● Ankle is a three bone joint

composed of the tibia , fibula

and talus

● Talus articulates with the

tibial plafond superiorly ,
posterior malleolus of the
tibia posteriorly and medial
malleolus medially

● Lateral articulation is with

malleolus of fibula

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 Ori
gi

Medial malleolus
consists of:
-Anterior
Colliculus
-Intercollicular
Groove
-Posterior
Colliculus
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PES Institute of Medical Sciences & Research
Intercollicular Medial
groove talus

Posterior
colliculus

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PES Institute of Medical Sciences & Research
PES Institute of Medical Sciences & Research
EPIDEMIOLOGY
● Most ankle fractures are isolated malleolar fractures
(2/3rd )
● bimalleolar fractures (1/4 th)
● trimalleolar fractures (5-10%)
● incidence- 187/1 L people each year
● open fractures -2% of all ankle fractures

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 Mechanism of Injury
Pattern of ankle fracture depends on many factors:
-Position of foot and direction of force,
-Chronicity or recurrent trauma leading to ligament injury
or laxity and distorted ankle biomechanics.
-Patients age,
-Bone quality

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clinical features

• Deformity around the ankle

• Swelling
• Haematoma
• Bony tenderness
• Instability and pain on attempting to walk

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OTTAWA ANKLE RULES

Pain exists near one or both of the malleoli PLUS one

or more of the following:

• Age > 55 yrs old

• Inability to bear weight
• Bone tenderness over the posterior edge or tip of
either malleolus .

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Radiographic evaluation

Plain X-ray Films:

•Anterior-posterior view of ankle,
•Lateral view of ankle,
•Mortise view of ankle,
•Stress views when required,
•Image the entire tibia, ankle to knee joint,
•Foot films when tender to palpation.

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An initial evaluation of the radiograph should
1st focus on

• Tibiotalar articulation and fibular shortening

• Widening of joint space

• Talar tilt

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PES Institute of Medical Sciences & Research
PES Institute of Medical Sciences & Research
◦Tibiofibular overlap
◦< 10mm is abnormal - implies syndesmotic injury
◦Tibiofibular clear space
◦> 5mm is abnormal - implies syndesmotic injury
◦Talar tilt
◦> 2mm is considered abnormal

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 ● Lateral malleolar fracture

● Tib/fib clear space

<5mm

● Tib/fib overlap >10 mm

● No evidence of
syndesmotic injury

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● Taken with ankle in
15-25 degrees of
internal rotation
● Useful in evaluation
of articular surface
between talar dome
and mortise

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10 degrees internal rotation of 5th MT with respect to a
vertical line PES Institute of Medical Sciences & Research
PES Institute of Medical Sciences & Research
● Medial clear space
◦ Between lateral border of
medial malleolus and medial
talus
◦ <4mm is normal
◦ >4mm suggests lateral shift
of talus

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lateral view
•Posterior malleolar
fractures
• AP talar subluxation
•Distal fibular translation
&/or angulation
• Syndesmotic relationship
•Associated or occult
injuries
–
Lateral process talus
–
Posterior process talus
–
Anterior process calcaneus

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  The ankle is a ring
◦ Tibial plafond
◦ Medial malleolus
◦ Deltoid ligaments
◦ calcaneus
◦ Lateral collateral ligaments
◦ Lateral malleolus
◦ Syndesmosis

Fracture of single part
usually stable
● Fracture > 1 part =
unstable
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 Stress
•
Views
– Gravity stress view
– Manual stress views
• CT
– Joint involvement
– Posterior malleolar fracture
pattern
– Pre-operative planning
Evaluate hindfoot and
– midfoot if needed
• MR
– Ligament and tendon
I injury
– Talar dome lesions
– Syndesmosis injuries

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Radiography after reduction should be
studied

• Normal relationship of ankle mortise must be

restored.

•Weight bearing alignment of ankle must be at right

angle to the longitudinal axis of leg

• Contour of the articular surface must be as smooth

as possible

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• Classification systems
• Lauge-Hansen
– Weber
– OTA
• Additional Anatomic Evaluation
– Posterior Malleolar Fractures
– Syndesmotic Injuries
– Common Eponyms

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● Based on cadaveric study
• Position of foot at time of injury
• Force applied to foot relative to tibia at time of injury

Types:
Supination External Rotation
Supination Adduction
Pronation External Rotation
Pronation Abduction
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PES Institute of Medical Sciences & Research
PES Institute of Medical Sciences & Research
PES Institute of Medical Sciences & Research
Remember the injury starts on the tight side of the
ankle! The lateral side is tight in supination,

while the medial side is tight in pronation.

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PES Institute of Medical Sciences & Research
 Stage 1
Anterior tibio-
fibular
ligament
Stage 2 Fibula
fx
Stage 3 Posterior
malleolus fx or
posterior tibio-
fibular ligament
4 1
Stage 4 Deltoid
3 ligament tear or
medial malleolus
2
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fx
PES Institute of Medical Sciences & Research
Lateral Injury: classic posterosuperior🡪anteroinferior
fibula fracture

Medial Injury: Stability

maintained
Standard: Closed
management
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Lateral Injury: classic posterosuperior🡪anteroinferior
fibula fracture
Medial Injury: medial malleolar fracture &*/or deltoid
ligament injury
Standard: Surgical
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 • Stage 1: fibula fracture
is transverse below
mortise.

2 • Stage 2: medial
malleolus fracture is
classic vertical pattern.
1

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PES Institute of Medical Sciences & Research
Lateral Injury: transverse fibular fracture at/below
level of mortise
Medial injury: vertical shear type medial
malleolar fracture BEWARE OF
IMPACTION
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• Important to restore:
– Ankle stability
– Articular congruity- including medial
impaction

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PES Institute of Medical Sciences & Research
 🞂 Stage 1 Deltoid
ligament tear or
medial malleolus fx
🞂 Stage 2 Anterior
tibio-fibular
ligament and
interosseous
membrane
🞂 Stage 3 Spiral,
proximal fibula
fracture
🞂 Stage 4 Posterior
malleolus fx or
1 2 posterior tibio-
3 fibular ligament
4 🞂

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PES Institute of Medical Sciences & Research
Medial injury: deltoid ligament tear &/or transverse medial
malleolar fracture
Lateral Injury: spiral proximal lateral
malleolar fracture
HIGHLY UNSTABLE…SYNDESMOTIC INJURY
COMMON PES Institute of Medical Sciences & Research
• Must x-ray knee to ankle to assess injury
• Syndesmosis is disrupted in most cases
– Eponym: Maisonneuve Fracture
• Restore:
– Fibular length and rotation
– Ankle mortise
– Syndesmotic stability

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 🞂 Stage 1 Transverse
medial malleolus fx
distal to mortise

🞂 Stage 2 Posterior
malleolus fx or posterior
tibio-fibular ligament

🞂 Stage 3 Fibula fracture,

1 typically proximal to
mortise, often with a
2 3 butterfly fragment
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PES Institute of Medical Sciences & Research
 Medial injury: tranverse to short oblique medial
malleolar fracture
Lateral Injury: comminuted impaction type distal lateral
malleolar fracture

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●Based on location of fibula
fracture relative to mortise
and appearance
🞂
Weber A fibula distal to mortise

Weber Bfibula at level

mortise
🞂 Weber Cfibula
proxima to mortise

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 Function:
Stability- prevents posterior translation of
talus & enhances syndesmotic
stability

Weight bearing- increases surface area of ankle

joint

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• Fracture pattern:
– Variable
– Difficult to assess on standard lateral
radiograph
• External rotation lateral view
• CT scan

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67 19
% %

Type I- posterolateral Type II- medial

oblique type extension type
14
%

Type III- small shell

type

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 FUNCTION:

Stability- resists external rotation, axial,

& lateral displacement of talus

Weight bearing- allows for standard

loading

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 Treatment
Indications for nonoperative treatment
• Undisplaced and stable fractures (for example isolated
B fracture of fibula).
• Clinically no injury of medial ligament.
• Patients with diabetes and impaired circulation.
• Unfit patients or limbs (e.g. swollen).

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Indications for operative treatment of ankle fractures
are dictated by
● stability of the ankle joint
● Articular fractures
● Displaced fractures
● Unstable fractures

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Surgery involves open reduction and internal fixation
(ORIF).

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Lateral malleolus

1. Approach
2. Reduction
3. Fixation
• A 3.5 mm cortex screw is inserted as a lag
screw. A neutralization (protection) plate is added.

• tension band wiring, intramedullary fixation of the

fibula with a large screw.

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PES Institute of Medical Sciences & Research
Medial malleolus

1. Approach
2. Reduction
3. Fixation

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PES Institute of Medical Sciences & Research
PES Institute of Medical Sciences & Research
Fixation
The medial malleolus is fixed with two partially threaded
cancellous bone screws 4.0 mm.
• If the quality of the bone is not so good, or the fragment
is small, a tension band wiring can be used.
• If the fragment is large and the fracture plane is vertical,
as in some type A fractures, the fracture is fixed with a
medial buttress plate.

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posterior malleoli

1. approach
2. reduction
3. fixation

. one or two partially threaded cancellous bone

screws
. small buttress plate
. 1/3rd tubular plate 3.5

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Maisonneuve Fracture
– Fracture of proximal fibula with syndesmotic disruption

Volkmann Fracture
– Fracture of tibial attachment of PITFL
– Posterior malleolar fracture type

Tillaux-Chaput Fracture
– Fracture of tibial attachment of AITFL

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REFERENCES:
● CAMPBELLS OPERATIVE ORTHOPAEDICS 14TH EDITION
● ROCKWOOD AND GREENS FRACTURES IN ADULTS 7TH
EDITION
● TEXTBOOK OF ORTHOPAEDICS AND TRAUMA BY GS
KULAKARNI 3RD EDITION

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PES Institute of Medical Sciences & Research