaneal ligament is brought into
alignment with the fibula and becomes the functional collateral ligament. Inman[112] demonstrated considerable
variation (70° to 140°) in the relationship between these two portions of the LCL complex (see Fig. 54-14 ). He
hypothesized that ankle inversion laxity may be present in individuals with a relatively greater arc between the anterior
talofibular and the anterior fibulocalcaneal ligaments, as a significant part of their ankle range of motion would be
without an appropriately positioned LCL.

An important corollary of the relative positions of the components of the ankle's LCL complex is that assessment of
stability must be done with regard to the position of the ankle joint. The anterior talofibular ligament resists inversion in
plantar flexion. It also resists anterior subluxation of the talus when the ankle is in neutral, as demonstrated by the so-
called anterior drawer test. The fibulocalcaneal ligament resists inversion when the ankle is dorsiflexed. Because either
or both components may be incompetent, an adequate examination requires testing inversion instability in both
dorsiflexion and plantar flexion.
The relationship of the fibulocalcaneal ligament to the subtalar joint is important. Normally, it lies on the conical plane of
motion of this joint and thus does not interfere with it.[112] If it is to be reconstructed surgically, deviation from its normal
location may compromise subtalar joint movement.

Syndesmosis

The syndesmosis firmly binds the fibula to the tibia and along with the deltoid ligament guides talar
motion within the mortise. The syndesmosis allows minor lateral motion and rotation of the fibula
during normal gait. Anatomic fibular length and rotation are a prerequisite to normal syndesmotic
function. Thus, "syndesmotic stability" is a term that requires evaluation of both osseous and ligamentous structures. In
particular, fibular length and rotation must be anatomic to ensure proper position of the talus ( Fig. 59-11 ).

Figure 59-14 The angle between the fibulocalcaneal and the anterior talofibular components of the lateral collateral ligament varies in normal
individuals from less than 80 degrees to more than 130 degrees. In ankles with a wide spread between the two, there may be a less effective
check to inversion of the ankle joint. Note that dorsiflexion brings the fibulocalcaneal ligament into position to resist inversion and that plantar
flexion does the same for the anterior talofibular ligament. (Redrawn from Inman, V.T. The Joints of the Ankle. Baltimore, Williams & Wilkins,
1976.)

Syndesmotic instability is recognized by movement of the talus in the mortise—most commonly demonstrated by
medial clear space widening. Although it appears as a lateral movement of the talus, external rotation and varying
degrees of posterior translation are also present.

Using a model of a Weber C fibula fracture with a disrupted deltoid ligament, the relative contribution of each
syndesmotic structure to talar stability has been studied by Solari and colleagues[259] ( Table 59-1 and Table 59-2 ).
With a similar model, Boden and co-workers[28] concluded that in the presence of a deltoid ligament tear, the critical
zone of syndesmotic disruption leading to talar instability is 3 to 4.5 cm above the mortise. In each study, the presence
of an intact deltoid ligament contributed significantly to talus stability and, in many instances, obviated the need for
syndesmotic fixation. I believe these guidelines cannot be strictly applied to the clinical situation.[204] In the final
analysis, syndesmotic stability, which comes into question primarily during treatment of lateral malleolar fractures, must
be assessed on an individual case-by-case basis.

Table 59-1 -- Progressive Increase in External Rotation Instability in Stages of Simulated Weber C Malleolar
Injury
Mean External Rotation Total Instability
Ankle Injury
(deg) (%)
Intact ankle 8 0
Medial malleolus fracture 14 25
Medial malleolus + AITFL 19 46
 Mean External Rotation Total Instability
Ankle Injury
(deg) (%)
Medial malleolus + AITFL + interosseous membrane + PITFL 24 67
Medial malleolus + AITFL + interosseous membrane + PITFL + lateral
32 100
malleolus fracture
Abbreviations: AITFL, anterior inferior tibiofibular ligament; PITFL, posterior inferior tibiofibular ligament.

Table 59-2 -- External Rotation Instability after Repair of Various Structures in Simulated Weber C Malleolar
Fracture Model
Mean External Rotation Increase in Stability
Repair
(deg) (%)
None 32 —
Lateral malleolus plate 24 32
Lateral malleolus plate + syndesmosis screw 22 51
Lateral malleolus plate + medial malleolus screw 14 73
Lateral malleolus plate + syndesmosis screw + medial malleolus
8 100
screw
Medial malleolus screw 18 56

BIOMECHANICS OF GAIT
The ankle helps to smooth the vertical movement of the body's center of gravity and to decrease the transient ground
reaction force during forward progression.[159] This function minimizes the energy cost of walking and moderates the
impact on the lower extremity. At heel strike, the ankle begins to plantar flex against the force of the anterior
compartment muscles contracting eccentrically. As the leg accepts weight, foot pronation and knee flexion decelerate
the body's fall. The plantar flexed ankle begins to dorsiflex. With further plantar flexion, the heel elevates and the foot
supinates, thus becoming rigid and propelling the body upward and forward ( Fig. 59-15 ). During this process the tibia
rotates—internally during swing and externally during stance—about its long axis. Inman pointed out that because of
the obliquity of the subtalar joint axis, internal and external rotations of the tibia are linked, respectively, to pronation
and supination of the foot.[112] It is important to remember that during the stance phase, the foot is fixed on the ground
and becomes the fixed point of reference for movements of the leg and body.

Figure 59-15 Ankle mechanics during gait. At heel strike, the dorsiflexors slow plantar flexion produced by the moment arm of the heel. Forward
momentum of the body next produces ankle dorsiflexion. This is restrained by the plantar flexors, which stabilize the foot during terminal stance.
(Redrawn from Inman, V.T.; Ralston, H.J.; Todd, F. Human Walking, Vol. 1. Baltimore, Williams & Wilkins, 1981, Fig. 1-9.)

Mann[159] described three intervals of the stance phase. In the first portion, from heel strike to foot flat, the initially
slightly dorsiflexed ankle plantar flexes to approximately 18° and then begins to dorsiflex, reaching neutral by the end
of this phase. The anterior tibial muscles contract throughout this phase, the foot progressively pronates through the
subtalar joint, and internal rotation of the tibia continues.
In the second part, or foot flat period of stance, the ankle moves from neutral to approximately 18° of dorsiflexion, with
heel rise beginning just before plantar flexion starts to end this phase. During the second phase, the plantar flexors of
the superficial and deep posterior calf compartments are active, controlling the forward motion of the tibia on the talus
(i.e., contracting eccentrically while the ankle dorsiflexes). Early in this phase, the internally rotated tibia begins to
rotate externally, and the foot supinates, becoming more rigid, supported also by the intrinsic muscles of the foot.

In the third and final portion of the stance phase, the ankle plantar flexes from its extreme of dorsiflexion to a little more
than 10° plantar flexion, with continuing contraction of the posterior calf muscles. The tibia remains externally rotated
and the foot supinated; the latter is made even more rigid by the windlass action of the dorsiflexed toes, tightening the
plantar fascia and elevating the longitudinal arch of the foot.

Mann[159] emphasized that the ankle joint's oblique axis determines relative motion of the leg. Heel strike and plantar
flexion produce apparent in-toeing. In midstance, the ankle dorsiflexes as the tibia moves forward, resulting in internal
rotation of the leg. When the heel begins to rise and plantar flexion occurs, the tibia externally rotates. The amount of
observed rotation of the leg is greater than that accounted for by ankle joint obliquity and is in fact accomplished
through motion of the subtalar joint, which is also oblique.

EVALUATION OF THE INJURED ANKLE

History
The major points to be gained from the history of a patient with an injured ankle are (1) how, when, and where the
injury happened; (2) the preexisting status of the injured part; and (3) the overall medical condition of the individual.

The mechanism of injury is only occasionally presented in a way that provides definitive understanding of the direction
and magnitude of applied force and a good clue to the diagnosis ("I stepped on a pebble and my foot turned inward
until I felt a pop on the outside of my ankle"). More often, the actual details are more vague but still helpful ("motorcycle
crash"; "tripped and fell down the stairs"; "jumped off a deck and landed flatfooted"). The location is important in
assessing the likely extent of contamination of an open wound. Elapsed time, correlated with the extent of swelling,
helps in assessing the patient's suitability for certain types of surgery.

The status of the leg before the present injury is also important. It includes, for example, whether the part was normal,
incompletely recovered from a prior injury, subject to recurrent instability or pain, or untrustworthy since a stroke.
Symptoms to be sought are those suggestive of neurologic difficulty, especially peripheral neuropathy, most often
caused by diabetes mellitus. Similarly critical is evidence of vascular disease, venous stasis ulcers, claudication, or
chronic infection. Other factors include pain, deformity, or altered function affecting the ankle or any other part of the
leg. Choice of treatment may be profoundly altered by these factors.

[49]
Systemic illness clearly has an impact on overall management and often on local treatment choice as well. Smokers
have a higher risk of problems with wound and fracture healing. An alcoholic person may not be able to cooperate with
limited weight bearing. A patient with cardiorespiratory disease may not be able to handle the energy cost of walking
with crutches or a cast. A patient with injuries of the opposite leg that prevent weight bearing requires rehabilitation
plans different from those of a patient with an isolated unstable fracture. Information on medications, drug allergies,
and familial problems must be obtained from the patient or from family members or friends.

Physical Examination
Physical examination of the injured ankle is conducted differently depending on the injury. A brief inspection may
reveal severe deformity or an open wound. The challenge then is to identify all elements of the injury and to proceed
rapidly with the treatment required to reduce a dislocation, relieve tension on overlying soft tissues, or decontaminate
and appropriately treat an open wound. Some parts of the examination may not be possible to perform or may even be
inappropriate until later in the patient's course. (For instance, an adequate distal motor examination may be
unobtainable while a fracture dislocation is markedly displaced. Exploration of any significant wound should be
deferred until the patient is in the operating room.)

Conversely, if the patient complains of an ankle injury but the problem is not obvious, it is necessary to carry out a
systematic assessment of each structure in the region before an injury can be excluded or identified. Because injuries
often occur in constellations but may coexist seemingly at random, it is especially important not to terminate the
evaluation after the first positive finding on either physical examination or radiography.
The ankle should be inspected circumferentially for open or impending wounds; crushed, abraded, or swollen areas;
and bone deformity. Pallor may suggest ischemia. Any open wound, even a small one, may communicate with
underlying crushed tissues, a fracture, or a joint, or a combination of these. It is vital to correlate the appearance of the
wound with the patient's history. For example, a small opening in the skin of a patient whose ankle was run over by a
car is not a grade I open fracture. A transverse, seemingly shallow laceration along the lateral surface of the ankle, just
distal to the lateral malleolus, may be the result of rupture of the overlying skin with a severe inversion injury and
complete failure of the LCLs. Such a laceration extends into the ankle joint.

The vascular examination must include palpation of the posterior tibial and dorsalis pedis pulses. Swelling or deformity
may interfere with this. A Doppler device can help identify the pulses, but it reliably assesses flow only if local arterial
pressure is measured with a pneumatic cuff on the calf. Skin temperature, capillary filling after blanching pressure,
venous engorgement, and edema should each be noted. A decision must be made about the adequacy of perfusion,
both before and after any treatment, with measures taken to identify and correct the cause of ischemia rapidly.

The nerves that cross the ankle are assessed by testing light touch and pain sensation in each of their sensory areas.
The sural nerve supplies the lateral heel and lateral border of the foot. The sole of the foot is innervated by the medial
and lateral plantar nerves, branches of the tibial nerve, which also gives medial calcaneal branches. The plantar
intrinsic muscles of the foot are supplied by this system but are hard to test because of the long motors of the toes.
Pain produced in the sole of the foot by forced passive dorsiflexion of the toes may indicate ischemia of the intrinsic
muscles.

The medial border of the foot is innervated by the saphenous nerve. The dorsal webspace between the great and
second toes is the territory of the deep peroneal nerve. This nerve gives motor branches to the short extensors on the
dorsum of the foot. Their contraction can be palpated locally if swelling is not excessive. The superficial peroneal nerve
provides sensation for the majority of the dorsum of the foot.

Function of the tendons crossing the ankle may be difficult to assess but must be checked initially and then reviewed
as a more thorough examination becomes possible. It is necessary to assess the strength generated, not just the
apparent motion of the part.

The Achilles tendon is checked by palpation for tenderness or a defect and by means of Thompson's test. In
Thompson's test, plantar flexion is produced in response to the examiner's squeezing the calf of a relaxed (usually
kneeling) individual ( Fig. 59-16 ). Definitive assessment of integrity and muscle strength of the gastrocsoleus
muscletendon unit requires checking the patient's ability to rise repeatedly on tiptoe, as this powerful muscle group
normally must exert forces far in excess of what is required to move the examiner's hand.

Figure 59-16 Thompson's test. Compression of the calf muscles normally produces plantar flexion of the ankle. If the Achilles tendon is
ruptured, this response is greatly diminished or absent.

The peroneus longus and peroneus brevis lie behind the lateral malleolus and may be locally
tender or palpably displaced if they have been dislocated from their superior retinaculum. The
peroneals evert the foot and should be checked, if possible, before a cast is applied that prevents
this maneuver.
The anterior compartment muscles dorsiflex the ankle and toes. Extension of both the hallux and the lesser toes
should be confirmed. A palpable contraction of the tibialis anterior is often present. This tendon rarely ruptures because
of attrition, but it may be tender and nonpalpable if this has occurred.

The deep posterior compartment muscles are the long flexors of the hallux and lesser digits as well as the tibialis
posterior. This important support for the longitudinal arch of the foot may be injured along with other ankle structures
and may also rupture on an attritional basis or in association with inflammatory arthritis. It inverts and plantar flexes the
foot and should be palpable during performance of these tasks. The toe flexors are tested by checking the strength of
that activity. These tendons should be palpated for tenderness behind the medial malleolus, where dislocation from
beneath the flexor retinaculum occurs occasionally.

It is essential to realize that ankle pain may be the complaint of a patient with a developing calf compartment
syndrome.[11] The pain of compartment syndrome is very severe and poorly responsive to immobilization. Impaired
distal motor and sensory function may be the early manifestation of such a problem, which should suggest a careful
search for calf tenderness, induration, and stretch-induced pain within involved muscle groups. When doubt exists,
measurement of calf compartment pressures may be diagnostic.

When assessing an ankle with less severe injuries, systematic palpation to localize tenderness is especially important.
The cooperative patient with normal sensation and no overbearing pain can often define the injured area quite
precisely because of the superficial location of most of the ankle's structures.

Each of the traversing structures reviewed previously must be checked for tenderness. Each bony prominence should
be assessed as well. Is a malleolus diffusely tender or tender only where a ligament attaches to it? Is tenderness
localized over one or more parts of the LCL, the nearby anterior syndesmosis, or the superficial deltoid ligament? The
deep deltoid ligament is intra-articular and nonpalpable, and may be ruptured without much medial tenderness—a vital
point to remember in assessing its integrity. The posterior syndesmotic ligaments are also buried more deeply and may
be ruptured without well-localized tenderness. The entire fibula must be palpated because standard ankle radiographs
do not demonstrate the occasional fracture of the upper fibula associated with disruption of the ankle joint
(Maisonneuve's fracture).

Examinations for range of motion and stability should be deferred if an obvious injury is present on the basis of either
physical examination or radiographs, which are often obtained before the orthopaedist is asked to see a patient with an
ankle injury. Otherwise, joint motion should be checked. Active and passive dorsiflexion and plantar flexion must be
compared with those of the contralateral side because of the wide range of normal values. The average is about 30°
[146][248]
dorsiflexion and about 30° to 45° plantar flexion. In assessing the ankle's range of motion, it is important to
recognize that a surprising amount of dorsiflexion and plantar flexion occurs in the tarsal and tarsometatarsal joints. A
better estimate of true ankle motion is obtained, as Segal suggested, by measuring the angle between the tibia and the
weight-bearing surface of the foot while the patient dorsiflexes maximally. The angle between the plantar surface of the
heel (only) and the tibia is the measure of plantar flexion.[248] By measuring the angle between the leg and the surface
on which the foot rests, tibiotalar motion can be better distinguished from that of more distal joints.

Inversion and eversion are intimately associated with ankle motion and should be assessed as well. They normally
occur at the subtalar joint, although an ankle with LCL insufficiency may invert at the tibiotalar joint as well. Inversion
stress radiographs are necessary to make this distinction and are thus required if excessive inversion is noted on
examination or a history of recurrent inversion injuries is obtained. Anterior displacement of the foot relative to the tibia
can be produced by performing an anterior drawer test ( Fig. 59-17 ). This finding implies laxity of the anterior
fibulotalar component of the LCL complex. The test may be easier to perform with the patient prone.[94]
Figure 59-17 Anterior displacement of the foot relative to the tibia by the so-called anterior drawer test indicates insufficiency of the anterior
talofibular ligament. This finding should be compared with that on the opposite side and may be quantified radiographically.

Instability of the mortise, with laxity or rupture of the syndesmotic ligaments, is suggested by
sideways movement of the talus within the mortise. This movement may produce pain and may
also be associated with a sensation of the talus'moving laterally or clicking back against the medial
malleolus after having been subtly displaced away from it. A stress view mortise radiograph may
be helpful in confirming such talar instability. The tibia is rotated internally to bring the malleoli into
a plane parallel with the film. The talus is then pulled laterally or externally rotated and is held in
this position while the radiograph is exposed. A control view of the other side may be helpful.
Remember that even a 1-mm lateral shift of the talus significantly decreases ankle joint contact
area.[218]

It is important to check other regional structures that might be injured in association with the ankle or that might lead
the patient to complain of ankle symptoms in spite of the tibiotalar joint's not being directly involved. In particular,
fractures of the anterior process of the calcaneus, the lateral process of the talus, or the base of the fifth metatarsal
may be missed, as might a fracture elsewhere in the calcaneus or talus, a fracture of the navicular, or
osteoligamentous injuries of the midfoot (e.g., a tarsometatarsal dislocation) (see Chapter 60 ).[125] Any findings
suggesting foot abnormalities should lead to a request for additional radiographic projections of the foot, as routine
ankle radiographs poorly demonstrate foot abnormalities.

Radiographic Imaging
Localized malleolar tenderness or inability to bear weight is the best indication to obtain ankle radiographs.[210][271]
Protocols exist to guide decision making on whether to obtain a radiograph in the first place.[184] Routine studies for the
ankle typically include anteroposterior (AP), lateral, and internally rotated mortise views.[54][83][180][181] Evidence suggests
that a mortise and a lateral view are sufficient for intraoperative use.[189] The mortise view is a true AP radiograph of the
ankle joint in a plane parallel to its intermalleolar empirical axis. The traditional AP view, in the anatomic coronal plane,
may provide additional evaluation of medial malleolar screws.[89] If proximal tenderness has been noted, full-length
views of the fibula are essential, as are all other radiographs necessary to evaluate symptoms and signs of other
potential injuries proximal to the ankle. The same holds true, as just noted, for radiographs of the foot.

Additional radiographic studies of the ankle may include one or more of several views. Forty-five degree oblique
radiographs can help identify and assess articular involvement and anatomic details of fractures affecting the distal
tibial metaphysis. Weight-bearing views of the ankle demonstrate the thickness of articular cartilage as well as joint
congruity during loading. They are a valuable part of follow-up evaluations after ankle fractures ( Fig. 59-18 ). Stress
views are the basis for confirming ligamentous instability. Comparison with the opposite ankle is helpful, but symmetric
laxity is not reliably present in normal individuals. Furthermore, in normal ankles, the range of inversion laxity varies
considerably.[225][233] Therefore, judgment must be used in interpreting stress radiographs. In general, they are not
indicated for assessment of an acute ligamentous injury but can be helpful in planning the appropriate management of
a chronically unstable ankle.
Figure 59-18 Weight-bearing radiographs demonstrate the true thickness of the articular cartilage and the congruence of the loaded ankle joint.
Anteroposterior (A) and lateral (B) views.

For assessment of the LCL complex, an anterior drawer lateral view is obtained with the foot supported by a pad under
the heel and a posteriorly directed force applied to the distal tibia. Broström[36] claimed that as little as 3 mm anterior
talar displacement indicates rupture of the anterior talofibular ligament.

Inversion instability of the tibiotalar joint is demonstrated by inversion stress radiographs.[54][107][225][282] These are
perhaps most consistently obtained with specific positioning and loading jigs, but the clinical value of such devices has
not been established. As noted in the section on biomechanics, an inversion stress radiograph in plantar flexion
demonstrates the competence of the anterior talofibular ligament, and one in dorsiflexion demonstrates the
fibulocalcaneal ligament. Gross instability (more than 25° talar inversion) in neutral strongly suggests incompetence of
both the anterior and the middle portions of the LCL complex. Inversion instability may also be caused by excessive
laxity of the subtalar joint. This may be demonstrated with appropriate stress radiographs.[33][302]

Ankle arthrograms and peroneal tenograms have been advocated for assessment of collateral ligament integrity.[282]
Leakage of dye occurs when there is a complete tear of the joint capsule, such as that produced by an LCL rupture.[26]
This rupture can also produce an abnormal communication between the ankle joint and the peroneal tendon sheath,
which lies immediately superficial to the fibulocalcaneal ligament. With the present trend toward functional
management of LCL injuries, clinical justification for confirming a complete LCL rupture is lacking, and these studies
are rarely indicated unless some special indication exists for surgical repair.[62]

Standard tomography (laminagrams) in AP and lateral projections may be helpful in documenting articular surface
deformity, fracture comminution, and osteochondral lesions of the talus ( Fig. 59-19a and Fig. 59-19b ).[40]
Figure 59-19a Painful episodes of giving way developed 9 months after ankle and tibia fractures sustained in a fall from a scaffold. Weight-
bearing radiographs are shown in Figure 59-18 . A, No instability is evident on an inversion stress (arrow) radiograph. B, An oblique radiograph of
the foot shows no abnormality of the anterior process of the calcaneus. C, A repeated plain film taken 2½ months later suggests a defect in the
lateral talar dome. D, Lateral tomogram reveals a cystic lesion of the talar dome.

Figure 59-19b E, Anteroposterior tomogram further localizes the lesion. This underlay a typical small osteochondral fracture, which responded
to excision and drilling of the defect. F, Magnetic resonance imaging coronal view of another patient clearly shows an osteochondral lesion of the
talar dome.
Computed tomography (CT), especially if carefully done with thin sections and maintenance of the patient's
positioning, can be even more informative, as it provides a cross section of the joint that clarifies the
relationship of the fibula to the tibia as well as the fit of the talus within the mortise and the status of soft
tissue structures.[229][230][231][272] Precise measurements are readily obtainable. The extent and location of
articular surface involvement are obvious, and planning of surgical approaches is facilitated. Computer
reconstructions in sagittal and coronal planes currently provide essentially as much information as standard
tomography, which does not offer the cross-sectional view ( Fig. 59-20 ). Although CT scans are rarely
needed for evaluation and treatment of routine malleolar injuries, they are very helpful for assessing plafond
involvement.[156][180][181] CT scans can accurately determine the size and location of posterior malleolar
fractures. Regular radiographs underestimate the size of the latter lesion.[71] If a CT scan is desired after an
ankle has been externally fixed, replacement of the metal connecting rods with radiolucent carbon fiber
composite rods makes it possible to obtain high-quality CT studies. CT cuts through the ankle region can be
made transversely, parallel to the tibiotalar articular surface, or coronally, nearly perpendicular to the injury,
by flexing the knee and tilting the CT gantry. The first are best for assessment of the mortise and pilon
region. The last are now standard for calcaneal fractures and subtalar joint visualization. CT studies may also
aid the evaluation of patients with chronic pain after inversion injuries.[177]

Figure 59-20 Computed tomographic (CT) scan of the ankle provides helpful detailed views of the pathologic anatomy of ankle injuries. A, B, A
transverse CT scan with sagittal and coronal plane reconstructions. C, Coronal plane CT scan of another patient shows impaction of the anterior
lateral margin of the distal tibia.

Magnetic resonance imaging can be valuable for assessing some ankle region injuries, especially occult tendon
ruptures and articular surface disruptions (see Fig. 59-19a and Fig. 59-19b ).

Bone scanning with Tc 99m diphosphonate or an equivalent agent can be helpful in localizing stress or other occult
fractures, infections, and neoplastic lesions.[40][166][170][207]

Other Studies
Ankle arthroscopy through anteromedial, anterolateral, or posterolateral portals may be helpful for diagnosing and
treating osteophytes, loose bodies, osteochondral fractures, ligamentous laxity, and synovitis. Smaller arthroscopes
are helpful; the technology continues to develop. Some means of ankle distraction aids entry and visualization.[279]
Arthroscopy is at present of greatest value for assessing ankles that remain painful after injury, often because of
anterolateral soft tissue impingement or osteochondritis dissecans.[69][101][164][206]

Arteriography, noninvasive vascular studies, and pulse oximetry can be helpful for assessing and monitoring perfusion
distal to an injured ankle. Compartment pressures may need to be measured in the leg or foot. Nerve conduction
velocities and electromyography may be helpful for assessing lesions of the tibial nerve, such as tarsal tunnel
syndrome.
Essential Studies to Exclude Other Injuries
A careful history and physical examination are the basis for identifying all of a trauma patient's injuries. Assessment
(and documentation) of peripheral pulses is essential to avoid missing limb-threatening ischemia. If the patient is not
conscious or is not able to cooperate, routine radiographs of the pelvis and spine are essential. An ankle fracture may
be the only outward sign of a fall from a height or a high-velocity motor vehicle crash. Inspection, palpation, and
assessment of range of motion and stability of the lower extremity proximal to the ankle are fundamental. Radiographs
up to and including the pelvis should be obtained unless the physical examination is completely normal.

Differential Diagnosis
It is wise to modify the traditional concept of differential diagnosis when dealing with trauma, especially in the ankle
region. Rather than thinking in terms of a list of potential diagnoses to be excluded one by one, the surgeon must
remain constantly aware of the likelihood of more than one lesion.[85][136][185][193][289] In addition to indicating local
structural damage, ankle pain may be the complaint of a patient with a leg compartment syndrome, proximal
neurovascular compromise, or a foot injury. Table 59-3 is a list of various injuries that can affect the structures of the
ankle.

Table 59-3 -- Injuries of the Ankle Region

BONE INJURIES (FRACTURES)
Malleolar
Metaphyseal—split
Metaphyseal—impacted
Ligamentous avulsion
Joint capsule avulsion
Other nearby fractures
Base of fifth metatarsal
Lateral process of talus
Anterior process of calcaneus
Tarsometatarsal complex
Many other possibilities
ARTICULAR SURFACE INJURIES
Fractures, as above, with articular involvement
Osteochondral fractures (predominantly talus)
LIGAMENT INJURIES
Lateral collateral complex injuries
Syndesmosis injuries
Medial collateral injuries
Injuries to other nearby ligaments
Subtalar
Tarsometatarsal
Midtarsal
SOFT TISSUE ENVELOPE INJURIES
Laceration
Contusion extending to crush injury
Avulsion or degloving
Foreign body retention
Edema
Preexisting compromise
TENDON INJURIES
 Intrinsic injury
Rupture
Laceration
Retinacular injury
Rupture; tendon dislocation
NERVE INJURIES
Laceration
Contusion
Entrapment
VASCULAR INJURIES
Arterial
Venous

MANAGEMENT OF ANKLE FRACTURES

General Principles
Adequate assessment and treatment of the entire patient and the entire injured limb generally have a higher priority
than assessment and treatment of the ankle (see Chapter 5 ). However, significant permanent disability, including that
from amputation, can be prevented by adequate care of an ankle injury. After lifesaving and limb-saving measures are
under way, the ankle injury must not be neglected. Priorities for the ankle itself include both diagnosis and treatment, in
the following order: (1) assurance of adequate blood flow; (2) provisional reduction of marked deformity or dislocation;
(3) care of any open wound or other injury to the skin and soft tissue envelope; (4) precise reduction of skeletal
deformity, which must be maintained throughout healing; (5) repair of tendons and nerves; (6) rehabilitation; and (7)
identification and treatment of any complications that develop.

Without adequate perfusion, the foot cannot survive. Therefore, it is crucial to recognize ischemia. Except in the case
of a mangled foot and ankle, it is unusual for an ankle level arterial injury to be limb threatening, probably because
three arteries cross the region. Thus, if the foot is ischemic, one must look for a more proximal arterial lesion. Some
injuries are unsalvageable, or an attempt at salvage may pose too much of a threat to the patient. For such patients, an
early amputation is the best treatment. This topic is discussed in further detail in Chapter 57 . An exceptional patient
with an injury that is more of a laceration than a crush may be a candidate for local microvascular reconstruction or
even replantation of a traumatic incomplete or complete amputation.

Marked deformity, usually resulting from a dislocation, fracture-dislocation, or severely displaced fracture, poses a
threat to the local perfusion of skin stretched over bony prominences. It promotes local swelling and may also interfere
with distal blood circulation. In addition, it is often quite painful and may injure articular cartilage impinged on by a
sharp bony edge. Therefore, provisional reduction to improve local perfusion and prevent further injury is urgent.
Application of a very well padded splint should follow. Although not always successful, an attempted manipulation in
the emergency department often yields at least some improvement and is an appropriate part of applying a splint. It is
better to return exposed and contaminated bone to the wound than to splint it in a position of excessive deformity.
Because urgent operative wound care must soon follow, the benefits of correcting deformity outweigh the theoretical
risks of introducing additional contamination into an already dirty wound.

Care of the soft tissues, including any open wound, is a vital element in the management of an injured ankle. There is a
[281]
surprising spectrum of both open and closed soft tissue injuries. Some low-energy ankle injuries have so little soft
tissue damage that it may be ignored. There is little swelling, and surgery, if indicated, can be carried out safely any
time after the injury. These injuries may lull the surgeon into thinking that all ankle injuries can be similarly treated. A
high-energy injury with extensive displacement of comminuted, impacted, and transverse fractures may not exhibit
much swelling during the first few hours, especially if the patient is in shock. However, such fractures are accompanied
by a high degree of soft tissue trauma, even if there is no open wound, and have very low tolerance for extensive
surgical approaches. Although all operations on ankle fractures must be done as atraumatically as possible, such
severe crushing injuries should be approached with trepidation, if at all.[32][61][273][275] Certainly, if there is evidence of soft
tissue compromise—marked swelling, blistering, abrasions, or early eschar formation—whatever the fracture pattern,
the surgeon must consider external fixation and should be willing to delay open reduction for several weeks if
necessary until the soft tissues recover.

Open wounds involving fractures and dislocations of the ankle represent only a part of the soft tissue damage. The
zone of injury extends beyond the open wound.[51][281] Each such open wound should be treated as any open fracture,
with sterile dressing, splint, tetanus prophylaxis, and urgent intravenous antibiotics (generally a first-generation
cephalosporin for less severe wounds, with an aminoglycoside or substitution of a third-generation cephalosporin for
those that are more severe). In addition to these adjuncts, prompt surgical débridement and irrigation in an operating
room are crucial to minimizing the risk of serious infection. If a fracture is present, immediate fixation with appropriate
techniques offers better results. With less severe injuries, fixation techniques are essentially the same as for closed
injuries. For more severe injuries, it may be appropriate to minimize the extent of surgical exposure and to employ
external fixation, at least provisionally, to immobilize both the foot and the ankle. In either case, the original open
wound is left open for delayed closure.

Articular fractures of the ankle have the best prognosis when they heal in an alignment as close as possible to their
original anatomy. It is generally accepted that the quality of the reduction is more important than whether it was
achieved with an open or a closed technique. With this recognition and with the development of internal fixation
methods that reliably maintain the tibiotalar relationship, open treatment of malleolar fractures has become more
popular. When AO principles and techniques are properly applied to malleolar fractures, good results can be obtained
in up to 90% of supination-external rotation malleolar fractures. Other fixation techniques have their proponents, but
[200]
they are now less widely favored, at least in North America. As Olerud and Molander have shown, less rigid fixation
with wires, pins, or staples works well for more stable unilateral injuries, but when there is involvement of both sides of
the ankle, reduction is more likely to be lost.

Fractures of the ankle vary widely in severity. Their effect on ankle stability and on the articular surface may range from
minimal to profound. Treatment of the fracture itself depends on its location, size, displacement, and effects on joint
stability. Opinions and recommendations for management of ankle fractures range equally widely, from nonoperative
management to anatomic repair of every fragment. Clearly, the treating surgeon must make a decision on the basis of
the reported results of injuries and treatment, the patient's injury and other characteristics, and his or her own personal
experience and expertise. Stable restoration of normal anatomy in the safest and most reliable way ought to be the
basic guideline for treatment of articular fractures about the ankle.

If any tendon injury accompanies or is the major component of ankle trauma, its surgical repair must be
considered.[73][268] In some patients, closed nonoperative treatment of a ruptured Achilles tendon may be
appropriate.[10][143] Unless repaired early, failure of the posterior tibial tendon usually results in a symptomatic flatfoot
deformity.[159][160] Lacerations or ruptures of other tendons may also prove less disabling if they are repaired. Therefore,
such tendon injuries often require surgical treatment, but only if there is an open wound is such treatment urgent.

The most disabling nerve injury of the ankle region is loss of the tibial nerve, which provides sensation for the sole of
the foot. Some have advocated amputation when adults sustain this injury along with an otherwise treatable arterial
injury because of the high risk of neurotrophic ulcers and their complications.[137] Such problems are more common
when the foot and ankle are stiff and deformed and do not necessarily accompany absence of plantar sensation. If
nerve continuity is present, functional recovery may occur, even after many months. A temporary but prolonged period
of dysesthesia may accompany recovery of tibial nerve function, either spontaneously or after repair. It may also
persist after an injury to the nerve and may respond to nerve repair. Experience with treatment of lower extremity nerve
injuries is rare. Sedel[247] recommended that microsurgical repair be considered for complete lesions of the major lower
extremity nerves. Seddon,[246] reviewing a large number of patients, few of whom were treated surgically,
recommended against nerve repair but emphasized the good functional result that can be obtained, even with a
complete tibial nerve palsy.[48]

Injuries of the other nerves crossing the ankle can become painful because of neuromas that are caught in the scar.
This problem may be prevented by transecting the injured nerve and burying it deeply in soft tissue, away from scar
and moving structures.

The ankle's ligaments are frequently damaged. The syndesmosis (distal tibiofibular ligaments) may be disrupted in
association with a fibular fracture. If it is unstable after the associated fracture has been repaired, surgical fixation of
the syndesmosis is the safest way of ensuring healing with stability in the correct configuration. Syndesmosis fixation
may not be required, especially if the AITFL or PITFL has caused an avulsion fracture that permits stable repair of the
ligament's attachment. Assessment of the stability of the tibiofibular relationship (as discussed later) is an essential part
of the operative treatment of any malleolar injury with a fibular fracture above the level of the plafond.
Acute surgical repair of the completely ruptured LCL complex has been advocated by a number of authors.[3][36][67][116]
Although this repair may improve apparent stability, it does not seem to provide a better result than functional
treatment, which has now become the more favored approach, even for vigorous athletes.[66][262] Should late instability
occur, delayed repair is as successful as primary suture, but it is not frequently required after adequate functional
management and rehabilitation.[42][140]

The medial collateral ligament (MCL) is rarely injured without a malleolar fracture.[113] When it occurs, deltoid ligament
failure is often the equivalent of a medial malleolar fracture, and unless the talus is visibly displaced when radiographs
are taken, the injury may be missed. Its repair has been advocated for unstable malleolar injuries, but this does not
effectively stabilize the talus. Moreover, it is unnecessary if the lateral malleolus has been restored securely to its
anatomic location. Isolated late insufficiency of the deltoid ligament is practically unheard of in spite of nonoperative
treatment, so skepticism about the need for primary repair of ruptured deltoid ligaments seems warranted.

Rehabilitation of ankle injuries emphasizes maintenance of a neutral functional position, protection of the injured area
from excessive forces, restoration of motion, and progressive resumption of weight bearing as soon as safe. Many
different approaches and recommendations exist. Whether one is better than another remains questionable.[1][249] The
surgeon who has managed the entire treatment of a patient with an ankle fracture and knows the quality of bone and
fixation is best equipped to manage the rehabilitation phase, as this information is not as readily conveyed to therapists
and other personnel. Finally, restoration of strength, endurance, and agility is necessary before a patient completes her
or his recovery.

Complications that may develop during care of ankle injuries are discussed later. Especially important to avoid, and to
recognize if they occur, are infection, skin slough, malalignment, loss of fixation, nonunion, and reflex sympathetic
dystrophy with its variants. Infection after open injury or surgical treatment may be occult and may involve the ankle
joint itself. Diagnosis requires a high index of suspicion and aspiration of the joint for Gram stain, cell count, and culture
and sensitivity testing. Wound exploration in the operating room may also be required. Skin sloughs, unless very small,
usually require plastic surgical repair, typically with a free flap in this region, which has limited local soft tissue.
Malalignment can be identified with adequate intraoperative radiographs. Patients being treated with cast
immobilization require regular follow-up radiographs with strict assessment according to standard criteria for reduction.
Fixation loss can be prevented by good technique and appropriate postoperative management. If it should occur,
reoperation is usually indicated. Nonunions, if symptomatic, need open reduction and often bone grafting. Reflex
sympathetic dystrophy should be considered as a potential cause of pain. Even after apparently satisfactory fracture
healing with an anatomic reduction, minor degrees of arthrosis are common, and 25%to 30% of patients have at least
[20]
some degree of subjective complaints.

Special Considerations for Polytrauma Patients

As noted previously, most other injuries take precedence over definitive treatment of the ankle. Evaluation with as
much history as possible, a brief physical examination, and application of a well-padded splint with provisional
reduction of dislocation or gross deformity may be all that can be done for some time. Adequate radiographs are
necessary for definitive diagnosis and treatment. If life- or limb-threatening injuries require urgent attention,
radiographs of the ankle should be deferred until the earliest appropriate time and can certainly be obtained in the
operating room. Although operative treatment of an open wound should be accomplished as soon as possible, fracture
fixation may need to be deferred for some time.

If soft tissue injury is severe or if a distraction force is needed to maintain reduction, an external fixator including the
tibia, calcaneus, and metatarsals is advisable and can be applied rapidly. This fixator maintains a neutral foot position,
provides access to soft tissue wounds, and permits suspension and continuous elevation of the injured limb. For less
severe injuries, a plaster cast or splint maintains a provisional reduction and allows the patient to be mobilized in bed
and chair while maintaining as much elevation as possible of the injured leg. It is important to use a great deal of
padding, especially posterior to the heel. If the injury is rotationally unstable, a short extension onto the thigh with the
knee moderately flexed improves the effectiveness of such a cast or splint. It is important to gain the best possible
provisional reduction and immobilization, for the multiply-injured patient may not be able to return to the operating room
as soon as initially planned for definitive care of the ankle. Marked displacement or instability may cause further
damage to the soft tissues. Ankle injuries for which operative treatment is optimal can often have this deferred for up to
a week or two without significantly compromising the ultimate result, if the patient's overall condition makes this
[132]
advisable and if adequate interim management is provided for the ankle.
CLASSIFICATION
Hamilton thoroughly and lucidly discussed malleolar fractures in his text Traumatic Disorders of the Ankle.[96] A number
of other helpful summaries are also available. This section reviews the pathophysiologic findings of Lauge-Hansen and
others to provide an understanding of injury patterns as related to mechanism. It then offers the Danis-Weber (AO)
classification as a practical clinical scheme and uses it as the basis for discussing treatment of malleolar fractures.[149]
As will become evident, the details of treatment depend more on the actual anatomy of a bone and ligament injury than
on its classification according to any system. However, the more thoroughly the surgeon understands the fracture
anatomy, the better he or she can plan and carry out effective treatment.

Lauge-Hansen
It is important to clarify Lauge-Hansen's terminology before considering his experiments and classification. His names
for fracture types refer to how he caused them in experiments with cadaver legs that were secured proximally while he
manipulated the foot. The first part of the name is the position of the foot—either supination or pronation. The second
part of the name indicates the force that was applied to cause the observed injury—external rotation, abduction, or
adduction. Unfortunately, Lauge-Hansen used the word eversion to mean external rotation and thus magnified the
complexity of his terminology.[141][142] Figure 59-21 illustrates the Lauge-Hansen malleolar fracture classification and the
corresponding Danis-Weber categories.

Figure 59-21 Correlation of the Danis-Weber (AO/ASIF [Association for the Study of Internal Fixation]) and the Lauge-Hansen classification
systems for malleolar fractures. The Danis-Weber system is based on the level of the fibular fracture, and the Lauge-Hansen system is based on
experimentally verified injury mechanisms. Type B injuries can be produced by two mechanisms: supination-external rotation and pronation-
abduction. See text.
SUPINATION-ADDUCTION
Adducting the supinated (inverted) foot, usually from unanticipated weight bearing on the lateral border, is the most
common mechanism of injury to the ankle. Failure occurs first on the lateral side, which is under tension, and is usually
limited to the LCL, which may be avulsed with a portion of the distal fibula. This mechanism thus produces the typical
inversion sprain. Avulsion fractures are recognizable as characteristically transverse, perpendicular to the applied
force. The second stage of this injury, produced by continued adduction of the supinated foot, is a shearing, medially
displaced fracture of the medial malleolus, which is pushed medially by the talus. This mechanism causes a vertical
fracture line that is distinct from the horizontal failure produced by tensile loading. It accounts for 10% to 20% of
malleolar fractures ( Fig. 59-22 ).[96]

Figure 59-22 Supination-adduction injury pathology. The first stage is lateral failure of either the malleolus or the collateral ligament. The
second stage is a vertical fracture of the medial malleolus, which may be associated with medial plafond impaction, as shown here.

The characteristic vertical appearance of the medial malleolar fracture reveals the injury mechanism, even if the lateral
failure is purely ligamentous. It is important to note that an undisplaced or minimally displaced medial malleolus
fracture may be produced by this mechanism without lateral failure if sufficient preexisting lateral laxity is present.
Because of the compressive forces applied medially, supination-adduction may produce impaction of the medial
plafond in addition to the medial malleolus fracture ( Fig. 59-23 ).
Figure 59-23 A supination-adduction stage II fracture with significant impaction of the medial tibial plafond. The type A lateral malleolus fracture
is undisplaced on this radiograph but was unstable to examination during surgery.

Oblique fractures of the medial malleolus are not often differentiated from vertical ones. Giachino and
Hammond[82]pointed out that they should be, because of their mechanism involving dorsiflexion as well as abduction
and external rotation, which also produces a frequently occult, impacted anterolateral tibial plafond fracture. These
oblique medial malleolus fractures are avulsion injuries rather than impacted ones and therefore are unstable in
tension and better treated with internal fixation.

SUPINATION-EXTERNAL ROTATION
External rotation of the supinated foot produces a common fracture pattern and is the cause of 40% to 75% of
malleolar fractures.[96] The pattern is a spiral oblique fracture of the lateral malleolus, beginning at the level of the tibial
plafond and extending a variable distance proximally ( Fig. 59-24 ). The plane of this injury is predominantly frontal, so
it is typically more evident on the lateral than on the AP or mortise radiograph, unless there is significant displacement.
The mechanism of the fibular fracture is a rotational shearing force produced by pressure on the fibula by the talus
while the tibia internally rotates, usually because of the body's falling to the opposite side.[161]

Figure 59-24 A slightly displaced supination-external rotation fracture of the lateral malleolus shows the typical pattern of fibular fractures
caused by this mechanism. The overall plane of the fracture is oblique, from low anteriorly to high posteriorly, so that displacement is more evident
on the lateral than on the anteroposterior view.

Lauge-Hansen demonstrated that during external rotation injuries, failure of structures around the ankle occurs
sequentially in a characteristic order. In supination-external rotation injuries, the first to fail is the AITFL, followed by the
fibula, then the PITFL, and then the medial side of the ankle mortise, where tensile failure may produce either a rupture
of the deltoid ligament or a generally transverse avulsion fracture of the medial malleolus ( Fig. 59-25 ). Knowledge of
the several components and sequence of injury brings some order to an otherwise chaotic collection of bone and
ligament injuries. This can help the surgeon identify an occult ligamentous injury or guide treatment.

Figure 59-25 Supination-external rotation injury pathology. The first stage is failure of the anterior inferior tibiofibular ligament (AITFL). The
second stage is a spiral lateral malleolar fracture at the level of the plafond. The third stage is posterior inferior tibiofibular ligament (PITFL) failure.
The fourth stage is medial failure of either malleolus or the deltoid ligament.

Note that in supination-external rotation injuries, the fibular fracture is at or just above the level of the plafond, so that
even with failure of the AITFL and the PITFL, the more proximal syndesmotic components stabilize the fibular shaft.
Thus, open reduction and internal fixation (ORIF) of the fibular fracture should restore the proper relationship of the
lateral malleolus to the distal tibia. Stability is not guaranteed, however, because it depends on integrity of the
interosseous tibiofibular membrane above the fracture. Occasionally, this structure is disrupted, explaining why
mortise-syndesmotic stability needs a case-by-case analysis.

Although the general pattern of each type of malleolar fracture is usually consistent, a moderate amount of variation is
seen. Thus, the supination-external rotation injury can be identified by its typical fibular fracture pattern. If it is explored
surgically, the AITFL disruption is obvious. The disruption may be through the substance of the ligament, by avulsion of
a bone fragment from Chaput's tubercle on the tibia, or by avulsion of its fibular attachment, called the Wagstaffe (Le
Fort) tubercle. This ligament can guide reduction of the normal tibiofibular relationship, and its repair may aid in the
secure healing of the syndesmosis. Although most supination-external rotation fibular fractures are at the level of the
[202]
ankle joint, the same pattern, resulting from the same mechanism, is occasionally seen at a higher level.

After the fibula, the PITFL is next in order of failure. Because of its posterior location, it is not exposed as often during
surgical treatment of malleolar fractures. It may fail in substance or by avulsion of its tibial attachment, often as a small,
extra-articular "posterior malleolar" fragment but occasionally as a large, intra-articular one. These posterolateral tibial
tubercle avulsion fractures are sometimes referred to as Volkmann's fragments.

The medial and final component of the supination-external rotation injury may be either a fracture of the medial
malleolus or a rupture of the deltoid ligament.[119] Rarely, a hybrid lesion is seen, with fracture of the anterior colliculus
representing superficial deltoid ligament failure and rupture of the fibers of the deep deltoid ligament while the posterior
colliculus remains intact[253] (see Fig. 59-32 ).
Figure 59-32 In spite of anatomic reduction of the medial malleolus, the talus is laterally subluxated, as it is not stabilized by the malreduced
lateral malleolus. The deep deltoid ligament is disrupted.

The surgeon must remember that an ankle with a radiologically apparent supination-external rotation fracture of the
lateral malleolus may have a completely unstable stage IV injury, with the deltoid ligament ruptured medially, or a
stable stage II injury, with an intact posterior syndesmosis and medial complex. Lateral talar shift, a posterior lip
fragment, and significant displacement of the fibular fracture are all evidence for more than a stage II injury. Differential
diagnosis is important because true stage II injuries do well with nonoperative weight-bearing treatment, even though
the potential for some lateral mobility of the talus is present.[19][44][107][134] However, if the injury is an unrecognized stage
IV, then talar subluxation, malunion, and arthrosis are potential sequelae that are preventable with surgery. If doubt
exists, follow-up radiographs should help identify an initially unrecognized deltoid ligament disruption.

PRONATION-ABDUCTION
Forced abduction of the pronated foot is responsible for this category of ankle injuries and typically fractures the fibula
at the level of the plafond. This pattern accounts for 5% to 21% of malleolar fractures.[96] Pronation-abduction fibular
fractures are distinguished from supination-external rotation injuries by their different pattern, which is transverse and
often laterally comminuted, as bending forces applied to the fibula result in medial tension and lateral compression (
Fig. 59-26 ). Some such injuries may be hybrids, with initiation by abduction followed by rotation externally about the
axis of the PITFL.[84] The transverse orientation and lateral comminution, which may be extensive, make ORIF of
pronation-abduction injuries more difficult than it usually is for supination-external rotation injuries.

Figure 59-26 Pronation-abduction fracture demonstrating a laterally comminuted, fairly transverse fibular fracture just above the plafond.

Lauge-Hansen demonstrated that the initial stage of failure (essentially a mirror image of the supination-adduction
pattern) is medial tensile failure, either through the deltoid ligament or with a transverse avulsion fracture of the medial
malleolus. The second stage is rupture or avulsion of the AITFL and PITFL of the syndesmosis. The third stage is the
fibular fracture ( Fig. 59-27 ). Limbird and Aaron[148] emphasized that these injuries may have an associated impaction
fracture of the lateral plafond, also analogous to the supination-adduction pattern. Although the syndesmotic fibers
proximal to the level of a pronation-abduction fracture are usually intact, the fracture itself may be proximal enough that
these fibers offer little stability to the tibiofibular relationship. Therefore, after repair of a pronation-abduction fibular
fracture, as with a supination-external rotation fracture, it is important to assess the stability of the syndesmosis.
Figure 59-27 Pronation-abduction injury pathology. The first stage is medial failure of either malleolus or the deltoid ligament. The second stage
is syndesmosis (anterior inferior tibiofibular ligament and posterior inferior tibiofibular ligament) disruption. The third stage is a bending fracture of
the lateral malleolus with a transverse, laterally comminuted pattern.

PRONATION-EXTERNAL ROTATION
With external rotation of the pronated foot, Lauge-Hansen produced another pattern of malleolar injury ( Fig. 59-28 ). In
this case, because the medial structures are placed under tension by pronation, the initial failure occurs on the medial
side with either deltoid ligament rupture or avulsion of the medial malleolus. In the second stage, the AITFL fails. The
pathognomonic third stage is a spiral or oblique fracture, which typically runs from anterior proximally to posterior
distally, rather than the reverse pattern seen in supination-external rotation fractures.[202] The location of the pronation-
external rotation fibular fracture is its most important characteristic, for it is above the level of the ankle joint plafond.
This level of fibular fracture is the hallmark of the Danis-Weber type C malleolar injury ( Fig. 59-29 ). A pronation-
external rotation mechanism can produce a fibular fracture in the proximal leg in conjunction with other malleolar
lesions—the Maisonneuve fracture. Thus, an apparently isolated medial or posterior malleolar fracture should lead to a
search for a proximal fibular fracture. The fourth stage is disruption of the PITFL osteoligamentous complex. Pronation-
external rotation injuries account for 7% to 19% of malleolar fractures.[96]
Figure 59-28 Pronation-external rotation injury pathology. The first stage is medial failure of either malleolus or the deltoid ligament. The second
stage is anterior inferior tibiofibular ligament disruption. The third stage is a spiral fracture of the fibula above the level of the plafond. The fourth
stage is posterior inferior tibiofibular ligament failure, demonstrated as a posterior malleolar failure.

Figure 59-29 Radiograph of pronation-external rotation ankle fracture. This stage IV injury has a ruptured deltoid ligament; a laterally displaced
fibula, indicating complete syndesmosis disruption; and a supra-articular short spiral fracture of the fibula, with orientation from low medial to high
lateral.
Thus, disruption occurs in the same direction around the ankle as it does with supination-external rotation injuries, but
the starting point is medial instead of anterolateral. Because supra-articular fibular fractures can also be produced by
supination-external rotation, a stage IV injury may be assigned to one category or the other on the basis of the
appearance of the fibular fracture.[202][203] Furthermore, a type C fibular fracture with little displacement may be a stable
stage II supination-external rotation fracture.

Danis-Weber
This system classifies ankle fractures into three groups, A, B, and C, on the basis of the level of the fibula fracture in
relation to the tibial plafond.[188]

Type A fractures involve the fibula distal to the level of the tibial plafond. Supination-adduction would be a typical
mechanism. Therefore, the syndesmosis is rarely damaged. The fibula fracture pattern tends to be transverse, with
medial pathology that is seen with supination-adduction forces.

Type B fractures involve the fibula at the level of the plafond. Supination-external rotation and pronation-abduction
both cause fractures at this level. Although components of the syndesmosis are routinely injured, functional instability
is unusual. This stability is due to sparing of the tibiofibular interosseous membrane proximal to the fibula fracture.
Medial pathology is that seen with either of these two mechanisms.

Type C fractures involve the fibula above the level of the plafond. Pronation-external rotation is the typical force
involved. Thus, all syndesmotic ligaments at the plafond are torn. Tearing of the tibiofibular interosseous membrane
extends at least to the level of the fibula fracture. Syndesmotic stability of the ankle once again is related to the level of
the tearing of the tibiofibular interosseous membrane as previously discussed.

AO-Orthopaedic Trauma Association

This classification is essentially a detailed, numerically based expansion of the Danis-Weber classification. However,
as with other detailed classifications, it probably suffers from interobserver and intraobserver variability. It is
cumbersome for day-to-day usage. It is an important research and publication tool. The reader is encouraged to use it
for such purposes. It can be found as Supplement I, Volume 10, 1996 in the Journal of Orthopaedic Trauma.

Significance of Classification

An important point about the supra-articular type C fibular fracture is that the entire ligamentous connection between
the distal tibia and the distal fibula may have failed, whether through the radiolucent ligaments or by avulsion of a bone
fragment. The need for operative stabilization of the syndesmosis is more likely with type C injuries and may be
confirmed by a stress test after fixation of the malleolar fracture.

Occasionally, with type C fibula fractures, remaining ligamentous connections are sufficient and additional
syndesmosis fixation is not necessary. If the supra-articular fibular fracture is caused by a stage II supination-external
rotation mechanism, as demonstrated by Pankovich,[202] displacement is less and the ankle may be quite stable.[276]
The potential for instability of the syndesmosis is the rationale for the separate category of type C injuries in the Danis-
Weber classification system.[223]

Neither the Lauge-Hansen nor the Danis-Weber classification provides with the categories a complete indication of the
pathology present and the treatment required.[149] A Lauge-Hansen grade IV supination-external rotation injury may or
may not have an unstable syndesmosis, a posterior articular lip fracture, an unstable fracture-dislocation, or a medial
malleolus fracture. It may even have a high fibular fracture. A Danis-Weber type A injury may or may not have a lateral
malleolus fracture, a medial malleolus fracture, or a medial articular plafond impaction. However, with a little more
anatomic detail, such classification systems provide an efficient means of categorizing and describing malleolar injuries
and developing a treatment plan.

Atypical Malleolar Fractures

A certain number of malleolar fractures are not classifiable according to the schemes presented. Those caused by
direct crushing or angulating forces, as seen often in open injuries, frequently fall into this category.[77][195] The so-called
Bosworth fracture-dislocation has a fracture just above the plafond with marked external rotation of the foot. The end of
the proximal fibular segment is incarcerated behind the tibia and usually requires open reduction.[105] Rarely, the fibula
may be dislocated anteriorly.[243]In cases of atypical malleolar fractures, careful analysis of the pathoanatomy should
lead to appropriate anatomic reduction.[197]

DEFINITIVE TREATMENT

Malleolar Fractures

Malleolar injuries are the most common significant lower extremity fracture.[57] Thus, most orthopaedic surgeons are
frequently called on to treat them. The understanding and philosophy of management of these injuries have changed
significantly since the 1970s. Current approaches appear to produce better results with fewer problems and more rapid
rehabilitation. However, some controversies remain, and complications still occur.

Using the Danis-Weber classification, this section reviews the general principles of treatment for each injury pattern.
Thereafter, details of operative management are provided. The basis of treatment for malleolar fractures is the secure
restoration of a normal tibiotalar relationship. This means anatomic repositioning of the talus under the plafond, with
anatomic realignment of the articular surface of the lateral malleolus to the plafond as well. In a displaced malleolar
fracture, the lateral malleolus follows the talus. If it is reduced and heals in its anatomic relationship with the ankle
plafond, it restores and maintains the proper tibiotalar relationship.

Assessing the reduction of the talus requires adequate radiographs and careful scrutiny of the relationships between
the plafond and the talar dome, between the lateral articular surface of the talus and the lateral malleolus, and between
[208][267]
the lateral malleolus and the distal tibial articular surface. Reduction of the fibular fracture site is, of course,
helpful. However, the lateral malleolar fracture is extra-articular, and it is the restoration of articular congruence that is
our primary goal. Length, rotation, and obliquity of the distal fibula are all-important aspects of a successful reduction.
The fibula must be appropriately seated in its incisural notch. Because of its greater distal diameter, proximal
displacement of the lateal malleolus interferes with the fit of the malleolus in this notch, displacing the fibula laterally
and thus widening the mortise. A comparison radiograph of the opposite ankle and, occasionally, a CT scan are helpful
tools for assessing the adequacy of lateral malleolus reduction.

Figure 59-30 demonstrates the radiologic landmarks for assessing the relationship of the lateral malleolus to both the
talus and the distal tibia. It is important to remember that a good closed reduction and a well-molded cast often align
the talus satisfactorily. However, unless the lateral malleolus heals anatomically, it cannot maintain talar position after
the cast is removed. Therefore, the surgeon must assess the position not only of the talus but also of the lateral
malleolus. Failure to reduce the fibula anatomically with a closed reduction is a prime justification for opening an
unstable malleolar fracture in an effort to minimize the risk of post-traumatic arthrosis. This goal is more relevant in the
young, active, healthy individual, for slight deviations from an anatomic alignment are often well tolerated by an older,
more sedentary patient. There are as yet no conclusive and well-accepted criteria, based on long-term clinical outcome
studies, for the limits of a satisfactory reduction. Other factors also affect the results.[20] The importance of an accurate
reduction has been convincingly demonstrated for more severe injuries,[149] but minor degrees of displacement in
relatively stable injuries do not have dire consequences, as shown by two long-term follow-up studies.[19][44][134] Rarely,
if ever, is primary ankle arthrodesis recommended for malleolar fractures.[270]
Figure 59-30 Restoration of the ankle mortise requires anatomic reduction of the lateral malleolus so that its articular surface is congruous with
the reduced talus. A, On a mortise view radiograph, the condensed subchondral bone should form a continuous line around the talus, and there
should be no proximal displacement, malrotation, or angulation of the lateral malleolus. B, C, A proper talocrural angle and normal joint space
width also indicate normality. The medial joint space should be less than 4 mm and the superior joint space within 2 mm medially of its width
laterally. D, Adequate tibiofibular overlap on the anteroposterior view indicates a proper syndesmotic relationship. The space between the medial
wall of the fibula and the incisural surface of the tibia should be less than 5 mm. The anterior tubercle of the tibia should overlap the fibula by at
least 10 mm. E, F, Talar malalignment is indicated by its lateral displacement or tilt into valgus. G, Although the talus may be reduced by external
pressure, its alignment is not maintained by a shortened, malrotated lateral malleolus, as shown.

Treatment Principles
TYPE A INJURIES
Type A injuries, caused by supination-adduction mechanisms, produce a tensile failure on the lateral side with either
LCL disruption or a transverse distal fracture of the lateral malleolus. On the medial side, an oblique medial malleolus
fracture may be present, rarely in isolation. The medial malleolar fracture may be more or less displaced, may extend
into the posterior articular surface, and may be associated with an impacted fracture of the medial plafond beginning
just lateral to the malleolar fracture line. The syndesmosis is rarely affected.

Truly undisplaced fractures of either malleolus do not require surgical treatment and can be managed well with a short
leg cast. Some displaced supination-adduction fractures of the medial malleolus with either a fracture or a ligament
rupture laterally can be reduced with a maneuver that reverses the mechanism of injury and corrects both angulation
and displacement by abducting the hindfoot. Overreduction is not likely, so a significant force can be applied and the
position maintained with a well-padded short leg cast molded medially over the talus and calcaneus to maintain a
valgus alignment of the hindfoot. Radiographic monitoring of the reduction is necessary.

If there is significant articular surface impaction, plafond incongruity resulting from a posteromedial fracture line, or an
inadequate closed reduction, ORIF is indicated. Isolated, purely ligamentous lateral injuries can be managed
satisfactorily nonoperatively (see "Lateral Collateral Ligament Injuries"). However, repair of the LCL is a relatively minor
procedure that may protect an unstable medial reconstruction. A type A lateral malleolus fracture should generally be
fixed for similar reasons unless the medial side is very secure and the lateral malleolus is completely undisplaced.
Displaced medial malleolar fractures should be fixed unless an anatomic closed reduction is obtained and preserved.
The same is true if there is plafond distortion by either a posteromedial fragment or an impacted area that requires
elevation, usually with bone grafting of the resulting defect ( Fig. 59-31 ). Depending on bone quality, security of
fixation, and extent of plafond involvement, postoperative weight bearing may need to be restricted.

Figure 59-31 A, This stage II supination-adduction fracture has significant plafond impaction medially. B, The impacted fragment was reduced
through the medial malleolar fracture plane. The defect was filled with local cancellous graft, and the fracture was stabilized with cancellous
screws and a K-wire.

TYPE B INJURIES
Type B injuries may be caused by either a supination-external rotation or a pronation-abduction mechanism. The
syndesmosis is occasionally disrupted. The medial injury may be an avulsion fracture of the medial malleolus, an MCL
rupture, or occasionally a combined lesion. Anatomic reduction and fixation of the medial malleolus cannot be counted
on to reduce and maintain talar alignment ( Fig. 59-32 ). Depending on the mechanism and stage, either or both of the
inferior tibiofibular ligaments may be ruptured, but above the level of injury, the ligamentous connections between the
tibia and the fibula are usually maintained. Often, but not always, they adequately stabilize the syndesmosis after the
distal fibular fragment is securely and anatomically reattached to the proximal one.

As discussed previously, the fibular fracture configuration depends significantly on the mechanism of injury. In
supination-external rotation fractures, the characteristic spiral oblique fracture usually begins in an almost transverse
plane distally on the anterior surface of the fibula. It then spirals lazily externally, extending a variable length up the
fibula to exit proximally on its posterior surface. Occasionally, the long posterior spike of the distal fragment may be
comminuted. The more transverse, often laterally comminuted, pronation-external rotation fibular fracture is usually
recognizable as different, even though its primary location is the same. Transitional forms incorporating some external
rotation about the intact PITFL are typically spiral but are oriented differently, from low medial to high lateral, and begin
above the plafond level.

In addition to the constant pathognomonic fibular fracture and the possibility of some form of medial side disruption,
type B injuries may have associated posterior lip fractures of larger or smaller size, with or without articular surface
involvement. Also, with pronation-abduction injuries, there may occasionally be impaction of the lateral tibial plafond.
Elevation and bone grafting may be required if a significant portion of the plafond is involved. Fragments and
deformation of the tibia may prevent satisfactory reduction of the fibula unless they are corrected. Anteriorly, the AITFL
may be avulsed with a bone fragment of the anterior tibia or fibula or may be a pure soft tissue injury.

Treatment of type B malleolar fractures is determined by the severity and anatomy of the injury. Undisplaced injuries
[284]
usually represent lesser degrees of severity and are well suited to nonoperative management. Grade I supination-
external rotation injuries, with damage limited to the AITFL, are hard to confirm but are recognized injuries. Such
anterior syndesmosis sprains are slow to heal. A more common example is the undisplaced or minimally displaced (up
to 2 or 3 mm) spiral fracture of the lateral malleolus exhibiting the pattern described previously but unassociated with
lateral displacement or tilt of the talus or evidence of medial side injury. Because the radiographic appearances are
similar, it is essential to differentiate this injury from unstable stage IV injuries with MCL disruption. A short leg walking
cast or brace for 6 weeks permits functional treatment of stable type B supination-external rotation fractures of the
lateral malleolus. Radiographs taken in the cast about 10 to 14 days after injury can be checked for talar shift to aid in
identifying a missed supination-external rotation stage IV deltoid ligament injury.

Closed reduction may succeed for management of displaced supination-external rotation injuries. The knee is flexed,
and the foot is distracted, pulled anteriorly, and internally rotated. Assessment of reduction should ensure not only
reposition of the talus relative to the plafond but also anatomic reduction of the lateral and (if present) medial malleolar
fracture. More than 2 to 3 mm of displacement of a malleolus or of a plafond fragment is a reason to consider ORIF.

When local and systemic conditions permit, ORIF of displaced external rotation fibular fractures usually provides the
best results and the quickest restoration of function. In general, the most secure fixation is with an interfragmentary lag
screw and a small plate for added strength. The plate may be applied posterolaterally, as advocated by Brunner and
[38][242]
Weber, or directly laterally. Syndesmosis stability must be confirmed, for occasionally such marked tibiofibular
instability is present that it is necessary to employ syndesmosis transfixation or repair the inferior tibiofibular ligaments,
if this is possible with security. Syndesmosis instability is more likely to occur with malleolar fractures that involve a
ruptured deltoid ligament than in those with medial malleolar fractures that are amenable to stable fixation.

With anatomic reduction of the lateral malleolus and a stable syndesmosis, talar position is maintained; there is no
benefit from repair of a torn deltoid ligament. To avoid the occasional symptomatic medial malleolus nonunion and
improve stability, most surgeons prefer to fix all but the smallest medial malleolar fractures associated with displaced
ankle injuries.

It is helpful to recognize the mechanism of type B injuries, for pronation-abduction fractures require a different
technique of closed reduction and may pose different surgical challenges from those with fractures associated with
supination-external rotation. Stage I pronation-abduction injuries have only isolated medial side lesions. If the injury is
ligamentous, repair is not required, and functional treatment is appropriate. The same is true for undisplaced medial
malleolar fractures, which may deserve fixation if there is more than 2 to 3 mm of displacement. Stage II injuries add
complete distal syndesmosis disruption, but unless a large avulsed fragment results in plafond or syndesmosis
incongruity, treatment is the same. Stage III injuries may be markedly displaced and usually require fixation of the
fibular fracture, although closed reduction by supination and adduction may be successful.

In pronation-abduction fractures, lateral comminution of the fibular fracture is frequently seen. It may be so severe as to
defy anatomic reduction by reassembly of the fragments. In such a situation, it is best to realign the talus and reduce
the lateral malleolus to it with provisional Kirschner wire (K-wire) fixation to the tibia or talus. The reduction is confirmed
with a mortise view radiograph checked against a control view of the other side. Then one can proceed with buttress
plate fixation and possibly bone grafting of a very comminuted fibular fracture. If possible, these comminuted lateral
malleolar fractures should be reduced indirectly, without exposing the fracture fragments. The intact soft tissue sleeve
aids reduction and promotes fracture healing (see Fig. 59-46 ). Often, initial reduction and fixation of the much less
complex medial malleolus fracture can aid repair of the comminuted lateral side of the ankle. In true pronation-
abduction lateral malleolus fractures, it is rarely possible to use a lag screw between the proximal and the distal
fragments, and as a result, lateral fixation may be less secure.
Figure 59-46 When a type C fibular fracture is comminuted, a plate can be used for indirect reduction while leaving soft tissue attachments on
comminuted fragments. A, The plate is contoured and attached distally and controlled proximally with a clamp, and a bone spreader is used
against a more proximal, temporary screw to push the distal fragment into a reduced position. Comminuted fragments may be teased gently into
place. B, If fracture configuration permits, compression across it may be obtained with a small Verbrugge clamp hooked over the proximal screw.
Lateral malleolar length must be maintained. C, The plate is then attached proximally. It is not necessary to place screws into small comminuted
fragments.

TYPE C INJURIES
The mechanism of type C malleolar injuries is classically pronation-external rotation. Stage I involves bone or
ligamentous failure medially. In stage II, the AITFL fails, along with the interosseous ligament and some of the
interosseous membrane. Stage III is the supra-articular fibular fracture at a variable height above the plafond. In
significantly higher fractures, such as the Maisonneuve, it is probably unlikely that the interosseous membrane tear
ascends as high as the fibular fracture. Rather, the intact proximal interosseous membrane does not interfere with
torsional failure of the proximal fibula after the more distal soft tissues rupture. Finally, stage IV involves PITFL rupture.
Anterior and especially posterior tubercular fractures may be a part of inferior syndesmotic ligament failure. Such
posterior malleolus fractures may involve the articular plafond.

Rarely, a type C malleolar fracture is stable, undisplaced, and amenable to nonoperative management. Much more
frequently, there are displacement and syndesmosis instability. Restoration of stability requires anatomic ORIF of the
fibular fracture. Next, the syndesmosis is assessed and, if it is unstable or remains displaced, fixed in a position of
anatomic alignment. Reduction and fixation of a large or destabilizing plafond fragment and of a medial malleolar
fracture complete the reconstruction of displaced type C injuries. When the fibular fracture is very proximal, it is
sufficient to regain length and rotation with only a distal exposure. After anatomic reduction of the lateral malleolar
articular surface, confirmed by a comparison radiograph, one or two transfixion screws are placed to maintain this
position during ligamentous healing of the syndesmosis. Type C malleolar injuries have a greater risk of syndesmosis
disruption and instability, even after fixation of the fibular fracture. This category therefore serves to warn the surgeon
of the need to assess syndesmosis stability. Particularly deceiving is the high Maisonneuve fracture with only a deltoid
ligament tear medially.[203] On a routine ankle radiograph, only subtle malalignment of the fibular malleolus indicates
the existence and nature of the injury.

NONOPERATIVE TREATMENT OF MALLEOLAR FRACTURES

Undisplaced malleolar fractures can usually be satisfactorily treated with the ankle in neutral in a short leg walking cast,
which should extend nearly to the knee. Rotational control is improved with triangular proximal molding of the cast to fit
the proximal tibia without pressure on the peroneal nerve. Medial or lateral distal molding of the cast can resist varus or
valgus angulation. It is important to distribute the contact area widely over the hindfoot rather than just around the
malleoli and to avoid focal pressure on bony prominences with thin overlying soft tissues.

For fractures seen acutely, 10 ml of local anesthetic injected into the joint can provide excellent pain relief and allow a
satisfactory closed reduction.[5] Alternatively, a general or regional anesthetic provides total relaxation and relief of
pain.

A satisfactory closed reduction becomes harder to achieve if more than a day or so has elapsed since injury. Closed
reduction is usually best achieved by reversing the mechanism of injury that produced the displacement and fracture
pattern evident on initial radiographs. Some distraction as well helps to disengage fragments and eases the
realignment of the talus with the mortise. Reduction of the talus, rather than direct pressure on the malleoli, brings the
malleoli back into position and maintains alignment.

Thus, a type A supination-adduction fracture is reduced by abducting (everting) the hindfoot and molding the medial
side of the distalmost part of the cast to retain this position. Three-point fixation is provided by a lateral mold proximal
to the ankle and another molded area extending medially along the proximal medial tibial shaft.

Type B supination-external rotation fractures are reduced with (1) distraction, (2) anterior traction, (3) internal rotation,
and (4) medial displacement of the talus. A long leg cast with the knee flexed is necessary to maintain the foot's
internally rotated position that resists redisplacement. Upward traction on the big toe with posterior pressure on the
distal medial tibia helps maintain the reduction while the cast is applied. Pronation is not necessary, and the foot
should be in a relatively neutral position. Although it may be tempting to supinate the hindfoot in an effort to restore
fibular length, this rarely works and may result in difficulties regaining a plantigrade foot. The long leg cast for a
supination-external rotation ankle fracture is best applied with the patient supine, the hip and knee flexed, the hip
abducted, and the foot held in internal rotation as shown in Figure 59-33 . The entire cast from toes to midthigh can be
applied at one time, after the reduction maneuver, if the foot and leg are held in the proper position by an assistant.
The weight of the externally rotated leg counteracts the internal rotation moment applied to the foot and stabilizes the
reduction. With adequate padding, molding of the cast is primarily over the lateral foot, around but not directly on top of
the lateral malleolus ( Fig. 59-34 ).
Figure 59-33 External rotation deformity can be reduced by internally rotating the foot relative to the abducted and flexed proximal leg. A well-
padded long leg cast is applied while the leg is held in this position.

Figure 59-34 Molding of this cast over the lateral hindfoot, combined with moderate internal rotation, holds the talus anatomically reduced. The
malleoli reduce with it, as they are attached by the collateral ligaments.

Type B pronation-abduction fractures are reduced by distraction and adduction. The presence of an intact medial
malleolus or at least an overhanging remnant thereof often prevents overcorrection and provides a template for
anatomic reduction. If there is no medial buttress (i.e., the medial malleolar fracture is at or above the plafond), the
ankle may be so unstable that a satisfactory closed reduction is not possible. Although rotation does not usually need
to be corrected, its control may enhance stability; thus, a long leg, bent-knee cast is better if the reduction is unstable.
The weight of the leg can be positioned to maintain a varus force on the ankle during reduction and cast application.

Type C pronation-external rotation fractures are best reduced with (1) distraction, (2) anterior displacement, (3) internal
rotation, and (4) medial displacement, similarly to supination-external rotation injuries. A long leg cast with the knee
bent and the foot in internal rotation is applied, as shown in Figure 59-33 , with the foot held gently internally rotated
but otherwise as neutral as possible.
Although a closed manipulation usually restores the talotibial relationship, for type C fractures, it rarely reduces the
lateral malleolus anatomically. Because some shortening or malrotation is likely to remain, the lateral malleolus is not
able to maintain the precise alignment of the talus after a cast is removed and normal weight bearing is resumed.
Thus, ORIF is generally preferred.

If closed reduction is chosen for treatment of a displaced malleolar fracture, it is important to monitor the reduction until
healing is secure, for if it is lost, prompt rereduction or ORIF may still provide a satisfactory result. In general, adequate
monitoring of an unstable malleolar fracture requires radiographs in the cast at 7 to 10 days and again at 3 weeks. If
reduction is maintained at 3 weeks, it is unlikely to be displaced during the next 3 weeks in a non-weight-bearing cast.
Many regimens have been proposed for immobilization after closed reduction of a displaced malleolar fracture. We
generally advocate 6 weeks in a non-weight-bearing cast molded primarily to preserve the reduction. Following this,
another 2 to 3 weeks in a plantigrade short leg walking cast or brace provides additional protection and helps with
rehabilitation. Variations from this protocol may be advisable on the basis of bone quality, fracture stability, and the
patient's characteristics.

When the cast is removed, the patient may need to resume crutch use for a while, even if he or she was able to
manage without them while in the cast. Stretching, progressive strengthening, endurance, and agility exercises are
required for several months if optimal results are to be achieved as rapidly as possible. After cast removal, an elastic
stocking may be needed for a month or two to control edema. Elevation of the leg when the patient is not actually
walking also helps.

Operative Treatment
INITIAL CARE AND TIMING OF SURGERY
Displaced malleolar fractures often involve significant subluxation or dislocation of the tibiotalar joint. To minimize pain,
swelling, and additional local trauma, such injuries should be treated with a prompt provisional reduction and
immobilization in a safe, effective splint. Evaluation of skin and neurovascular status precedes this, with follow-up
reassessment periodically thereafter.

If possible, a formal closed reduction maneuver is carried out in the emergency department with appropriate analgesia.
Then a very well padded cast is applied. This cast provides the best possible splint. Extra padding is necessary to
accommodate swelling and protect the skin from the cast saw blade. Once hard, the cast can be split and spread or
bivalved, if necessary, to accommodate swelling and facilitate removal in the operating room. Radiographs are
obtained in the cast to assess reduction, which should be repeated immediately only if there is gross deformity with
skin or neurovascular compromise. An anatomic reduction obtained without the foot's being placed in an extreme
position suggests consideration of nonoperative management unless the fracture is very unstable. Unsuccessful closed
reduction in this setting may still be improved with a manipulation under anesthesia, but if an anesthetic is required, we
feel that only strong local contraindications would dissuade us from ORIF of an unstable malleolar fracture.

If an abrasion of any significance is present about an injured ankle, ORIF can be done urgently, as with open fractures,
[132]
or delayed until the skin has healed. A povidone-iodine dressing over such a superficial skin wound may reduce the
rate of bacterial colonization. If there is only slight soft tissue injury, indicated by mild initial displacement and little
swelling, ORIF can be done essentially electively during the early postinjury period, although it becomes progressively
less easy after about 10 days and is often quite difficult after 3 weeks because of early fracture healing and disuse
osteoporosis, which is a potentially severe problem in older women.[22][45]

Because it is associated with a reduced likelihood of anatomic reduction, delay in ORIF of malleolar fractures beyond 2
weeks is associated with poorer results. If an anatomic reduction is achieved, however, the outcome may closely
approach that obtainable by early surgery.[75] It is wise to remember that unappreciated swelling may increase the risk
of such procedures during the first several days after injury. Therefore, during the early postinjury period, the skin
should be reassessed just prior to inducing anesthesia for ORIF of an ankle fracture. If significant soft tissue injury with
marked swelling and blisters is evident, ORIF should be delayed until the local tissues have recovered, which may take
7 to 10 days or more of strict elevation. The return of cutaneous wrinkles indicates the resolution of edema. If soft
tissue trauma is exceptionally severe, it is often best to treat the ankle with closed reduction and external fixation,
deferring open reduction, if it is required, until the risk of wound slough has diminished.

It is important not to accept poor ankle alignment and an inadequate splint because early surgery is planned. The
opportunity to operate may be lost for a variety of reasons, and the ankle may suffer additional insult without proper
early care.
Konrath and colleagues[132] compared early versus delayed (mean of 14 days) fixation of severe ankle fractures and
found that a shorter postoperative hospital stay in the delayed fixation group was the only significant difference.

CHOICE AND PLANNING OF FIXATION

A satisfactory fixation technique must have a low risk of failure, must resist the forces that are likely to cause
redisplacement of the fracture, and must not be likely to increase comminution or cause displacement during its
application. Many techniques of malleolar fracture fixation have been advocated.[18] The ones described here are
essentially those advocated by AO/ASIF. They have been generally accepted and work well for us.[186] Less rigid
techniques have also been advocated, and although they are often successful, especially in more stable injuries, they
are not as reliable as those of the AO in maintaining reduction of bimalleolar or trimalleolar and equivalent fractures.[200]
Absorbable implants have also been used, but they have not yet won a place in our armamentarium.

Adequate preoperative radiographs are required for planning fixation. Comparison views of the uninjured ankle can be
very helpful. An explicit preoperative plan guides positioning and choice of incision and also provides a shared
operative strategy that increases the efficiency of the entire surgical team.[169]

OPERATIVE ADJUNCTS
A plan for intraoperative radiographic control should be made—either fluoroscopic or plain films. The patient is typically
positioned on a radiolucent table. A roll is placed under the ipsilateral pelvic area (proximal to the sciatic nerve) to
rotate the leg medially and facilitate exposure of the fibula. If fixation of a posterior malleolus is anticipated, this position
can be exaggerated even more to allow posterolateral access. Tourniquet use is optional. There is some evidence that
its use can increase postoperative pain and swelling and lead to wound complications. Long-acting local anesthetic
with epinephrine is a good alternative and assists with postoperative pain control.

LATERAL MALLEOLUS FRACTURES

A secure anatomic repair of a displaced lateral malleolus fracture is one of the most important steps in operative
management of a malleolar fracture because of the role this structure plays in maintaining tibiotalar alignment.

Because of its posterior location, the fibula is easier to approach if a cushion is placed under the supine patient's
ipsilateral buttock to rotate the trunk and leg internally. A safety strap about the pelvis allows the table to be tilted
further if needed. A pneumatic tourniquet is a conventional adjunct but may wisely be omitted in patients with impaired
perfusion or vascular disease.

A longitudinal lateral incision provides adequate access to the distal fibula. Because the primary purpose of the
procedure is to reconstruct the alignment and integrity of the ankle joint, not to improve the appearance of the fibular
fracture, it is important that the lateral incision also permit exposure of the anterior syndesmosis, in particular the AITFL
and the superolateral corner of the anterior ankle joint ( Fig. 59-35 ). Exposure of the AITFL requires incision of the
extensor retinaculum—a structure potentially confused with the AITFL. Inspection of the relationship of the talus, tibial
plafond, and lateral malleolus reveals the congruity or lack thereof of the articular surfaces. This area is better seen if
the distal end of the incision is angled slightly anteriorly and carried sufficiently distally. The distal end of the incision
permits an arthrotomy for irrigation and inspection of the ankle joint to identify and remove loose osteochondral
fragments and intra-articular clot. The proximal extent of the incision is determined by the requirements for fixation of
the fibular fracture.
Figure 59-35 The incision to repair a lateral malleolar fracture should provide access to the anterolateral ankle joint, as well as the anterior
inferior tibiofibular ligament. This access is necessary to search for osteochondral injuries and especially to ensure anatomic repair of the mortise.

Flaps should be kept as thick as possible and handled gently. A more extensive fasciotomy may be wise in patients
with more soft tissue swelling. If an anteromedial incision is also used, the lateral incision must be more posterior, as it
also should for access to the posterolateral tibia through the interval between the peronei and the Achilles tendon or for
posterior plate fixation of a supination-external rotation fibular fracture. The sural and superficial peroneal nerves have
branches in the region of this lateral incision and should be protected or resected and buried away from the scar to
avoid a painful neuroma.

Through this lateral incision, it is possible to repair the lateral ligaments as well as to fix fractures of the lateral
malleolus. The torn LCL complex is reapproximated with interrupted, medium-weight sutures. A small, very distal
fibular avulsion fracture can be reattached with sutures to bone or soft tissue or with a small fragment or minifragment
screw and plastic ligament washer, whose small spikes prevent pressure necrosis of the soft tissue it secures to
[111][227]
bone. A larger avulsed fragment of the distal lateral malleolus, typical of type A injuries, is best fixed with either a
tension band wire or a small oblique screw. Fixation must resist distraction forces produced by inversion of the hindfoot
( Fig. 59-36 ).

Figure 59-36 Repair of type A lateral ankle injuries. A, Ligament tears are sutured. Low transverse fibular fractures are reduced anatomically
and fixed with K-wires and a tension band (B) or a small oblique lag screw (C) that penetrates and anchors in the medial cortex proximally
Reduction is begun by clearing clot and minimally reflecting the periosteum to see the bone apposition. The distal
fragment is grasped with a small forceps, guided into place, and held with a sharp dental probe. For tension band
wiring, it is fixed with two 1.25- or 1.6-mm K-wires, which may be oblique or intramedullary. Advancing and then
withdrawing them permits their impaction into the bone after the exposed ends are cut and bent into a J shape ( Fig.
59-37 ). The figure-of-eight 1.25-mm tension band wire can be anchored proximally by passage through a transverse
drill hole in the fibula or, more easily, around a small cortical screw. If an oblique lag screw is chosen instead,
provisional fixation of the fragment with a small K-wire aids in holding position during screw insertion.

Figure 59-37 A, Type A bimalleolar fracture with significant comminution of a small medial malleolar fragment. B, K-wires with tension bands
provide fixation.

Supination-external rotation type B injuries, as discussed previously, generally cause a spiral fracture that exits the
anterior surface of the fibula distally at or just above the level of the plafond. The malleolar fragment carries the lateral
attachment of the AITFL. This structure can often be a guide to reduction. Comminution produced by its avulsion from
either the tibia or the fibula may add another element of complexity.

The incision previously described is used for lateral malleolus ORIF. It should extend sufficiently proximal to provide
easy access to the posterior proximal end of the distal fragment. Unless excessively comminuted, this posterior spike
can guide restoration of length and rotational alignment. It can often be repositioned first and held in place while the
reduction is completed. After exposure of the fracture and the anterior surface of the fibula proximal to it, the joint is
explored, aided by an intra-articular angled retractor anteriorly. Then the distal fibula is grasped with a pointed forceps,
such as a towel clip, and teased into place with traction and repositioning of both foot and fracture fragment as needed
( Fig. 59-38 ). Be cautious with strong forces if the bone is osteopenic. Simultaneous control of the proximal fibular
fragment with a bone clamp may aid reduction.

Figure 59-38 Reduction of the common supination-external rotation lateral malleolar fracture requires grasping the distal fragment (cautiously if
the patient is osteopenic) and bringing it into precise alignment with the proximal fragment, after which a reduction forceps is tightened,
perpendicular to the fracture plane.
A small, pointed, or lobster-claw reduction forceps is used to appose the bone edges as proximal and distal pieces are
realigned. The reduction forceps should be applied perpendicular to the fracture plane or it may cause redisplacement.
It should not interfere with placing an AP lag screw perpendicular to the fracture, and it should not be so close to the
end of the proximal piece that it produces comminution. A satisfactory reduction results in good apposition at the
fracture line on the anterior and lateral surfaces of the fibula, restores the position of the proximal spike, places the
AITFL so that its ends lie anatomically, and restores the relationship of the lateral malleolus, lateral plafond, and lateral
edge of the talar dome, as seen in the anterolateral corner of the mortise. If reduction is not readily achieved, the
possibility of a medial obstruction—fracture fragments or an intra-articular flexor tendon—must be excluded by
exploration of the medial side of the joint.

If a truly anatomic reduction has been achieved, a lag screw is applied perpendicular to the fracture using a 3.5-mm
cortical screw with the anterior cortex overdrilled. Two or more such lag screws can be used as the entire fixation if the
bone is of excellent quality and a cast will be used for protection. More secure fixation is achieved with a one-third
tubular plate contoured to fit the concave, slightly spiral, lateral surface of the fibula. This plate is usually applied with
three or four screws proximal to the fracture's distal obliquity and at least two in the distal fragment, placed carefully
and checked with radiographs to ensure that they do not enter the joint space ( Fig. 59-39 and Fig. 59-40 ).

Figure 59-39 Repair of type B lateral malleolar injuries. A, A long spiral fracture can be repaired with two or more lag screws. External
protection is required. B, C, A single lag screw and a one-third tubular neutralization plate are more secure. D, E, An antiglide plate (one-third
tubular) can be applied posteriorly, where it resists proximal displacement of the distal fragment. F, A lag screw can be used with a posterior plate,
either through the plate, as illustrated, or previously placed from anterior to posterior (see Fig. 59-41 ). The principle of the posterior antiglide plate
is illustrated. (A, Redrawn from Müller, M.E.; et al. Manual of Internal Fixation, 2nd ed. New York, Springer-Verlag, 1979. B, Redrawn from Heim,
U.; Pfeiffer, K.M. Small Fragment Set Manual: Technique Recommended by the ASIF Group, 2nd ed. New York, Springer-Verlag, 1982. D–F,
Modified from Brunner, C.F.; Weber, B.G. Special Techniques in Internal Fixation. New York, Springer-Verlag, 1982.)
Figure 59-40 A, B, This type B lateral malleolar fracture was fixed anatomically with two lag screws across the fracture line, barely visible at its
most proximal extent on the lateral view. A one-third tubular plate adds support to the fracture, with cortical screws proximally and cancellous fully
threaded screws distally. Screws could probably have been placed through the empty holes and into the anterior portion of the proximal fibular
fragment.

Alternatively, as proposed by Brunner and Weber,[38] a similar plate can be applied on the posterolateral surface of the
fibula, where it overlies the posterior fracture spike of the distal fragment and prevents its gliding proximally.[242] This
plate is less prominent laterally and may be better tolerated, although it requires more posterior exposure ( Fig. 59-41 ).
Any technique that is used for fixation of the lateral malleolus must resist proximal migration or rotation of the distal
fragment. Therefore, most intramedullary techniques are risky, although special devices such as the Inyo nail may be
successful.[173][174]
Figure 59-41 This type B fracture was reduced anatomically and fixed with a single anteroposterior (AP) lag screw perpendicular to the fracture
plane. An antiglide plate was applied to the posterolateral surface of the malleolus, avoiding prominent lateral hardware. With an undisplaced
medial malleolus fracture, the patient is fully weight bearing in a patellar tendon-bearing cast. A, AP radiograph. B, Lateral radiograph.

Pronation-abduction type B injuries cause a transverse and often comminuted fracture at or just above the level of the
plafond. Depending on the extent of comminution, reduction of the lateral malleolus may be quite difficult. Preoperative
radiographs usually define the pathology and allow a modified operative plan.[148] Lateral plafond impaction may need
to be elevated through or around the fibular fracture; a CT scan may be a considerable aid to planning. The medial
side of the ankle is a helpful guide to reduction. If its malleolus is intact, the talus can be pushed back medially against
it. If there is a transverse fracture that can readily be fixed, it, too, can provide support. With the talus reduced against
the medial side of the mortise, the lateral shoulder of the talus provides a template for reduction of the lateral
malleolus. Provisional fixation with K-wires to the talus or tibia, or both, permits radiographic confirmation of reduction (
Fig. 59-42 ). This view is compared with a mortise view of the opposite ankle, and if reduction is satisfactory, a plate
(either a one-third tubular or, if the fracture is very comminuted and the patient is large, a stouter 3.5-mm dynamic
compression plate) is applied as a buttress. Bone graft may aid healing of a comminuted fibular fracture. Indirect
reduction techniques can help with these challenging fracture reductions (see Fig. 59-46 ).
Figure 59-42 A, A pronation-abduction type B fracture with lateral plafond impaction. Arrows show marginal lateral impaction and medial
malleolar fracture. B, The fracture has been realigned by reduction and fixation of the medial malleolus, followed by provisional K-wire fixation of
the lateral malleolus. Radiographic confirmation of this reduction precedes definitive internal fixation and bone grafting of the fibula. Arrows show
marginal lateral impaction. (A, From Limbird, R.S.: Aaron, R.K. J Bone Joint Surg Am 69:881, 1987.)

The AITFL disruption should be repaired, at least to confirm appropriate reduction of the syndesmosis. Avulsion of the
ligament with or without a fragment of bone from the Wagstaffe (Le Fort) or the Chaput tubercles can often be repaired
with a small screw or ligament washer. A mechanically insecure horizontal mattress suture apposes the ends of a
rupture in substance and may improve the ultimate quality of the healed ligament ( Fig. 59-43 ).

Figure 59-43 The anterior inferior tibiofibular ligament ends should appose perfectly if reduction is precise. The ligament can be repaired with a
horizontal mattress suture, with a screw through an avulsed bone fragment, or with a small, spiked, plastic ligament washer.

Repair of the PITFL is not as easy but has been recommended as justification for reduction and fixation of all
posterolateral tibial lip (Volkmann's) fragments, even those that are extra-articular, because of the presumed benefit of
immediate syndesmosis stabilization ( Fig. 59-44 ).[102] Possibly this may eliminate the need for syndesmosis
transfixation. Strong evidence that refixation of the PITFL to the distal tibia makes a difference in outcome has not yet
been provided.[100] The value of fixation of a small Volkmann fragment thus remains controversial.
Figure 59-44 The posterior inferior tibiofibular ligament can be repaired by reduction and fixation of a posterolateral avulsion fracture
(Volkmann's fragment) of the distal tibia.

After fixation of the lateral malleolus, it is important to assess stability of the syndesmosis by externally rotating the foot
and pulling the repaired fibula laterally with an encircling clamp. The anterolateral corner of the malleolus is observed,
and demonstrable laxity of more than 3 or 4 mm with such maneuvers should be considered an indication for use of a
syndesmosis transfixation screw.

In higher lateral malleolus fractures (those classified as type C injuries), the fracture is often relatively transverse.
Fixation with an interfragmentary lag screw may be impossible, but comminution is not as frequent a problem as it is in
typical pronation-abduction injuries ( Fig. 59-45 ). If comminution and shortening of the fibula are significant, indirect
reduction using a small distractor or a plate with a tension device or bone spreader to regain length may be very helpful
( Fig. 59-46 ).[168] Provisional fixation and confirmation of reduction by radiographs and direct visualization of the ankle
joint are essential. The surgeon should resist the temptation to reduce the high lateral malleolus fracture without
exposing the joint and should not be misled by an apparent reduction of a comminuted fracture site. Ankle joint
restoration, not fibular fracture reduction, is the goal ( Fig. 59-47 and Fig. 59-48 ). Use of a syndesmosis transfixation
screw without precise fibular fracture reduction is unlikely to provide an anatomic reduction because of difficulty in
assessing and obtaining length and rotational alignment. Therefore, this approach should also be avoided.

Figure 59-45 Repair of type C lateral malleolar fractures requires precise anatomic reduction of the articular fragment and usually plate-and-
screw fixation of the fracture. Occasionally, the fracture permits use of a lag screw as well, but more often it is transverse or comminuted. A one-
third tubular, small fragment plate or a 3.5-mm dynamic compression plate may be used, with three or four screws above and below the fracture
Figure 59-47 A, Type C bimalleolar fracture. B, Typical fixation with a one-third tubular plate and lag screw for a comminuted fragment and two
4.0-mm cancellous lag screws for the medial malleolus.

Figure 59-48 A, Type C, atypically high pronation-abduction fracture, indicated by a transverse, laterally comminuted fracture. Injury was
caused by a heavy blow to the lateral leg, just above the ankle. B, Intraoperative mortise radiograph shows 3.5-mm dynamic compression plate
fixation, additional repair of the syndesmosis with a screw and ligament washer to reattach the anterior inferior tibiofibular ligament to the tubercle
of Chaput, and two 4.0-mm cancellous lag screws for the medial malleolus. C, D, Ten weeks later, both fractures had healed. Note heterotopic
ossification of the torn lower interosseous membrane.
Only very proximal fibular fractures (upper third) with mortise disruption are reasonably treated without direct reduction
and fixation, but mortise reconstruction and transfixation must still be done with great care.

SYNDESMOSIS TRANSFIXATION
Syndesmosis stability is checked by laterally displacing the distal fibula from the tibia while observing the relationship
of the two bones. If more than 3 to 4 mm of lateral shift of the talus occurs, instability is present. This check has been
called the Cotton test ( Fig. 59-49 ). Gross displacement indicates the need for surgical stabilization of the
syndesmosis. As previously discussed, laboratory studies point to a disruption of the interosseous membrane 3.5 to
4.0 cm above the mortise as leading to syndesmotic instability if the MCL is disrupted.

Figure 59-49 After repair of the fibula fracture, syndesmosis stability is confirmed by attempting to displace the malleolus laterally while
observing the anterolateral corner of the joint for excessive movement of the fibula and talus.

Various beliefs exist regarding indications and technique for stabilizing a disrupted syndesmosis. Few hard data
support them, so skepticism is warranted. As with other controversial topics, it may be that controversy flourishes
because there is little difference in outcome. The problem is that sometimes, after seemingly satisfactory reduction of
the medial and lateral malleoli, the space between the tibia and the fibula widens and the talus fits loosely in the
mortise. Pain, instability, and post-traumatic arthrosis may follow. It is clear that the fibula bears some weight and that
in some individuals, at least, it moves slightly relative to the tibia with normal gait. The strength of the forces that
displace the fibula laterally is not known. Significantly controversial issues include (1) when syndesmosis fixation is
necessary (e.g., internal fixation between the tibia and the fibula that prevents diastasis), (2) how such fixation should
be carried out, (3) what activities should be permitted when the distal tibia and fibula are fixed together, and (4) how
long such fixation should be retained.

Obvious distal tibiofibular diastasis on initial or subsequent radiographs or gross mechanical instability of the
syndesmosis signals the possible need for syndesmosis transfixation. The amount of fibular motion that indicates
[111][122][124][191]
critical instability is not certain. Slight laxity (up to 2 to 3 mm) of a well-reduced fibula, especially if there is
a good end-point, rarely indicates a significant risk of late diastasis. Adjunctive syndesmosis stabilization through repair
of avulsed inferior tibiofibular ligaments may improve such a situation. There is some evidence that stability increases
over time.[200] The use of a long leg, non-weight-bearing cast for a few weeks may also prevent loss of alignment in
questionable cases. It is vital to remember that if the fibula is not first reduced satisfactorily, transfixation of the
syndesmosis is unlikely to yield an acceptable result.

TECHNIQUES
Inman,[112] who agreed with Grath,[91] cited Grath's study as evidence that only slight lateral motion (0 to 2 mm) of the
lateral malleolus occurred with full ankle dorsiflexion.[91][112]Olerud[198] demonstrated loss of 0.1° of dorsiflexion for every
degree of plantar flexion the ankle was in at the time the syndesmosis was fixed. For this reason, it seems wise to fix
the syndesmosis with the talus held fully dorsiflexed. Fixation is usually obtained by placing one or two screws from
posterolaterally in the fibula to antero-medially in the tibia about 1.5 to 3.0 cm above the plafond ( Fig. 59-50 ). Direct
observation of the ankle joint provides assurance that the screw is at the desired distance from it. It is essential that the
tibiofibular relationship be anatomic when such screws are inserted. Provisional K-wire fixation or an appropriate clamp
may help with this ( Fig. 59-51 ).

Figure 59-50 A, A syndesmosis transfixation screw must be inserted with care from posterolaterally in the fibula to anteromedially in the tibia.
The appropriate angle is approximately 30 degrees from the coronal plane. B, The fibula must be held reduced during screw placement, and the
ankle should be fully dorsiflexed. In this example, the screw is inserted through the fibular plate. C, Two screws are used for improved control
when a proximal fibular fracture is not internally fixed. (A–C, Redrawn from Heim, U.; Pfeiffer, K.M. Small Fragment Set Manual: Technique
Recommended by the ASIF Group, 2nd ed. New York, Springer-Verlag, 1982.)
 Figure 59-51 Maisonneuve fracture. A, Ankle radiograph shows mortise widening and lateral displacement of the talus. B, A spiral
fracture of the proximal fibula is present. C, Intraoperative radiograph confirms satisfactory reduction of a provisionally fixed syndesmosis.
D, E, Definitive fixation with two 4.5-mm cortical position screws threaded into both the fibula and the tibia. F, One year after injury, fixation
has been removed and the ankle mortise remains congruent.

The AO group advocated use of a fully threaded screw, a "position screw," with threads tapped in a pilot hole in both
the fibula and the tibia. This procedure allows essentially no motion between the two bones unless the screw loosens,
as it often does. It avoids the risk of overtightening inherent with a lag screw but permits no adjustment of the
relationship between the fibula and the tibia from that existing when the screw is placed between the bones. The
optimal type of screw is also debated and is as yet unproved. Generally, a 4.5- or 3.5-mm cortical screw is chosen.
Some advocate its insertion only part way through the tibia, so that the screw soon loosens. There is a small incidence
of screw fracture, and removal of a retained fragment in the tibia is traumatic. Use of a stronger screw, limited weight
bearing, early screw removal, provision for some motion around the screw, and use of other devices are various ways
to avoid screw failure.

Aware of the risks of overtightening a lag screw, one might use the original AO 4.5-mm malleolar screw for
syndesmosis fixation ( Fig. 59-52 ). With the fibula reduced, a 3.2-mm drill is used to prepare a hole through the fibula
and tibia. The screw length is chosen to penetrate deeply into the tibial metaphysis, approximately 3 cm above the
plafond. The fibula and tibia are held reduced with the ankle fully dorsiflexed. Reduction is ascertained by inspection of
the superolateral corner of the mortise, which is observed as the screw is inserted. The screw is tightened only enough
to prevent lateral displacement of the fibula without compression of the mortise, which can be observed through the
arthrotomy. The screw head stabilizes the fibula, preventing lateral displacement. Its nonthreaded shaft is slightly loose
within the fibula, permitting a small amount of fibular motion around the screw, which is anchored securely in the tibia.
Figure 59-52 The syndesmosis was unstable after reduction and fixation of this type C supra-articular lateral malleolus fracture. A, The
syndesmosis was stabilized with a 4.5-mm malleolar screw inserted with the syndesmosis held reduced and the ankle fully dorsiflexed. The screw
was tightened just enough to retain the position of the fibula in the incisural notch, with direct inspection of the ankle to ensure that it was not
compressed. B, The patient was allowed to bear weight with the screw in place; it was removed at 3 months. A year after injury, the patient had a
stable syndesmosis and normal, pain-free ankle function.

The purpose of transfixing the syndesmosis with a screw is to maintain the distal tibiofibular relationship until the
syndesmotic ligaments have healed enough to do so on their own. How long it takes for sufficient ligament healing is
not certain, but inference from clinical and experimental studies of the healing of other ligaments suggests that at 6
weeks little strength has returned. Therefore, the frequent recommendation of only 6 weeks of transfixation seems
risky ( Fig. 59-53 ). A related issue is the weight-bearing regimen prescribed during and after syndesmosis screw
fixation, ranging from no weight bearing to full weight bearing.
Figure 59-53 A, The danger of too early removal (at 6 weeks) of a syndesmosis screw is demonstrated by this type B malleolar fracture with a
deltoid ligament rupture. B, Postoperative view demonstrates excellent reduction. C, Eight weeks after screw removal, medial joint space widening
was noted, and a syndesmotic reconstruction was required.

In attempting to choose the best approach, the surgeon finds an opinionated literature with few supporting data. One
author used 4.5- or 3.5-mm cortical position screws and delayed weight bearing for the first 6 weeks, without routinely
removing the screws. This approach has an approximately 10% incidence of screw breakage. Leaving a few screw
threads through the medial cortex can assist later retrieval if breakage occurs. Another author generally used a 4.5-mm
malleolar screw, encouraged full weight bearing in a short leg cast if the fibula was fixed securely, and left the screw in
place for a minimum of 3 months.

POSTERIOR TIBIAL LIP FRACTURE REDUCTION AND FIXATION

A posterior lip fracture may be associated with essentially any mechanism of malleolar fracture and may be caused by
the interplay between tensile forces applied through the PITFL and compressive weight-bearing forces applied by the
talar dome ( Fig. 59-54 ). The posteromedial lip of the mortise may also be fractured by the supination-adduction
mechanism.[96] Posterior lip fragments are often difficult to assess in fracture dislocations until a provisional reduction
has been achieved. They are best demonstrated by a transverse CT scan ( Fig. 59-55 ). On the AP or mortise
radiograph, the posterior lip fragment can often be observed as a double density superimposed on the tibial
metaphysis. These views help in assessing the proximal extent and width of the fragment and in determining whether it
is posteromedial or posterolateral. Comminution and obliquity of the posterior lip fragment may not be easily
appreciated on the lateral ankle radiograph. Because of obliquity, the apparent size of the fragment may differ from
reality. A transverse CT scan provides an explicit image of the size, location, comminution, and displacement of
posterior lip fractures. The ankle should be inspected carefully for posterior subluxation of the talus relative to the tibia;
this subluxation is more common with larger posterior lip fragments.
Figure 59-54 Posterior malleolar fractures may be small (A), often extra-articular, or there may be large articular fragments that require
reduction to prevent posterior dislocation of the talus (B). Careful inspection of anteroposterior and mortise radiographs often reveals whether the
fragment is more medial or lateral in location.

Figure 59-55 Lateral (A) and oblique (B) radiographs demonstrate a small, displaced posterior lip fracture. C, The computed tomographic scan
shows impaction, interposed fragments, and significant displacement just above the articular surface.

Occasionally, loss of the posterior lip in combination with fibula fracture produces such instability that the
talus redislocates posteriorly and cannot be held reduced in a cast ( Fig. 59-56 ). Dorsiflexion tends to worsen
this situation by increasing the tension on posterior myotendinous units. Small posterior lip fragments may be
extra-articular avulsions. Larger ones, however, involve the joint. Most authors agree that if more than 25%to
35% of the joint surface is involved, the fragment should be reduced and fixed to stabilize the ankle and
decrease the risk of post-traumatic arthrosis caused by irregularity of the joint surface.[96][155][172][292][293]
Although closed reduction of a displaced posterior lip fragment is rarely successful, such fragments are
usually connected to the distal fibular fragment by the PITFL. Therefore, precise open reduction of the lateral
malleolus often results in a close, if not anatomic, realignment of the posterior tibial lip fragment. Some
suggest that this is all that is necessary unless the weight-bearing surface of the plafond is distorted or
posterior subluxation of the talus persists.[101] Others advise routine fixation of all posterior lip fragments.[102]
The optimal approach remains controversial.

Figure 59-56 After an attempted closed reduction, posterior dislocation persists. Note that the ankle has been dorsiflexed to neutral, probably
increasing the tension in posterior soft tissues and adding to the difficulty of regaining tibiotalar alignment.

Indications and techniques for reduction and fixation of posterior lip fragments thus depend significantly on the
judgment of the surgeon. Posterior talar subluxation or dislocation, plafond articular incongruity, and possibly
stabilization of the syndesmosis are the usual reasons for ORIF of a posterior lip fragment.

The surgical approach should be guided by the location of the fragment, by the incisions required for treatment of
associated components of the ankle injury, and by the preoperative plan for fixation.[103] Generally, some direct access
to the posterior fragment is necessary, although often the articular surface reduction is not fully visualized. When the
joint surface is not seen and its reduction is judged by the extra-articular portion of the fracture line, it is wise to obtain
an intraoperative lateral radiograph after provisional K-wire or clamp fixation of the fragment before definitive screws
are inserted. Revision of fixation may not be possible after lag screws have been placed.

Posterior lip fragments can best be reattached with one or two lag screws, occasionally supplemented with K-wires,
washers, or, rarely, a small buttress plate. It is important to avoid penetrating the ankle joint with such implants, but
they must be close to it to obtain good fixation, as the distal base of the wedge-shaped fragment is thickest. The most
secure fixation is provided by interfragmentary fixation with lag screws, which must glide through the fragment adjacent
to their head and be threaded only into the opposite fragment. Such screws can be placed from posterior to anterior if
the fragment is exposed using a posterolateral incision. Otherwise, they must be inserted from anterior to posterior
using the anteromedial incision or a small anterolateral stab incision. Screws placed from posteriorly can be either 4.0-
or, rarely, 6.5-mm cancellous lag screws or fully threaded screws inserted through a predrilled sliding hole in the
posterior fragment. Lag screws inserted from anteriorly pose the problem of gaining maximal purchase in the posterior
fragment without having threads on both sides of the fracture line. It is rare, and difficult to ensure, that a partially
threaded lag screw is appropriate for this. Sometimes cutting off a portion of the screw's tip permits these screws to be
used this way.
A better technique is to overdrill a gliding hole and place the appropriate insert drill sleeve in the anterior metaphyseal
fragment before reduction. Then the posterior lip fragment is reduced and provisionally fixed, its alignment is confirmed
by a lateral radiograph, and the threaded hole is drilled through the sleeve and tapped if necessary. Finally, the
fragments are lagged together with a fully threaded 3.5- or 4.5-mm cortical screw of appropriate length. In general, AP
screws are better suited for larger posterior fragments. The choice of whether to use a medial or a lateral insertion site
can be made according to the obliquity of the fragment and the need for other incisions. Unless the piece is small, a
second screw or at least a heavy K-wire may be advisable to prevent rotation around a single implant. Small posterior
fragments are best fixed with screws inserted from posterior to anterior, with care taken to avoid the joint surface,
which is convex proximally.

Reduction of posterior lip fragments can be done indirectly through either posteromedial or posterolateral incisions.
The choice is often best made by the location of the fragment on the AP radiograph. Posteromedial exposure is by
retraction of the flexor tendons and neurovascular bundle from the posteromedial tibial cortex ( Fig. 59-57 ). As
illustrated in Figure 59-57 , it may be possible to insert a posteroanterior screw in such a fragment through a plane
between the deep flexors and the Achilles tendon.

Figure 59-57 Reduction and fixation of a posterior malleolar fragment through a posteromedial approach. The flexor tendons and neurovascular
bundle are retracted posteriorly with a Hohmann retractor (A), the fragment is manipulated into place (B), and provisional fixation is made, often
with a pointed reduction clamp (C). Occasionally, the articular surface reduction can be seen directly through an unreduced medial malleolar
fracture. A confirmatory radiograph should be taken. Definitive fixation is obtained with anteroposterior lag screws (D) or occasionally, as also
shown, with a screw inserted through the interval between the Achilles tendon and the structures behind the medial malleolus (E). (A–E, Redrawn
from Heim, U.; Pfeiffer, K.M. Small Fragment Set Manual: Technique Recommended by the ASIF Group, 2nd ed. New York, Springer-Verlag,
1982.)
Posterolateral exposure of a posterior lip fragment is through the interval between the peroneal tendons and the
Achilles tendon ( Fig. 59-58 ). Attention must be paid to protect the sural nerve. This approach is greatly facilitated by
having the patient lie prone or on the unaffected side. Unfortunately, both these positions hamper medial exposure and
interfere with reduction and fixation of the medial malleolus. With the prone patient, internal rotation of the leg, aided by
a cushion anterior to the opposite hip, eases access to the medial malleolus if it must also be fixed.

Figure 59-58 Reduction and fixation of a posterior tibial fragment through a posterolateral approach. A, The extra-articular fracture line is used
for reduction because the joint cannot usually be directly visualized. B, Fixation is with a lag screw inserted posteriorly, with attention to aiming
proximally enough to avoid the convex joint surface. C, The approach is between the peroneal tendons and the flexor hallucis longus. D, A
partially threaded 4.0-mm cancellous lag screw provides interfragmentary compression. (A–D, Redrawn from Heim, U.; Pfeiffer, K.M. Small
Fragment Set Manual: Technique Recommended by the ASIF Group, 2nd ed. New York, Springer-Verlag, 1982.)

Through either a posterolateral or a posteromedial approach, the fragment is retracted and hematoma removed from
the fracture cleft with irrigation and suction. The peripheral margin of the fracture is used as a guide to fragment
reduction, perhaps aided by a small arthrotomy or occasionally by visualization of the plafond through the bed of an as
yet unreduced medial or lateral malleolar fracture. A sharp dental pick, K-wires, and the three-hole pointed drill guide
aid reduction. Provisional fixation from the anterior tibia to the posterior lip fragment is achieved with K-wires or,
occasionally, large, pointed reduction forceps. Unless the articular surface is well seen, a lateral radiograph of the
provisional reduction should be obtained before definitive fixation. Final intraoperative radiographs are routinely
obtained after all fixation is in place but before the sterile field is broken in case changes are required ( Fig. 59-59 , Fig.
59-60 , and Fig. 59-61 ).
Figure 59-59 A, B, Fracture-dislocation of the ankle with a large posterior lip fragment and extensive medial malleolar comminution. C, A
cannulated screw inserted over a provisional K-wire fixes the posterior lip fragment. A medial cloverleaf plate and standard lateral malleolar
construct complete the fixation.

Figure 59-60 A, Articular incongruence is primarily caused by a large, displaced, posterior malleolar fragment. B, A comminuted medial
malleolar fracture is also present. C, After predrilling the anterior distal tibia for a 3.5-mm sliding hole, the insert drill sleeve is placed, and a
provisional reduction is accomplished with K-wire fixation. This radiograph confirms anatomic realignment of the joint surface. D, E, Fixation is
completed with multiple lag screws and a fibular plate. The fracture healed uneventfully.
Figure 59-61 A, B, Trimalleolar fracture-dislocation with a significant posterior lip fragment. C, D, Fixation with two 4.0-mm cancellous lag
screws inserted from front to back. It was fortunate that the threads were the right length for this fixation, which would have been impaired had
they crossed the fracture plane.

Clearly, in view of the many options and multiple steps involved in fixing a trimalleolar fracture, the surgical team is
aided and the result often improved by careful preoperative assessment and a detailed, explicit preoperative plan for
positioning, exposure, reduction, fixation, and radiographic documentation. If many radiographs are needed or if parts
of the reduction and fixation are to be done without direct visualization, the use of image intensification fluoroscopy is
helpful, and appropriate positioning and use of the table should be planned. Image quality, however, may lack the
detail obtained with standard radiographs, which are the best confirmation of final reduction and fixation.

When there is a large posterior lip fracture, extensive visualization of the plafond is possible by delivering the distal
tibia through a medial incision, as advocated by Shelton and described by Grantham.[90] Both advised release of the
posterior lip fragment from its attached PITFL and a careful search for any comminuted fragments of articular surface
in the joint. The entire distal tibial plafond is delivered through an approximately 7-inch medial incision while the talus,
lateral and medial malleolar fragments, and foot are dislocated laterally. This delivery requires release and posterior
retraction of the posterior tibial tendon sheath. According to the technique's proponents, comminution and bone
grafting, if needed, can readily be dealt with through this approach. After reconstruction of the plafond, the talus is
relocated, and the lateral and medial malleoli are fixed in the usual fashion.
ANTERIOR LIP FRACTURES
The location and character of anterior lip injuries determine the approach and fixation. A CT scan may be helpful for
preoperative planning. If extensive comminution of the anterior lip is a relatively isolated injury, an anterolateral
arthrotomy lateral to the extensor tendons may provide the best access. Extensive comminution may require buttress
fixation with a small plate. An avulsed Tillaux fragment (anterolateral articular surface) should be reduced and fixed
with a lag screw. An impacted anterolateral fragment may be excised, if small, or elevated with bone grafting if it
involves a significant part of the articular surface.

MEDIAL MALLEOLAR AND LIGAMENTOUS INJURIES

Operative treatment of medial ligamentous disruptions in malleolar injuries may not always be necessary. Since
recognition of the vital role of the lateral malleolus, many authors have reported satisfactory results with anatomic
repair of the lateral malleolus and nonoperative management of complete deltoid ligament disruptions. In general,
fractures of the medial malleolus should be reduced and fixed to add stability, maintain joint congruity, and decrease
the rather low risk of a symptomatic medial malleolar nonunion.

A straight, slightly oblique, or curving incision is made according to the surgeon's preference and the planned fixation (
Fig. 59-62 ). Anteriorly, the saphenous vein and its accompanying cutaneous nerve branches should be protected. The
incision should permit an anteromedial ankle arthrotomy as well as visualization of both the anterior and the medial
aspects of any malleolar fracture. The joint is inspected, and any loose osteochondral shards are removed. Retraction
of the malleolar fragment demonstrates the flexor tendons, which are occasionally injured. The tibialis posterior is most
commonly involved, and it should be checked to exclude injury. Local comminution may be associated with posterior
tibial tendon involvement.[266]

Figure 59-62 The medial malleolus is approached through a longitudinal incision that allows access to the anteromedial corner of the ankle joint
and as much of the distal tibia as required. A longer incision is better than too vigorous retraction. Attention is paid to the saphenous nerve
branches; a painful neuroma may result if they are caught in the scar.

The medial surface of the plafond should be assessed through the fracture site, especially in supination-
adduction injuries, to search for an impacted area that may need elevation and bone grafting of any resulting
defect. Usually, only a small amount of graft is required, and this can be obtained from the more proximal
part of the tibial pilon or, through a separate incision, from Gerdy's tubercle ( Fig. 59-63 and Fig. 59-64 ).
Figure 59-63 A, The vertical type A medial malleolar fracture is fixed with two or more lag screws inserted perpendicular to the fracture. The
use of washers or, rarely, a buttress plate is wise. B, If there is impaction of the medial plafond, the articular cartilage and subchondral bone are
carefully pried en masse back into place against the reduced talus, and bone graft is inserted into the defect before the medial malleolus is
repaired.

Figure 59-64 Occasionally, the supination-adduction medial malleolus fracture requires buttress support, analogous to an impacted tibial
plateau fracture. A one-third tubular plate has been flattened, cut through the distal hole to provide prongs for additional fixation, and secured with
multiple screws. This weight-bearing radiograph was taken 9 months after fixation of the fracture seen in Figure 59-23 .
If repair of the deltoid ligament is desired, its deep portion must be visualized, usually posteriorly after retraction of the
tendons, and sutures placed before the lateral side has been fixed. The talus must be displaced laterally to permit this.
Depending on the location of the tear, sutures may be placed through drill holes in the malleolus or talus to provide
secure reattachment. A few sutures in the superficial deltoid ligament may improve the appearance of the repair but
probably add little to stability of the ankle.

Avulsion fractures of the medial malleolus are best reduced after exposing both the anterior and the medial aspects of
the fracture by sharply turning back the periosteum and attached fascia. The fragment is grasped with a small towel
clip or pointed reduction forceps and maneuvered into place with this and a sharp dental pick. It can be held in place
with this or with a bone hook while two fixation points are achieved. For smaller fragments, especially if comminuted,
two small K-wires (1.2 or 1.6 mm) may be chosen. For intermediate-sized fragments, one wire and a 2.0- or 2.5-mm
drill bit are used to prepare a hole for a 4.0-mm partially threaded cancellous screw. For larger fragments, two such
drills are used for provisional fixation and replaced one at a time with the 4.0-mm partially threaded screws.

Cancellous screws for fixation of medial malleolar fractures should be inserted to avoid comminution of the fragment
(i.e., not too close to its edge and not overtightened). They should be oriented perpendicular to the plane of the
fracture. To obtain a lag effect, their threads must not cross the fracture. They should be seated in the dense bone of
the central distal tibial metaphysis and thus should be approximately 40 mm long. The surgeon must not attempt to
anchor them in the far cortex, which is too thin to provide much purchase. Doing so can cause either the drill or the
screw to deviate during the insertion process and thus lead to malreduction or comminution of the malleolar fragment.
Although tapping of cancellous bone is not needed and may reduce the pull-out strength of screws, the use of an
appropriate tap through the malleolus and just across the fracture may ease screw insertion and reduce risk of
comminution. A preliminary small incision of the superficial deltoid ligament fibers before drilling the pilot hole is helpful.

When the medial malleolar fragment is too small for screws or if comminution develops, the use of K-wires with a
figure-of-eight tension band can provide satisfactory fixation. The ends of the K-wires are bent over and gently
[81]
impacted over the tension band. Proximal anchorage for the wire can be over a screw head rather than through a
transverse drill hole ( Fig. 59-65 and Fig. 59-66 ). Tension banding is also useful in osteopenic bone.
Figure 59-65 Fixation of avulsion fractures of the medial malleolus depends on their size and comminution. A, B, Small or comminuted
fragments are best repaired with K-wires and a tension band wire. C, A larger piece can be fixed with a single K-wire and a lag screw or two lag
screws. D, Usually, 4.0-mm partially threaded lag screws are used. They are inserted perpendicular to the fracture line. Provisional fixation of a
medial malleolar fragment is often better done with K-wires or 2.5-mm drill bits rather than clamps, which might comminute or displace it.
Figure 59-66 Medial malleolus fixation with two 4.0-mm cancellous lag screws. On mortise (A) and lateral (B) radiographs, note insertion of the
threads into only the densest bone of the central metaphysis and their posterior orientation to accommodate the anteriorly situated medial
malleolus. C, K-wires and a tension band loop are more appropriate for a small or comminuted medial malleolar avulsion. Note the use of a screw
for proximal anchorage of the wire.

If the medial malleolar fracture is vertical or oblique, as in supination-adduction type A injuries, the orientation of lag
screws to fix the fracture must be different from that used for horizontal plane avulsion fractures. They must be inserted
perpendicular to the fracture and thus are fairly transverse. Washers are more likely to be needed because of the
thinner medial cortex, and occasionally even a small medial buttress plate is advisable if the bone is osteopenic or
excessively comminuted. Three or more screws may be needed for vertical fractures with large medial fragments.

INTRAOPERATIVE RADIOGRAPHS
Adequate intraoperative radiographs must be obtained to confirm the reduction and fixation of any periarticular
fracture, and this holds true for malleolar injuries. In general, AP, lateral, and mortise exposures are made during or
just prior to wound closure, although the need for an AP view as well as a mortise view has not been proved. The ankle
should be in neutral during these radiographs, which should be carefully checked for adequate positioning and
exposure, malleolar fracture reduction (especially the talotibial relationship), the tibiofibular relationship (syndesmosis),
the articular surfaces, the length and rotation of the lateral malleolus, and the location of any inserted hardware.

WOUND CLOSURE AND POSTOPERATIVE CARE

After fixation has been confirmed, the wounds are irrigated and closed atraumatically, usually with interrupted
nonabsorbable skin sutures, although some advise that deeper tissues be approximated as well. Small suction drains
may decrease problems from hematomas. Generally, a very well padded, loosely wrapped short leg splint is applied to
hold the ankle fully dorsiflexed. Such a splint can be used until the sutures are removed and the surgeon's choice of
subsequent immobilization is applied. It seems wise to splint the ankle in as much dorsiflexion as possible, for this is
hard to regain if an equinus contracture is allowed to develop.

According to Ahl and co-workers,[1] it makes little difference to most patients what postoperative immobilization regimen
is followed, although with tenuous fixation, osteopenic bone, or an uncooperative or neuropathic patient, more rather
than less protection may be advisable. Accordingly, the ankle may be placed in a long or short leg non-weight-bearing
cast, a short leg walking cast, a hinged brace, a removable bivalved cast, or an elastic support with crutches to limit
weight bearing.* One study has documented improved early outcomes with early range of motion versus casting.[65] In
the neuropathic patient, most commonly with diabetes, a bent-knee long leg cast may be required to prevent weight
bearing for as long as 8 weeks.[49] After the first 6 weeks (if the fracture is only malleolar) or longer (if there is plafond
involvement), progressive unrestricted weight bearing can usually be allowed with safety. Crutches are appropriate
until the patient is walking well without a limp and radiographic healing is advanced. Range-of-motion, strengthening,
endurance, and agility exercises are also necessary elements of the rehabilitation program, which usually lasts several
months before the patient can successfully return to vigorous work and athletics. Some swelling of the soft tissues
frequently persists for months.[63]

Special Treatment Groups

OSTEOPENIA

As the population ages, the incidence of fractures with osteopenia will rise. One needs to weigh carefully the risks and
benefits of operative fixation in light of the chances of securing stability. If ORIF is chosen, standard techniques can be
used. Alternative methods such as tension band wiring or intramedullary fibula fixation and cerclage can be used.
Placing the fibular plate posteriorly is one method to obtain longer and typically stronger screw purchase.

DIABETIC PATIENTS

A severe ankle fracture in the diabetic patient places the treating surgeon directly on the uncomfortable horns of a
dilemma. The literature documents a significant increase in complications with either operative or nonoperative
treatment.[27][74] In particular, skin ulceration, infection, and malunion occur much more frequently than in the general
population.[27][74] The literature fails to provide a guiding consensus. We approach these injuries with the following
guidelines:

1. One needs to ensure that the fracture represents an acute injury and not part of an ongoing Charcot process.
With a Charcot process there is typically a history of weeks of swelling and pain in the ankle. A misdiagnosis of
cellulitis or deep vein thrombosis may have been made. A Charcot ankle generally requires casting, elevation,
and non-weight bearing to reduce the hyperemic process. Once this process "quiets down," surgical treatment,
if needed, can be considered.
2. Fixation must be rigid. We tend to overuse syndesmotic fixation simply as a means to stabilize the mortise.
3. Postinjury immobilization is typically a bent-knee long leg cast for 6 weeks, followed by a short leg walking cast
for 1 month. The patient is kept in bed to chair with short-distance ambulation only. A wheelchair is provided. In
our experience, neuropathy with loss of protective proprioception is the major factor that leads to early weight
bearing despite strict instructions otherwise. This early weight bearing results in a reddened, hyperemic wound
accompanied by early fixation failure. Although this regimen places a hardship on the patient in the short run, it
can help to minimize long-term complications.
4. Despite the surgeon's best efforts, problems do occur. Early intervention for developing complications is
warranted.

Results of Treatment
The outcome of an injury is best judged by how much it affects the patient.[190] Pain, impaired function, deformity, and
loss of motion are all-important factors. A variety of rating systems have been proposed for the subjective and objective
components of clinical results of ankle injuries. Results are usually stratified into groups for analysis. Outcome criteria
are not uniform, so it is unwise to compare published series directly. Rating and scoring systems often give different
levels of importance to different variables, and most include several interrelated aspects of ankle function or anatomy.
Some systems consider only functional outcome; others include clinical examinations and radiographic findings. Some
rely heavily on the ability to work or participate in sports, criteria that are irrelevant to certain categories of patients. The
American Orthopaedic Foot and Ankle Society has devised a rating scale based largely on function ( Table 59-4 ). Its
use is recommended.

Table 59-4 -- American Orthopaedic Foot and Ankle Society Rating Scale for Ankle Injury
Hindfoot Scale (100 Points
Feature
Total)
PAIN (40 POINTS)
None 40
Mild, occasional 30
Moderate, daily 20
Severe, almost always present 0
 Hindfoot Scale (100 Points
Feature
Total)
FUNCTION (50 POINTS)
Activity limitations, support requirement
No limitations, no support 10
No limitation of daily activities, limitation of recreational activities, no support 7
Limited daily and recreational activities, cane 4
Severe limitation of daily and recreational activities, walker, crutches, wheelchair,
0
brace
Maximal walking distance, blocks
Greater than 6 5
4–6 4
1–3 2
Less than 1 0
Walking surfaces
No difficulty on any surface 5
Some difficulty on uneven terrain, stairs, inclines, ladders 3
Severe difficulty on uneven terrain, stairs, inclines, ladders 0
Gait abnormality
None, slight 8
Obvious 4
Marked 0
Sagittal motion (flexion plus extension)
Normal or mild restriction (30 degrees or more) 8
Moderate restriction (15–29 degrees) 4
Severe restriction (less than 15 degrees) 0
Hindfoot motion (inversion plus eversion)
Normal or mild restriction (75%–100% normal) 6
Moderate restriction (25%–74% normal) 3
Marked restriction (less than 25% normal) 0
Ankle-hindfoot stability (anteroposterior, varus valgus)
Stable 8
Definitely unstable 0
ALIGNMENT (10 POINTS)
Good, plantigrade foot, ankle-hindfoot well aligned 10
Fair, plantigrade foot, some degree of ankle-hindfoot malalignment observed, no
5
symptoms
Poor, nonplantigrade foot, severe malalignment, symptoms 0

Radiographic results may be assessed separately or combined with subjective and objective clinical data. Both the
quality of reduction after healing and the presence of degenerative changes are pertinent. Joy and co-workers[120]
presented objective techniques for measurement of malleolar and talar displacement. Goergen and associates[83]
emphasized the value of adequately positioned radiographs for such assessments. Pettrone and colleagues[208]
demonstrated the predictive validity of radiographic criteria—particularly displacement of either malleolus, syndesmosis
widening, and increased clear space between the medial malleolus and the medial surface of the talus. In a
prospective study, Phillips and co-workers[209] noted that the significant indicators of a poor result after severe external
rotation ankle fractures were talar subluxation on the lateral radiograph and lateral malleolar shortening, as measured
directly or by a talocrural angle different from that on the normal side (see Fig. 59-11 ).
Osteoarthritis of the ankle joint, rare except after injury, is manifested by osteophyte formation, narrowing of the
radiolucent cartilage space, and subchondral sclerosis and cyst formation. Radiographs taken during weight bearing
have not always been used to diagnose joint narrowing. The changes of osteoarthritis tend to develop early (within 2 to
3 years) after injury and may not progress.[150] Although the significance of slight joint narrowing is not clear, poor
clinical results are associated with more advanced osteoarthritis.

A number of factors affect the outcome of ankle fractures.[303] An important one is the severity of the original injury. The
severity is indicated primarily by the amount of damage to the plafond and by the amount of impaction, comminution, or
displacement of the posterior lip fracture. Involvement of multiple structures is also pertinent, as higher grade injuries,
in the Lauge-Hansen system, have a poorer prognosis, as do trimalleolar fractures when compared with those
involving a single malleolus. Some, but not all, reports suggest that women and older patients experience poorer
results. The fracture type (Lauge-Hansen or AO/ASIF) carries variable prognostic weight, depending on the
study.[96][150] The presence of a posterior lip fracture, even when small, adversely affects the prognosis of malleolar
fractures.[103][117]

A well-established finding is the benign nature and good outcome of supination-external rotation grade II lateral
malleolar fractures. Prolonged follow-up after nonoperative treatment in a short leg weight-bearing cast reveals an
extremely low incidence of arthrosis and symptoms in spite of an initial 2- to 3-mm displacement of many of these
isolated injuries. It is important to distinguish these from the similar supination-external rotation type IV injuries with
deltoid ligament ruptures medially, as the latter have a much worse prognosis.

The adequacy of reduction after fracture healing is a significant determinant of outcome. Lindsjö[150] reported 87% good
to excellent results in 217 patients with well-reduced, originally displaced malleolar fractures, compared with 68% good
to excellent results in 89 patients with inadequate reductions. These patients were treated with AO fixation techniques
and had a higher incidence of maintained reduction and of good outcomes than those in a series reported by Cedell[43]
with less rigid fixation. Similar good results after anatomic reduction and rigid fixation were reported by others,
including Hughes and associates, from several Swiss centers. Satisfactory outcomes were achieved in 78% to 83% of
type A, 76% to 83% of type B, and 62% to 85% of type C malleolar injuries. A comparable group of patients with similar
injuries treated nonoperatively had satisfactory results in 71% to 75% of type A, 35% to 43% of type B, and 23% to
37% of type C fractures.

Results with less satisfactory approaches to reduction and internal fixation (i.e., medial fixation alone, approximate
reduction, or avoidance of lateral plates) are generally poorer as well, although they are not strictly compared in the
literature. Subjective complaints are common after malleolar fractures, even after several years. Many authors reported
an approximately 30% incidence of such symptoms, although there is evidence that the symptoms gradually resolve.
Removal of prominent implants can relieve symptoms from this source.[114][226] The reported incidence of significant
post-traumatic osteoarthritis after malleolar fractures ranges from negligible in supination-external rotation type II
injuries to 37% or more in more severely displaced patterns, especially if posterior malleolar involvement is present.[19]
It is also clear that the incidence of arthritis is much greater if a malleolar fracture heals with significant displacement.

SOFT TISSUE INJURIES OF THE ANKLE

Lateral Collateral Ligament Injuries
Ankle "sprains" are frequent injuries and are thus familiar to both patients and physicians.[219][240] They are the most
common injury resulting from recreational sports, have a considerable socioeconomic impact, and have generated an
abundant literature that has been extensively reviewed.[123][140][235][258] According to Bröstrom,[36] common ankle sprains
have complete ligament ruptures in 75% of cases. Two thirds of these are isolated injuries of the anterior talofibular
ligament.

This section emphasizes (1) the need for appropriate diagnosis, (2) the currently favored nonoperative management of
essentially all closed LCL ruptures, and (3) late instability resulting from functional or mechanical causes and its
management.

DIAGNOSIS
The complaint of a sprain by a patient with a swollen, tender ankle is so common in the urgent care setting that it is
often disregarded if ankle radiographs fail to reveal a fracture. Systematic evaluation is necessary to avoid missing a
less obvious injury.[184] The patient's description of the injury is important, and it should be determined whether the
onset was sudden, with an injury episode, or gradual.
An inversion mechanism, with the foot forcibly supinated, as has been previously discussed, produces failure of the
LCL complex. The anterior talofibular ligament is the structure most likely to be partially or completely torn. If the foot
was dorsiflexed, the fibulocalcaneal ligament may also be involved. If it was plantar flexed, the anterior capsule is often
torn as well. If the applied force externally rotated the foot (often in a pronated position), the injury is likely to involve
the tibiofibular syndesmosis and possibly the deltoid ligament (see the discussion of pronation-external rotation in the
previous section "Malleolar Fractures"). If no fracture is present on the ankle radiographs, this injury may be mistaken
for an LCL sprain in spite of syndesmotic involvement and the risk of a higher fibular fracture or talar instability in the
mortise. Tendon ruptures or dislocations have a characteristic history of failure under load, without extreme twisting of
the ankle. It is important to ask about prior difficulties with the ankle to identify tendon degeneration and other chronic
conditions.

Physical examination is often difficult because of tenderness.[179] Status of the skin and neurovascular function is
important. Very forceful inversion injuries may rupture the lateral ankle skin, producing a characteristic transverse
wound that looks almost as though it were made with a scalpel. Peroneal nerve palsies and occasionally delayed
compartment syndromes accompany inversion sprains.[11][136][193] Localization of tenderness is essential to identify the
injured structures. If the LCL complex is involved, there is tenderness over the anterior talofibular ligament and possibly
over the fibulocalcaneal ligament, the anterior capsule, and the MCL. LCL injuries should not produce tenderness over
the syndesmosis, the malleoli themselves, the proximal fibula, or the Achilles or other tendons, although the nearby
peroneal tendons may be rather sensitive. Rarely, an LCL disruption occurs in company with a lateral malleolar
fracture.[289]

Assessment of stability is the basis for confirming and grading a ligament injury. The assessment is often difficult in the
case of an acute ankle injury and is even harder after a day or two have elapsed. Anterior drawer motion of the
plantigrade foot is a sign of anterior fibulotalar laxity, which can be confirmed and quantitated by stress radiography.
Inversion laxity may be caused by deficiencies of the fibulocalcaneal ligament (in dorsiflexion) or the anterior talofibular
ligament (in plantar flexion). It is hard to judge because of the patient's discomfort and the normal motion of the
subtalar joint, which itself may be unstable in as many as 10% of patients with inversion laxity.

Confirmation of ligament rupture is possible with peroneal tenography or ankle arthrography, but neither defines the
degree of instability. This definition can be made with stress films, with or without special apparatus or anesthesia.[4][138]
With general anesthesia, stress radiographs are quite accurate (92%), but accuracy with local anesthesia falls to 68% (
Fig. 59-67 ).[107] Although academically interesting, such studies do not convincingly improve the patient's outcome
after acute ankle sprains, so they are rarely indicated.

Figure 59-67 Inversion stress radiographs demonstrate 14 degrees of varus tilt of the right talus (A) versus 2 degrees of varus on the left (B).

It is vital to inspect carefully the standard radiographs of a patient with a presumed ankle sprain. Osteochondral
fractures of the talus may be present on either the lateral or the medial dome; their identification is necessary for
proper management (see Chapter 60 ).[96][299] A fracture of the lateral process of the talus may simulate an LCL sprain,
as may a fracture of the anterior process of the calcaneus. The latter is hard to see without oblique radiographs of the
foot, although its characteristic tenderness is more anterior. Avulsion of the base of the fifth metatarsal may occur with
an inversion injury with or without associated ankle LCL rupture.

Small ligamentous avulsion fractures from the lateral malleolus or ankle capsular attachments are occasionally seen
with sprains and should not affect treatment or outcome. Bröstrom[36] found these in 14% of patients using standard
radiographs. Meyer and colleagues,[177] using high-resolution CT, reported them in 42% of patients.

TREATMENT
The goals of treatment for LCL injuries are to achieve rapid and complete rehabilitation with minimal morbidity and cost
and the lowest possible risk of late instability. Many approaches, with a great number of variations, have been
reported.[97] At present, there appears to be little justification for primary surgical repair, which has been shown by
several randomized prospective studies not to improve the outcome of either isolated ruptures of the anterior talofibular
ligament or those with concomitant fibulocalcaneal rupture. Furthermore, late reconstructions for those who need them
are no less successful than early repair.[42]

Optimal nonoperative management of ankle LCL sprains should involve functional aftercare. Because late instability
may be caused by functional or anatomic factors[9][140][237] and may respond to appropriate rehabilitation measures,
including exercises for muscle strength and agility, such measures may have a role in the management of acute
injuries, as may various physical modalities that increase comfort and provide support for the ankle. On the other hand,
many patients with these common injuries do so well with independent rehabilitation programs that routine prescription
of physical therapy and long-term bracing carries a significant unnecessary economic burden.

The patient with an acute ankle LCL sprain may have a minor injury with tenderness, slight swelling, and little difficulty
walking. More demanding activities may be symptomatic, and the risk of reinjury is probably significant if she or he
returns immediately and without protection to challenging activities. The patient with a moderate injury has significant
swelling and tenderness, walks with difficulty on the ankle, and is unable to participate in vigorous work or sports. The
patient with a severe LCL injury has such significant pain and tenderness that he or she is unable to bear weight
without rigid immobilization or crutches and usually has documentable evidence of a complete disruption of both the
anterior talofibular ligament and the fibulocalcaneal ligament.

Treatment of minor ankle sprains is directed at relief of symptoms and prevention of further injury. It consists of
reduced activity, stretching and strengthening exercises, and the use of a training-type brace that provides
proprioceptive input. Moderate and severe ankle sprains are difficult to differentiate precisely without anesthesia.
Therefore, similar treatment regimens are advised. Although a more precise diagnosis might expedite rehabilitation for
athletes under pressure to return to competition earlier, it is unnecessary and not cost effective in the majority of cases.
Progressive return to normal activity can be determined by the patient's clinical course.

The acutely injured ankle with a moderate or severe sprain is best immobilized in a well-padded plaster splint. Ice,
elevation, and crutch walking are advised. Within 2 or 3 days, as the acute swelling diminishes, the patient is
reassessed. Generally, a stirrup splint with pneumatic or other cushions (e.g., Aircast or equivalent) is applied over a
sock or a light, loose elastic wrap, and the patient is encouraged to bear weight progressively as tolerated and to
[23][217]
discard the crutches as soon as comfort and security permit ( Fig. 59-68 ). For a noncompliant patient with a
severe injury, a cast may be considered. Generally, however, it is withheld unless the patient is so disabled that rigid
external support is necessary for comfort. In such a case, a short leg walking cast can be applied as soon as swelling
permits and used for 1 to 3 weeks until full weight bearing is possible in the cast. At this point, the functional brace is
substituted.
Figure 59-68 A stirrup splint with air-filled cushions and Velcro fasteners provides secure, functional support for a lateral collateral ligament
injury after the acute pain and swelling have resolved.

An important part of the aftercare of an acute LCL ankle sprain is a functional rehabilitation program. This program
usually consists of progressive resumption of activity, stretching and strengthening exercises, functional bracing or
taping, and proprioceptive drills. Many such regimens have been described and are reported in the literature.

Late Inversion Instability

Chronic instability has been reported to follow 20% to 40% of acute inversion ankle sprains.[106] The patient reports
recurring inversion sprains or the feeling that the ankle will "give way" in this manner. Prospective randomized studies
provide little support for the belief that acute surgical treatment reduces this risk.[66][133][140][262] More effective early
nonoperative management may be beneficial, however.

Instability may be mechanical with documentable inversion laxity of the ankle or subtalar joint. It may also have
functional causes, such as impaired proprioception and balance or, rarely, peroneal rupture or palsy. History,
examination, and stress radiographs usually permit diagnosis of the cause of ankle instability. If a trial of intensive
rehabilitation is unsuccessful and mechanical instability is present, some form of lateral ligamentous reconstruction is
appropriate. High success rates have been reported for treatment of recalcitrant mechanical instability by most of these
various procedures, which range from repair of the residual ligament to its advancement or to its augmentation with
local or more distant tendon grafts. If subtalar instability is present, the ligament reconstruction must address it.
Anatomic repairs (e.g., Bröstrom) are currently in favor, but acceptable results can be obtained with a number of
operations.

Persistent Pain
Occasionally, ankle pain, rather than a sensation of instability per se, is a residual problem after an ankle inversion
injury. It may be the result of one or more of several factors. An osteochondral fracture of the talus should be
considered.[96][297] There may be impingement on the talus by a synovial thickening or hypertrophic AITFL.[17] Another
possibility is a post-traumatic sinus tarsi syndrome with damage to the restraining ligaments of the subtalar joint, which
can be demonstrated by posterior subtalar arthrography.[178] CT or magnetic resonance imaging evaluation, bone scan,
or ankle arthroscopy may help with the evaluation and management of these often puzzling injuries.

Ankle Dislocations
ANKLE DISLOCATIONS WITHOUT FRACTURE

Although most ankle dislocations are part of a complex malleolar injury, the tibiotalar joint rarely dislocates without a
fracture.[52][278] Approximately one third are open, with an associated risk of infection that can be diminished with
appropriate wound care and delayed closure.[129] Neurovascular injuries are frequently associated with these
dislocations. Closed reduction is usually successful, with a generally satisfactory result and little risk of long-term
functional instability or arthritis. The results of open dislocations are poorer.

Occasionally, there is a complete dislocation of the talus with dislocation from the subtalar and talonavicular joints as
well. These extruded talus lesions are usually open and have a high risk of sepsis, avascular necrosis, and ultimate
amputation. Despite these problems, an attempt at salvage of the talus is warranted. If complications ensue, talectomy
and early tibiotalar arthrodesis may be the best means of salvaging a functional foot.[129]

SPRAINS OF THE SYNDESMOSIS—THE "HIGH ANKLE SPRAIN"

Sprains of the syndesmotic ligaments are reported in 1% to 11%of all ankle sprains. They are identified by a history of
external rotation with tenderness over the AITFL. In the absence of concomitant fibular fracture, compression of the
fibula to the tibia in the proximal half of the leg produces pain in the syndesmotic area (squeeze test).[109] These less
frequent ligamentous injuries of the ankle are slower to recover and may benefit from a somewhat more restrictive
approach to management, including a period of a few weeks in a non-weight-bearing cast.[23][236] Disability for sports
participation can extend to 3 to 4 months.

It is important to exclude the diagnosis of complete ligamentous disruption with displacement of the fibula from the
incisural notch. This diagnosis is suggested by mortise widening or by a separation of 5 mm or more between the fibula
and the lateral border of the notch on mortise radiographs. Remember that a high fibula fracture or plastic deformation
of the fibula may accompany these injuries. Precise documentation of the distal tibiofibular anatomy is readily obtained
with a CT scan. If displacement is present, closed management is not likely to replace the fibula, and ORIF is
indicated. In the absence of displacement of the fibula, protection and progressive rehabilitation are advised.

TIBIOFIBULAR DIASTASIS

Widening of the ankle mortise occurs occasionally without obvious fracture.[158][166] It may be occult, with a syndesmosis
disruption that requires stress radiographs for confirmation. It may also be frank and visible on routine radiographs (
Fig. 59-69 ). Edwards and DeLee[64] described four types of this rare injury. In type I, there is a direct lateral
displacement of the otherwise normal fibula. This type is best treated with open reduction and syndesmosis
transfixation. Type II injuries are similar but have plastic deformation of the fibula and may need an osteotomy as well
as open reduction of the distal fibula. Type III injuries have posterolateral rotatory subluxation. Type IV have
interposition of the superiorly dislocated talus. Types III and IV are usually managed well with closed reduction and
cast immobilization, according to Edwards and DeLee.[64]

Figure 59-69 Tibiofibular diastasis with a small posterior avulsion fracture of the tibia in a teenaged
patient. Plastic deformation of the fibula required osteotomy and fibular fixation.

Medial Collateral (Deltoid) Ligament Ruptures

The deltoid ligament is usually injured as a component of a malleolar fracture, and this has been discussed previously.
Rarely, it appears as an isolated injury.[99] Nonoperative management should provide satisfactory stability unless
unrecognized syndesmosis disruption is present.
Achilles Tendon Ruptures
A myriad of pathologic conditions may affect the Achilles tendon, including Achilles tendinitis, partial or incomplete
ruptures of the tendon, bursitis, and tenosynovitis. Because of the large mass of the triceps surae and its importance in
control of the tibiotalar relationship during walking, running, and jumping, the Achilles tendon is subjected to large loads
on a regular, recurrent basis. Achilles tendinitis is an overuse syndrome and must be differentiated from more acute
problems such as tears, partial tears, muscle strains, and thrombophlebitis. Radiographic examinations are usually
noncontributory except in the case of a large posterosuperior calcaneal spur. Most of the overuse syndromes respond
to activity modification, a heel lift, stretching exercises, night splints, and oral anti-inflammatory agents. Injections with
steroid preparations should be discouraged as they damage the collagen matrix and may result in iatrogenic tendon
ruptures.

Ruptures of the Achilles tendon are usually secondary to forced dorsiflexion of the plantar flexed foot. Typical patients
are middle-aged "weekend athletes." Not uncommonly, rupture occurs in high-demand sports such as basketball,
football, or tennis. A possible contributory factor may be failure to stretch and warm up appropriately for the sporting
[165]
event. Rarely, these ruptures accompany fractures of the ankle.

Examination of the patient with an acute Achilles tendon rupture usually demonstrates a defect in the heel cord with
exquisite pain and inability to plantar flex the ankle completely. Swelling may obscure the tendon defect. The
Thompson test is performed by manually squeezing the calf while the patient is kneeling. This action normally
produces passive plantar flexion of the ankle. The injured Achilles tendon demonstrates less plantar flexion than the
normal calf when the test is performed (see Fig. 59-16 ).

The treatment for Achilles tendon rupture includes conservative management with the foot held in the plantar flexed
position for at least 8 to 12 weeks, open management with primary repair and preservation of the tenosynovium,
percutaneous repair through small stab incisions, and open repair with or without augmentation. The literature offers
various opinions about the results of treatment.[92][143] A large, randomized study demonstrated little difference in
outcome, and similar complication rates, between nonoperative and operative treatments.[192] However, it is usually
suggested that "serious athletes" should be treated with operative repair, which may offer a more functional result than
conservative management. The reported risk of rerupture is lower after surgical treatment unless care is taken with
nonoperative treatment.

Surgical technique should include a posteromedial skin incision rather than one in the midline, which could be
associated with shoe wear problems as well as skin sloughs. The paratenon should be preserved and repaired, if
possible, to prevent adhesions between the skin and the tendon repair. The tendon ends are reapproximated with
appropriate suture techniques in the manner of Bunnell or Kessler.[277] Loose ends of the tendon can be sutured into
bundles before being reconnected.[24] The plantaris tendon can be used to augment the primary repair if it does not
appear strong enough. Dacron mesh or other fabric can also be used to reinforce an Achilles tendon repair. An
alternative technique relies on a suture placed percutaneously through the tendon ends, which are not exposed in an
effort to avoid skin complications, which may be a problem with open repairs. After primary repair or augmentation,
short leg immobilization for 6 to 8 weeks is usually adequate, followed by use of a heel lift to protect the repair for an
additional 6 weeks.

Late repairs of neglected Achilles tendon ruptures can be augmented with a turndown of the gastrocsoleus fascia, a
strip of fascia lata, plantaris tendon, or flexor hallucis longus.[16]

Less Common Tendon Injuries

Other less common tendon injuries around the ankle include ruptures and dislocations of the peroneal or posterior tibial
tendons. Posterior tibial tendon rupture or dysfunction is usually due to attritional failure. It typically results in a painful
flatfoot deformity of fairly sudden onset in middle-aged or elderly individuals. Any ankle tendon is at risk of laceration in
an open wound. Loss of peroneal tendon function may be manifested as inversion instability.[131][274]

PERONEAL TENDON DISLOCATIONS

Dislocations of the peroneal tendon are fairly rare and usually result from forced dorsiflexion or forced
inversion.[12][50][196] The injury is easily misdiagnosed as an ankle sprain and treated with early mobilization, with
attendant risk of redislocation or chronic dislocation. Radiographic evaluation of a patient with a peroneal tendon
dislocation reveals a small fleck of bone off the posterior aspect of the lateral malleolus. This is well seen by CT. Such
an avulsion fragment, in association with the classic physical findings of pain behind the lateral malleolus and localized
swelling, is the hallmark of the diagnosis.

If reduction of the dislocated tendons is stable, these injuries can be treated with closed reduction of the tendons and a
below-knee walking cast for 6 to 8 weeks. In some cases, little intrinsic stability exists after retinacular rupture, and
open reduction with retinacular repair or reconstruction is advisable.

Recurrent dislocation (or subluxation), however, poses a more difficult reconstructive problem. Surgical alternatives
include transfer of the lateral Achilles tendon sheath, fibular osteotomy to create a deeper pulley for the tendons, and
rerouting peroneal tendons under the fibulocalcaneal ligament. *

POSTERIOR TIBIAL TENDON RUPTURES

Acute posterior tibial tendon ruptures are difficult to diagnose and are frequently unrecognized for long periods of time.
Occasionally, they accompany malleolar fractures. They are usually found in patients in the fourth to sixth decades of
life who present with a recently developed, painful flatfoot deformity. Standing radiographic evaluations classically
show a flatfoot deformity with asymmetry of the talonaviculocuneiform arch. The tendon can be visualized by CT and
especially well by magnetic resonance imaging, which greatly aid diagnosis. Complete ruptures that have been
diagnosed early can be treated with repair, usually with augmentation from the adjacent toe flexors.[160] However,
chronic posterior tendon ruptures may require a subtalar or triple arthrodesis, depending on the severity of symptoms.
Rarely, dislocations of the posterior tibial tendon may occur.

COMPLICATIONS
Shelton and Anderson[251] provided a thorough and exceptionally detailed analysis of the complications of ankle injuries
and their treatment. On the basis of our review of the literature and extensive personal experience, this definitive work
is strongly recommended.

Most complications of ankle injuries are related to one of three basic areas: infection, soft tissue problems, or malunion
and arthrosis (osteoarthritis).

Wound Sloughs
Soft tissue wounds around the ankle usually result from high-energy trauma. Open ankle fractures should be treated as
mentioned previously with aggressive surgical débridement, immediate internal fixation, and delayed wound closure. In
the event of a superficial skin loss, the wound can be treated with wet to dry dressing changes for a 5- to 7-day period,
followed by split-thickness skin grafting with a 1:1.5 mesh. Alternatively, skin substitutes (e.g., Epigard) or Seligson's
bead pouch technique can be used, especially if there is exposed bone and tendon, to prevent desiccation and
infection. Local fasciocutaneous flaps are useful in selected cases.[95]

With the sophistication of microvascular transfer techniques, consultation with a microvascular surgeon well versed in
orthopaedic injuries can provide reconstructive options not previously available.[86][252] Small, well-perfused free tissue
transfers may be more cosmetic and more functional than the split-thickness skin graft that was previously placed on
granulating periosteum. Such free tissue transfer can salvage the ankle after a potentially catastrophic injury,
especially in the event of an open joint. If severe cartilage injury has occurred to either the tibial or the talar articular
surface, ankle arthrodesis may be required.[46] Such free tissue transfers provide a much more appropriate surgical soft
tissue environment for arthrodesis.

Infection
The open ankle fracture is at highest risk for developing an infection after internal fixation. However, in several large
series of open ankle fractures treated with immediate internal fixation, rates of infection were acceptable. The main
reason for this success is a combination of compulsive surgical technique, open-wound management, and
perioperative antibiotics. The improved outcome of open ankle fractures treated with appropriate wound care and
immediate internal fixation justifies this change from traditional orthopaedic teaching.

Infection may be difficult to identify after surgical treatment of an ankle fracture. It may be limited to a surgical wound
but often involves the ankle joint. Aspiration of the joint and proper evaluation of its fluid are thus mandatory whenever
an infection is possible. Studies should include Gram stain, cell count, and culture and sensitivity.
If an infection ensues after ORIF of the ankle, an aggressive approach must be undertaken with immediate surgical
débridement, multiple deep wound cultures, initially open-wound management, and appropriate antibiotics. The ankle
joint should not be left open but should be closed over a suction tube to prevent any accumulation of pus under
pressure. If the ankle joint cannot be closed, serious consideration must be given to early local soft tissue transfers or
free microvascular tissue transfer.

There may be disagreement between infectious disease consultants and orthopaedic surgeons concerning the
necessity of hardware removal in the event of an infection. If the hardware is providing stability, even in the presence of
gross infection, it should generally not be removed until the fracture has united. Instability of the infected fracture
fragments provides a less desirable biologic environment in which to fight infection. Obtaining a durably functional
ankle without chronic infection requires a combination of adequate débridement of necrotic and infected bone and soft
tissue, anatomic reduction, rigid stability, appropriate antibiotics, occasional soft tissue coverage (which might entail a
[92]
free muscle flap), and ultimately an aggressive postoperative ankle rehabilitation program. If internal fixation does
not provide adequate stability, external fixation should be used instead, generally with distal purchase in both
calcaneus and forefoot.

Malunion
Malunion of an ankle fracture may be caused by an inadequate closed reduction or by loss of such a reduction. If it is
caused by one of these, early recognition and correction, usually with ORIF, may resolve the problem, although the
difficulties of a late operation must be remembered. Malalignment may follow ORIF if reduction is inadequate and not
recognized or if it is lost because of failure of fixation. It may result from an uncooperative or neuropathic patient or
from mechanical problems of fixation or bone quality. The risk of inadequate reduction of an ankle fracture is
significantly increased in severe injuries with comminution, impaction, bone loss, and obscured landmarks for
reduction.

The operating surgeon must compulsively examine the intraoperative radiographs to be absolutely certain that an
anatomic reduction has been achieved. Failure to do so is a not infrequent source of error. Well-positioned and
satisfactorily exposed AP, lateral, and mortise views must be obtained intraoperatively and carefully reviewed, perhaps
by comparison with the opposite side, to be sure that the bone relationships are appropriate.

The most common malunion of the ankle has been reported to be shortening and malrotation of the fibula. Weber and
[288]
Simpson described a corrective osteotomy to bring the fibula back to length and restore appropriate rotation. This
procedure requires preoperative planning, the use of intraoperative distraction, bone grafting, and rigid fixation.[296] If
the fibula has been brought to appropriate length and reduced, aggressive physical therapy should follow. This
osteotomy may have limited application, as many malunions of the ankle are associated with pain and severe
degenerative changes. If loss of motion, pain, and severe degenerative changes are present, the lengthening
distraction osteotomy may not be enough to provide the patient with a functional ankle. However, such a procedure,
along with correction of all other deformities affecting the ankle, should be seriously considered unless end-stage
functional impairment is present, as nearly three fourths of such patients can have significant, long-lasting
improvement.

Post-traumatic Arthrosis
Post-traumatic arthrosis may be manageable with reduced activity, nonsteroidal anti-inflammatory medication, a well-
cushioned shoe with a heel lift, or a fixed-ankle short leg brace with a cushioned rocker heel. If these measures are
inadequate, arthrodesis is a reasonable consideration ( Fig. 59-70 ).[171][232] Ankle replacement arthroplasties have not
proved as successful as arthrodesis for most patients with post-traumatic arthrosis. Occasionally, however, removal of
osteophytes, especially from the anterior ankle, with open or arthroscopic techniques can significantly relieve
symptoms.
Figure 59-70 A, B, Post-traumatic arthrosis several years after a malleolar ankle fracture. C, D, Because of progressive severe symptoms,
unresponsive to conservative treatment, an arthrodesis was performed with good result.

Total ankle replacement is receiving renewed attention. It offers the promise of preserved motion with pain relief. Initial
reports are encouraging for this technically demanding procedure. Caution is warranted given the previous history of
ankle replacement. This topic is discussed further in Chapter 61 .

Late Syndesmotic Instability

Occasionally, following an ankle fracture and despite normal bone anatomy, medial clear space widening with
concomitant pain and swelling develops. In most cases, the deltoid ligament is insufficient, along with the lateral
syndesmotic complex. A method of surgical reconstruction was detailed by Kelikian and Kelikian.[127] In this procedure,
both the medial and the lateral ankle are exposed. Debris must be cleared from the tibial incisura and the medial joint
space. The syndesmosis is reduced and clamped, and stability confirmed visually and radiographically. The anterior
tibiofibular ligament is reconstructed with the extensor tendon to the fifth toe. Two staples are used for fixation of the
tibiofibular joint. Alternatively, screws can be used. The patient is kept non-weight bearing for 6 weeks.

Tibiofibular Synostosis
After disruption of the tibiofibular syndesmosis, heterotopic bone occasionally forms in the soft tissues between the
tibia and the fibula and may unite with both to produce a synostosis. It occurs with and without syndesmosis
transfixation screws and is probably dependent primarily on the severity of the original injury. It may be completely
asymptomatic or may be associated with pain during push-off.[175] If so, its excision may help relieve symptoms.

Nonunion
Nonunions of the ankle, albeit rare, are usually treated with small autogenous cancellous bone grafts and stable
internal fixation. Medial malleolar nonunions with interposed periosteum have been successfully treated with curettage
of the fibrous interface, packing of cancellous bone grafting, and rigid screw fixation. Fibular nonunions result from
unreduced significant displacement, comminution, or bone loss. In the case of bone loss or comminution, bone grafting
should be considered. When grafting is anticipated, the iliac crest should be prepared. An alternative is Gerdy's
tubercle in the proximal tibia, where a small to moderate amount of cancellous graft is readily available.