ANKLE FRACTURES

EPIDEMOLOGY
• REPRESENTS 10% OF ALL FRACTURS
• SECOND MOST COMMON LOWER LIMB FRACTURE
AFTER HIP FRACTURES
• BIMODAL DISTRIBUTION ,PEAK INCIDENCES IN
YOUNGER MEN & OLDER WOMEN
• OBESITY IS RISK FACTOR
 ANATOMY
• Ankle joint is complex hinge
joint , articulations among fibula ,
tibia & talus with complex
ligamentous system.
• Distal tibial articular surface is
referred to as PLAFOND which
together with medial & lateral
malleoli forms Mortise
• Talus articulates with tibial
plafond superiorly, posterior
malleolus of tibia posteriorly &
medial malleolus medially.
 ANATOMY
• Talar dome is trapezoidal with anterior aspect
2.5 mm wider than posterior talus.
• Medial malleolus articulates with medial facet of
talus & divides anterior & posterior colliculus .
• Medial malleolus is shorter & anterior, thus axis of
joint is in 15 degree of external rotation.
• Talus is remarkable for 3 reasons
-70 % covered with
articular surface -No direct
ligamentous attachments for muscle action
- Tenuous retrograde vascular blood supply
• As a frustral shape, talus is compressed within
mortise of ankle dorsiflexion causing more
stable articulation , While plantarflexed
position more mobile & less stabilized by
ligamentous structure.
• Tibio-talar articulation is considered to be
highly congruent.
 LIGAMENTS
• DELTOID LIGAMENT – Is
medial support Separated into
1) Superficial portion-
originate on anterior colliculus ,
composed 3 ligament a)
naviculotibial b) tibiocalcaneal
c) talotibial Adds little stability
2) Deep portion – intraarticular
ligament originate on intercollicular
groove & posterior colliculus . Its
primary medial stabilizer against
lateral displacement of talus.
• LATERAL COLLATERAL
LIGAMENT- Provides lateral
supports, made up of 3
ligaments
• a) Anterior talofibular ligament –
prevents anterior subluxation of
talus primarily in plantar flexion
• b) Posterior talofibular ligament-
prevent posterior & rotatory
subluxation of talus
• C) calcaneofibular ligament-
stabilize subtalar joint & limits
inversion ; ligaments ruptures
• SYNDESMOTIC LIGAMENT
COMPLEX
:Exists between distal tibia & fibula ,
resists axial , rotational & translational
forces to maintain structural integrity of
mortise
Composed of 4 ligaments
a) Anterior inferior tibiofibular
ligament
b) Posterior inferior tibiofibular ligament:
thicker & stronger
c) Inferior transverse tibiofibular ligament
d) Interosseous ligament
 BIOMECHANICS
• Normal ROM of ankle in dorsiflexion – 30 degree , in
plantar flexion 45 degree .
• As per motion analysis study 10 degree dorsiflexion &
20 degree plantar flexion is required for normal gait .
• Axis of flexion of ankle runs between distal aspects of
two malleoli, which externally rotated 20 degree
compared knee axis
• 1 mm lateral talar shift within the mortise decrease the
joint contact area by 42 % ; while 3 mm shift results in >
60% decrease.
• Disruption of syndesmotic ligaments may result in
decreased tibiofibular overlap.
 Mechanism of injury
Pattern of ankle fracture depends on many
factors;
mechanism –axial Vs rotational
chronicity or recurrent trauma leading to
ligament injury or laxity & distorted ankle
biomechanics.
patients age , bone quality, position of foot at
time of injury , direction ,magnitude
 Clinical Evaluation
• Patient may have variable presentation , ranging limp to
non ambulatory in significant pain , swelling, tenderness
& variable deformity.
• Neurovascular status should be carefully documented
• Extent of soft tissue injury should be evaluated
• Entire length of fibula should be palpated for
tenderness
• Dislocated ankle should be reduced & splinted
immediately
• It provides assistance in determining the need
of x-ray , offers sensitive & cost effective
method of identifying those patient
presenting with ankle injury.
 Radiographic evaluation
• AP , Lateral & mortise view
• AP view –
a) Tibiofibular overlap <10 mm
& Tibiofibular clear space > 5
mm implies syndesmotic injury.
b) Talar tilt – difference in
width of medial & lateral
aspects of superior joint space
of > 2 mm is abnormal ,
indicates medial or lateral
disruption.
 Radiographic evaluation
• Lateral view
- Dome shape of talus should
be centered under tibia &
congruous with tibial plafond.
- posterior tibial tuberosity
fracture can identified
- avulsion fracture of talus by
anterior capsule can be identified.
- anterior or posterior
translation of fibula
 Radiographic evaluation
• Mortise view-
- Taken with foot 15-20 degree of
internal rotation to offset the
intermalleolar axis
- medial clear space >4-5 mm is
abnormal & indicates lateral shift
- Talocrural angle: angle subtended
between intermalleolar line & line
parallel to distal tibial articular surface , it
should between 8 to 15 degree. Angle
should be should be within 2-3 degree of
uninjured ankle.
-Tibiofibular overlap < 1 cm indicates
syndesmotic disruption.
- Talar shift > 1 mm is abnormal
• CT scan help to delineate bony anatomy
especially in plafond injury
• MRI may be used for assessing occult
cartilaginous , ligamentous or tendinous injury
 Classifications
• Lauge hansen ( rotational ankle fracture)
- based on cadaveric studies
- pattern may not reflect clinical reality
- system takes into accounts 1) position of foot at time
of injury 2) direction of the deforming force

- Supination –adduction is only type associated with

medial displacement of talus
Lauge hansen classification
 Denis-weber classification
• Based on location &
appearance of fibular
fracture
AO Classification
 Surgical approaches for ankle fracture
• Medial Approach –
- Allows access to medial malleolar fracture
- Internervous interval between dorsiflexor ( deep
peroneal nerve) & invertors & plantarflexors
(posterior tibial nerve)
- great saphenous vein & nerve at risk
 Approaches
• Posteromedial approaches –
- not frequently used
- allows access to posterior malleolus
- Safest interval between FHL & peroneal tendon
• Lateral approach –
- Incision made directly over subcutaneous
border of fibula, length & center of incision
being dictated by level & type of fracture
present .
- Superficial peroneal nerve at risk.
• Posterolateral approach-
- Access to posterior malleolar
fracture, & to posterior aspect of
fibula .
- Incision made midway between
posterior border of lateral
malleolus & lateral border of
achilles tendon.
- Internervous plane between
peroneal tendon ( superficial
peroneal nerve) retract laterally
& FHL ( tibial nerve)
 Management of ankle fracture
• Isolated lateral malleolus fracture
-truly stable fracture
- SER 2 & SAD 1 type
- no tibiotalar incongruence
- can be managed conservatively with
functional bracing or casting
 Lateral malleolus fracture associated
instability
• A/W deltoid ligament injury
-one of two variant of SER type 4 renders ankle
instability .
-needs surgical reduction & fixation of lateral
malleolus with intraoperative assessment
syndesmosis .
 Occult ankle instability
• A) clinically-
swelling, tenderness , bruising over posterior aspect of medial malleolus

B) Stress view radiographs – mortise view

medial clear space > 5 mm
surgical fixation required in such a cases.
In many centres pragmatic walking test approach is taken , if there no talar
shift is noticed on one week f/u x ray ankle has proved its stability.
Isolated medial malleolus fracture
• This includes
- Anterior colliculus # with or without deltoid injury
- Posterior colliculus fracture
- Supracollicular #
- Chip avulsion fracture
undisplaced / minimally displaced isolated
fracture can treated conservatively with 6 wks in
plaster or functional brace with full weight bearing as
tolerated ,
when displaced or fracture enters joint through
tibial plafond ,needs surgical reduction & fixation
 Bimalleolar fractures
• These fractures are by definition unstable injuries
& should be treated by reduction with internal
fixation.

• if entirely undisplaced fracture particularly in

elders can be treated non operatively with cast or
brace provided patient is kept under close clinical
& radiographic review until union has occurred.
 Posterior malleolus fractures
Indications for fixation-
1) Fracture involving > 25 % of posterior malleolus.
2) > 2 mm displacement
3) Persistent posterior subluxation of talus .
pre-op CT scan is required.
Majority of cases are stabilized with percutaneous
antero-posterior screws,
Large irreducible fragment are treated with
posterior plating
 Syndesmotic Injuries
• Fibula fracture above plafond & where clear
widening of syndesmosis with talar instability
requires surgical stabilization.

• After fixation medial & lateral malleoli ,

syndesmosis should be stress intra-operatively by
lateral pull on fibula with bone hook or by
stressing the ankle external rotation.
 Fracture variants
1. Maisonneuve fracture- ankle injury with fracture
of proximal third of fibula
PER type of injury
2 .Curbstone fracture- Avulsion fracture off the
posterior tibia
3. LeFort-Wagstaffe fracture- Anterior fibular
tubercle avulsion fracture by anterior tibio-fibular
ligament. SER Type
4. Tillaux-chaput fracture- Avulsion of anterior tibial
margin by ATFL
 Ankle fracture fixation technique
• Fibular fixation
1) plating
Reduction can achieved & held by the application of
serrated lobster claw clamp. There are number of
maneuver that may assist with reduction
firstly gentle torsional movement with reduction clamp
may be sufficient to walk the two fractured surface out
to length & into place.
if more force necessary ,distraction & inversion of foot
& ankle will assist in regaining fibular length.
Finally if required , pointed reduction clamp can be
applied to the metaphysis of distal fragment in AP
 Cont-
• Next stage to place lag screw
• One third tubular plate should select of
sufficient length to allow placement of 3 screw
above & below fracture
• 3 bicortical screw in proximal diaphysis & 3
cancellous screw in distal metaphysis
 Ankle fracture fixation technique
• Medial malleolus
- Anteromedial incision , 2 cm to fracture line extent
distally & slight posteriorly end 2 cm distal to tip of
malleolus.
- Reflect the flap with its underlying subcutaneous
tissue .
- Remove the periosteum fold & debride small loose
osseous or chondral fragment.
- Reduce fracture fragment with bone holding
clamps & temporary fixed with 2 k wires, check
under fluoroscopy if reduction is satisfactory.
 cont

• Remove 1 k wire & insert 4 mm lag screw

• alternatively , drill with 2.5 & 3.5mm bit can use to
create path for screw
• Long pelvic drill bit necessary if bicortical screw
fixation is chosen.
• Carefully inspect joint particularly superomedial
corner.
• If fragment is very small or comminuted , use several
k wires, minifragment screw or tension band wiring.
 Ankle fracture fixation technique
• Posterior malleolus
- Insert 2 k wires 1-3 cm above anterior tibial lip,
directed antero-posterior to engage posterior
fragment, if temporary fixation is satisfactory ,
insert malleolar , small fragment screw & tighten
together .
- If conventional screw is used, overdrill anterior
cortex to achieve lag effect.
- If posterior malleolar is located more laterally , use
posterolateral incision

- Establish normal articular relationship between

talus & tibia by anterior traction on foot & by
adduction & inversion.

- Correct proximal displacement of posterior lip of

tibia by placement of joystick for manipulation & fix
fragment by 1 or 2 lag screw from posterior to
anterior into tibial metaphysis or place posterior
antiglide plate
Surgical stabilization of syndesmosis
• Screw should be positioned 2-3 cm proximal to
tibial plafond , if placed too far proximally it may
deform fibula & cause mortise to widen.

• Directed parallel to joint surface, if not parallel

fibula may shift proximally .

• Angled 30 degree anteriorly so that it is

perpendicular to tibiofibular joint, if not
perpendicular fibula may laterally displaced.
 Open Fracture
• Requires urgent irrigation & debridement
• External fixator may used as temporary fixation .
• Stable fixation is important prophylaxis against
infection & helps soft tissue healing .
• Tourniquet use is usually unnecessary in the cases
& leads postsurgical swelling & reperfusion injury.
• Antibiotic prophylaxis should be continued
postoperatively for 24 hr.
 Risk factors
• 1) Diabetes – requires perioperative
management with close glucose monitoring.
- wound dehiscence & infection up to 32%.
2)Obesity – increases risk of fixation failure by
up to 3 times.
3) Smoking- increase risk of deep infection by 6
times.
4) Alcohol – wound dehiscence / infection 4
times higher in alcohol abusers.
 Complications
Early

1. Wound infection/ dehiscence- occurs > 2% of

close fractures, leave implant in situ , if stable .
One can remove implant after fracture unites.
2. Loss of reduction- most common in
conservatively treated, unstable fracture.
3. Thromboembolism
 Complications
• Late
1) Non union- rare, most commonly affecting medial
malleolus . Associated with close treatment,
residual fracture displacement or interpose soft
tissue . If symptomatic may requires fixation +/-
bone grafting .
2) malunion
3) post traumatic arthritis – secondary to damage at
time of injury , from alter mechanics or as result
of inadequate reduction.
• 4) compartment syndrome – rare, associated
with high energy fracture.
• 5) neuroma – superficial peroneal , sural &
saphenous nerve all are at risk in
subcutaneous layer & injury may result in
patch of anesthetic , or worse, dysesthetic
skin.
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