Chapter 59: Ankle Fractures

Timothy O. White, Kate E. Bugler

Chapter Outline

Introduction

Epidemiology of Ankle Fractures

Ankle fractures represent 10% of all fractures with an incidence of around 137/105/year,31,75,80,170 making these the second most common lower limb fractures after hip fractures.74 The mean age at injury is 45 years,75 significantly older than that of patients sustaining isolated ankle sprains.391 Both injuries have a bimodal distribution, with peak incidences of ankle fractures in younger men and older women and a 50-year gap between peaks 75,170(see Fig. 3-3). These are typically low-energy injuries with the majority occurring due to simple falls or sport.75,80,170 Even open ankle fractures are predominantly low-energy injuries caused by simple falls with the highest incidence in elderly women. 
The epidemiology of the specific fracture patterns does however vary. Patients with an AO/OTA type C fracture more commonly sustain their injury because of a fall from a height or a motor vehicle accident than patients with AO/OTA type A or B fractures in which the most common cause is a simple fall.75 Evaluation of only bimalleolar and trimalleolar ankle fractures reveals that these fractures do not have a bimodal distribution but instead a type E distribution (see Fig. 3-3) with a peak only in elderly women.74 
The already high incidence of ankle fractures is increasing sharply in line with the ageing demographic of most Western populations. Kannus et al.179 reported an increase of 319% in the overall annual number of low-energy ankle fractures in elderly patients admitted to hospital over the three decades between 1970 and 2000. From this data they predicted that the number of low-energy ankle fractures could be expected to triple by 2030. They forecast a higher rate of increase in females (Fig. 59-1). 
Figure 59-1
Data from Kannus et al.179
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Figure 59-1
The changing epidemiology of ankle fractures.
Data from Kannus et al.179
Data from Kannus et al.179
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The epidemiology appears to be varying with time: Between 1950 and 1980 an increase in incidence amongst younger males and elderly females was seen31 however more recently the incidence amongst younger males has appeared to remain static whilst the increase in elderly women has continued.193,373 The mechanism of injury has also changed with a reduction in fractures occurring because of severe trauma between 1950 and 1980 and a concomitant increase in the proportion of fractures caused by sporting activity in males.31 
Although ankle fractures are not associated with systemic low bone mineral density per se,146,343 the microarchitecture of the trabecular bone in the distal tibia of elderly patients with ankle fractures is abnormal and depleted, and bone stiffness is reduced, compared with uninjured controls,343 suggesting that these injuries should be considered to be true osteoporotic fractures. 
Specific risk factors for sustaining ankle fractures have been investigated. Hasselman et al.146 undertook a prospective study of 9,704 women over the age of 65 and found that ankle fractures were more common in the obese and those with a history of multiple falls. Further evidence for obesity as a risk factor comes from the international GLOW study of 60,393 women. They found that obese women over the age of 55 years were significantly more likely to sustain an ankle fracture than nonobese women.68 Moreover, Margolis et al.232 found that patients with a greater percentage increase in weight since the age of 25 were also significantly more likely to sustain an ankle fracture. Obesity also predisposes to more severe injury. Spaine and Bollen341 found that patients with an unstable ankle fracture were far more likely to be obese (29%) than patients with stable ankle fractures (4%). Alcohol use also appears to be a risk factor and Jensen et al.170 reported that 29% of patients in their series were found to have consumed alcohol in the four hours preceding fracture. 

Pathoanatomy, Applied Anatomy, and Biomechanics Relating to Ankle Fractures

The surgical anatomy of the ankle joint has been well described in detail elsewhere.129,159 The joint functions as a mortise with the body of the talus articulating with a confluent area of the tibia consisting of the tibial plafond (ceiling) superiorly, and the medial malleolus medially. A dorsal projection of the tibia, the posterior malleolus, serves to enlarge this confluent area. The lateral articulation of the talus is with the distal fibula. Each of these articular surfaces shares in load distribution during weight bearing, with the fibula, for example, taking 1/6th of the load.205,360 The medial malleolus is both shorter and more anterior, and thus the axis of the joint is in 15 degrees of external rotation. The tibial and fibular articular surfaces together comprise the mortise in which the talus sits (Fig. 59-2). 
Figure 59-2
Bony anatomy of the ankle.
 
Mortise view (A), inferior-superior view of the tibiofibular side of the joint (B), and superior–inferior view of the talus (C). The ankle joint is a three-bone joint with a larger talar articular surface than matching tibiofibular articular surface. The lateral circumference of the talar dome is larger than the medial circumference. The dome is wider anteriorly than posteriorly. The syndesmotic ligaments allow widening of the joint with dorsiflexion of the ankle, into a stable, close-packed position.
Mortise view (A), inferior-superior view of the tibiofibular side of the joint (B), and superior–inferior view of the talus (C). The ankle joint is a three-bone joint with a larger talar articular surface than matching tibiofibular articular surface. The lateral circumference of the talar dome is larger than the medial circumference. The dome is wider anteriorly than posteriorly. The syndesmotic ligaments allow widening of the joint with dorsiflexion of the ankle, into a stable, close-packed position.
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Figure 59-2
Bony anatomy of the ankle.
Mortise view (A), inferior-superior view of the tibiofibular side of the joint (B), and superior–inferior view of the talus (C). The ankle joint is a three-bone joint with a larger talar articular surface than matching tibiofibular articular surface. The lateral circumference of the talar dome is larger than the medial circumference. The dome is wider anteriorly than posteriorly. The syndesmotic ligaments allow widening of the joint with dorsiflexion of the ankle, into a stable, close-packed position.
Mortise view (A), inferior-superior view of the tibiofibular side of the joint (B), and superior–inferior view of the talus (C). The ankle joint is a three-bone joint with a larger talar articular surface than matching tibiofibular articular surface. The lateral circumference of the talar dome is larger than the medial circumference. The dome is wider anteriorly than posteriorly. The syndesmotic ligaments allow widening of the joint with dorsiflexion of the ankle, into a stable, close-packed position.
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The relationship between the tibia and fibula centers on the syndesmosis where the fibula lies in the incisura of the lateral aspect of the tibia, and is stabilized by the anterior-inferior tibiofibular ligament (AITFL), the posterior-inferior tibiofibular ligament (PITFL), and the interosseous ligament which is confluent with the interosseous membrane above (Fig. 59-3). The AITFL arises from a prominence of the anterolateral tibia known as the tubercle of Chaput (which may be avulsed, typically in children’s ankle injuries), and inserts onto an equivalent prominence on the fibula: The tubercle of Wagstaffe. The PITFL arises from Volkmann’s tubercle of the posterior malleolus. It is extremely strong and in trimalleolar fractures the fragment usually remains solidly attached to the fibula via this ligament. This relationship can be exploited surgically: Reduction of the distal fibula usually assists in reduction of the posterior malleolus, and stabilization of the posterior malleolus will often restore stability to a fractured fibula.119,251 
Figure 59-3
Three views of the tibiofibular syndesmotic ligaments.
 
Anteriorly, the AITFL spans from the anterior tubercle and anterolateral surface of the tibia to the anterior fibula. Posteriorly, the tibiofibular ligament has two components: The superficial PITFL, which is attached from the fibula across to the posterior tibia, and the thick, strong ITL, which constitutes the posterior labrum of the ankle. Between the anterior and PITFLs resides the stout interosseous ligament (IOL).
Anteriorly, the AITFL spans from the anterior tubercle and anterolateral surface of the tibia to the anterior fibula. Posteriorly, the tibiofibular ligament has two components: The superficial PITFL, which is attached from the fibula across to the posterior tibia, and the thick, strong ITL, which constitutes the posterior labrum of the ankle. Between the anterior and PITFLs resides the stout interosseous ligament (IOL).
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Figure 59-3
Three views of the tibiofibular syndesmotic ligaments.
Anteriorly, the AITFL spans from the anterior tubercle and anterolateral surface of the tibia to the anterior fibula. Posteriorly, the tibiofibular ligament has two components: The superficial PITFL, which is attached from the fibula across to the posterior tibia, and the thick, strong ITL, which constitutes the posterior labrum of the ankle. Between the anterior and PITFLs resides the stout interosseous ligament (IOL).
Anteriorly, the AITFL spans from the anterior tubercle and anterolateral surface of the tibia to the anterior fibula. Posteriorly, the tibiofibular ligament has two components: The superficial PITFL, which is attached from the fibula across to the posterior tibia, and the thick, strong ITL, which constitutes the posterior labrum of the ankle. Between the anterior and PITFLs resides the stout interosseous ligament (IOL).
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The talus itself is remarkable for three reasons. Its surface is 70% covered in articular cartilage, it has no direct ligamentous attachments for muscle action and it has a tenuous retrograde vascular supply. The body of the talus is geometrically complex and describes a frustum, a cone with its apex removed, lying transversely in the mortise, being broader anteriorly and narrower posteriorly. This complex shape prevents the medial and lateral facets of the talus, and their relationships with their respective malleoli, from being seen on any single radiographic projection and this results in considerable uncertainty when attempting to measure joint spaces. As a result of its frustral shape, the talus is compressed within the mortise of the ankle in dorsiflexion (the position of heel strike), causing the fibula to rotate externally, and is most stable in this position. In plantarflexion (at toe off) the talus is held less rigidly, allowing physiologic external rotation and inversion.246 Osseous stability of the ankle increases with axial loading, when the congruency of the articular surfaces provides very substantial stability even after division of all ligamentous restraints.239,345 
The superior surface of the talus (the talar dome), conforms closely to the plafond of the tibia, and the contact area between the two surfaces decreases markedly with displacement of the talus. Ramsey and Hamilton’s309 famous study reported a decrease in contact area of 42% after just 1 mm of lateral talar displacement, an effect confirmed by other authors.220,256 Although this study has been criticized,62,294,389 and the precise relationship between displacement, contact area, and contact pressure remain contentious,79,186,370 it is widely accepted that loss of congruence of the mortise leads to altered biomechanical loading and is principally responsible for the poor outcomes observed in patients with residual displacement of the talus after ankle fracture. 
The stability of the ankle is enhanced by its capsule and ligaments. Medially, the deltoid (medial collateral) ligament has two components. The superficial deltoid ligament arises from the anterior colliculus of the malleolus and extends in a broad fan shape to insert into the talus, navicular, and the sustentaculum of the calcaneus. This insertion is continuous with the tendon sheaths of the tibialis posterior and flexor hallucis longus tendons. The deep deltoid ligament is intra-articular and extends from the posterior colliculus (and intercollicular groove) of the malleolus to the dome of the talus. It is the deep component that is important in restraining the talus against lateral displacement and rotation, and it is the focus of much interest and research.288 The anatomy of the deltoid ligament is shown in Figure 59-4. The lateral collateral ligamentous complex consists of three defined ligaments. The anterior talofibular ligament (ATFL) is the weakest of these and is commonly injured in ankle sprains. The posterior talofibular ligament (PTFL) extends backward from the tip of the fibula, and between these two the fibulocalcaneal ligament (FCL) passes vertically down to an insertion on the lateral aspect of the calcaneus. The ankle is therefore considered to have three important static stabilizers: The medial and lateral osteoligamentous complexes and the syndesmosis. The relative importance of these stabilizers has been widely debated, but it is clear that each has an important role.246 A useful simplification is that two out of the three complexes should be intact for the ankle to be stable.38,249 The anatomy of the lateral ligamentous complex is shown in Figure 59-5
Figure 59-4
The deltoid ligament and its individual components.
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Figure 59-5
The lateral ligamentous complex of the ankle and its individual components.
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Whereas the static stabilizers of the ankle have been widely characterized in cadaveric studies, it is clear that they have an uncertain relevance to the clinical situation, and this is partly explained by our relatively poor understanding of the dynamic stability of the ankle. Axial loading fundamentally changes the behavior of the ankle, increasing the restraining effect of bony congruity and making the ankle stiffer. Moreover, six important musculotendinous groups cross the ankle joint which act to stabilize as well as move the ankle. Four of these units are placed at the four “corners” of the ankle joint and act in concert. The tibialis anterior acts to dorsiflex the ankle along with the peroneus tertius, and to invert the ankle along with tibialis posterior, whilst peroneus longus and brevis act to plantarflex with tibialis posterior and to evert with peroneus tertius. Dynamic stability is provided by antagonistic contraction of these groups of muscles. Power and stability are augmented by the action of two further units: Dorsiflexion by extensor digitorum longus and extensor hallucis longus, and plantarflexion by the triceps surae (gastrocnemius and soleus), plantaris, flexor hallucis longus, and flexor digitorum. Michelson demonstrated that even when both the medial and lateral osteoligamentous complexes are completely defunctioned by injury, the talus is surprisingly stable: Its range of movement in relation to the mortise during the gait cycle in each of the coronal, sagital, and transverse planes is no more than a single degree in excess of that of intact ankles.246 This concept of dynamic instability is clearly highly important when considering the nature of ankle injury and repair, and suggests that the large volume of static biomechanical data in the published literature should be viewed with extreme caution. 
The anatomy of the soft tissues crossing the ankle joint is shown in Figure 59-6
Figure 59-6
 
A: Structures crossing the medial ankle. B: Structures crossing the anterior ankle. C: Structures crossing the lateral ankle.
A: Structures crossing the medial ankle. B: Structures crossing the anterior ankle. C: Structures crossing the lateral ankle.
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Figure 59-6
A: Structures crossing the medial ankle. B: Structures crossing the anterior ankle. C: Structures crossing the lateral ankle.
A: Structures crossing the medial ankle. B: Structures crossing the anterior ankle. C: Structures crossing the lateral ankle.
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Structures crossing the ankle joint anteriorly pass under the superior extensor retinaculum proximal to the ankle and the Y-shaped inferior retinaculum distal to the joint. Tibialis anterior passes most medially and extensor hallucis longus passes adjacent to it. A safe plane for an anterior surgical approach to the ankle lies between these tendons. Lateral to the extensor hallucis lie the deep peroneal nerve and the dorsalis pedis artery, and then the tendons of extensor digitorum longus and peroneus tertius. The tendons, and the superficial peroneal nerve which lies in the subcutaneous plane, can often be seen and palpated with the ankle and toes maximally dorsiflexed. Laterally, the peronei lie deep to the peroneal retinaculum immediately posterior to the fibula. The retinaculum may be ruptured here resulting in tendon subluxation. The superficial peroneal nerve emerges from the deep fascia at a variable point in the distal third of the leg before dividing: A substantial branch has been reported to lie within 5 mm of the fibula in 50% cases when measured at 10 cm from the lateral malleolar tip and in 20% cases at 5 cm from the tip,163 leaving it vulnerable to injury in the lateral approach to the fibula. Also in the subcutaneous plane, the sural nerve lies in a variable position approximately two-thirds of the way between the distal fibula and the tendo Achilles. Medially, a number of structures run posterior to the medial malleolus under the lacinate ligament, (which forms the tarsal tunnel) and their constant relationship from anterior to posterior is classically remembered according to the pneumonic Tom, Dick, and very nervous Harry: Tibialis posterior, flexor digitorum, the tibialis posterior artery and vein, posterior tibial nerve, and flexor hallucis longus. Superficially in the subcutaneous plane, the great saphenous vein and nerve pass immediately anterior to the medial malleolus where the vein can be conveniently exposed for emergency vascular access, or more inconveniently damaged during the surgical approach to the medial malleolus. 

Surgical Approaches for Ankle Fractures

Medial

The medial approach allows access to medial malleolar fractures and exploits an internervous interval between the dorsiflexors (deep peroneal nerve) and invertors and plantarflexors (posterior tibial nerve) of the ankle. Two variations exist: A straight longitudinal incision directly over the malleolus is often simplest and allows easy access to the fracture and the start point for screw insertion at the malleolar tip. Alternatively, a curvilinear incision may be made further anteriorly over the front of the medial malleolus to allow visualization of the medial corner of the plafond, curving posteriorly distal to the malleolus to allow screw or plate placement. In either case, the great saphenous vein and nerve are at risk in the subcutaneous fat as they pass just anterior to the malleolus. 

Posteromedial

Although not frequently used, the posteromedial incision allows access to the posterior malleolus and can be particularly helpful where the fracture plane results in a posteromedial distal fragment. The incision is made longitudinally half way between the medial malleolus and the Achilles tendon. Blunt dissection will expose the fascia overlying the flexor tendons and this can be incised longitudinally well away from the back of the medial malleolus. The safest interval is found between the flexor hallicus longus (FHL) tendon (which can be identified by the muscle fibers which insert into it at this level) and the peroneal tendons lateral to it. Retracting FHL medially will expose the back of the ankle joint whilst protecting the neurovascular bundle. Access to the malleolus more medially requires the identification and careful retraction laterally of the neurovascular bundle. 

Lateral

The line of the incision is made directly over the subcutaneous border of the fibula, the length and center of the incision being dictated by the level and type of fracture present. The principle structure at risk is the superficial peroneal nerve as it pierces the deep fascia and lies in the subcutaneous fat. It is increasingly vulnerable as one moves proximally from the fibular tip, but its course is variable and a substantial branch lies within 5 cm of the tip of the malleolus in 20% of patients163: Blunt dissection through fat is recommended. The periosteum should be elevated from the fracture margins only enough to allow an anatomical reduction. Strategic perforations may be made in the anterior fascia to allow the placement of reduction clamps without excessive dissection. Occasionally, the incision may be curved anteriorly at its distal extent to allow an arthrotomy and inspection of the articular surface of the ankle joint, or for access to the tubercle of Chaput. Alternatively, for posterior plating of the fibula, the incision is aligned with the posterior border of the fibula and the peroneal tendons are retracted away from the posterior surface of the bone. The more posterior location of the incision prevents satisfactory access to the AITFL and ankle joint, and will not allow fixation of a Chaput tubercle fracture. 

Posterolateral

This approach allows access to posterior malleolar fractures, and to the posterior aspect of the fibula and is performed with the patient prone. The longitudinal incision is made midway between the posterior border of the lateral malleolus, and the lateral border of the Achilles tendon. Blunt dissection through fat avoids injury to the sural nerve and exposes the deep fascia of the leg which is incised sharply. The internervous plane is between the peroneal tendons (superficial peroneal nerve) which are retracted laterally, and the FHL (tibial nerve). The FHL has muscular origins from the fibula and tibia even at this level, and should be elevated and retracted medially to expose the posterior malleolus. 

Assessement of Ankle Fractures

Classification of Ankle Fractures

Pott Classification

Classification of ankle fractures may be undertaken on the basis of anatomy, injury mechanics, or stability. Whilst multiple classification systems have been developed, only a few remain in frequent use. Pott provided the first known detailed description of ankle fractures in 1769,302 prior to the discovery of medical radiographs in 1895, but the classification system based on the number of fractured malleoli that is commonly ascribed to him may have been first described by Cooper.70 Fractures can be classified as unimalleolar, bimalleolar, or trimalleolar based on the combined fractures of the lateral, medial, and posterior malleoli. As the number of fractured malleoli increases the prognosis worsens.45 Despite, or perhaps because of, the simplicity of the system it remains in widespread use. 

Danis–Weber and AO/OTA Classifications

An alternative classification developed by Danis81 and modified by Weber,393 describes the injury based on the location of the lateral malleolar fracture. Fractures may be classified as A, B, or C with a fracture below, at the level of, or above the syndesmosis respectively. The distribution of fractures between these groups varies depending on the selection criteria for the study but values of 38% for A, 52% for B, and 10% for C are typical.75 This classification remains popular and has been shown to have substantial inter- and intraobserver reliability.229 Lindsjo218 commented that this is a system “even an exhausted doctor on emergency call at four in the morning should be able to apply without too much error.” However, although there is a general relationship with fracture stability, it does not accurately predict the presence or level of syndesmotic injury,271 it does not address the presence (or absence) of injury to the medial side of the ankle, and the classification does not provide robust prognostic information.45,181 
Further work on the Danis–Weber system by the AO/ASIF group lead to the development of the AO classification of ankle fractures which has also been adopted by the Orthopaedic Trauma Association (OTA). This classification is shown in Figure 59-7. This is far more encompassing with a total of 27 different subtypes describing injury to the bony and soft tissue structures of the ankle.15 Acceptable interobserver reliability and ease of application have been reported.75,78 Arthroscopic investigation of ankle fractures has shown that the degree of articular cartilage damage present corresponds with the AO/OTA subgroups from 1 to 3,152 and therefore this extended classification may have some prognostic significance. 
Figure 59-7
The AO-OTA classification.
 
This classification system is based upon the location of fracture lines and degree of comminution and serves to describe the severity and degree of instability associated with a particular fracture pattern. The AO-OTA classification expands on the Danis–Weber classification scheme, which is still in use and is perhaps the most rudimentary of the classification systems and is based simply on the level of the fibula fracture. The basic fracture types are shown.
This classification system is based upon the location of fracture lines and degree of comminution and serves to describe the severity and degree of instability associated with a particular fracture pattern. The AO-OTA classification expands on the Danis–Weber classification scheme, which is still in use and is perhaps the most rudimentary of the classification systems and is based simply on the level of the fibula fracture. The basic fracture types are shown.
View Original | Slide (.ppt)
This classification system is based upon the location of fracture lines and degree of comminution and serves to describe the severity and degree of instability associated with a particular fracture pattern. The AO-OTA classification expands on the Danis–Weber classification scheme, which is still in use and is perhaps the most rudimentary of the classification systems and is based simply on the level of the fibula fracture. The basic fracture types are shown.
View Original | Slide (.ppt)
This classification system is based upon the location of fracture lines and degree of comminution and serves to describe the severity and degree of instability associated with a particular fracture pattern. The AO-OTA classification expands on the Danis–Weber classification scheme, which is still in use and is perhaps the most rudimentary of the classification systems and is based simply on the level of the fibula fracture. The basic fracture types are shown.
View Original | Slide (.ppt)
This classification system is based upon the location of fracture lines and degree of comminution and serves to describe the severity and degree of instability associated with a particular fracture pattern. The AO-OTA classification expands on the Danis–Weber classification scheme, which is still in use and is perhaps the most rudimentary of the classification systems and is based simply on the level of the fibula fracture. The basic fracture types are shown.
View Original | Slide (.ppt)
Figure 59-7
The AO-OTA classification.
This classification system is based upon the location of fracture lines and degree of comminution and serves to describe the severity and degree of instability associated with a particular fracture pattern. The AO-OTA classification expands on the Danis–Weber classification scheme, which is still in use and is perhaps the most rudimentary of the classification systems and is based simply on the level of the fibula fracture. The basic fracture types are shown.
This classification system is based upon the location of fracture lines and degree of comminution and serves to describe the severity and degree of instability associated with a particular fracture pattern. The AO-OTA classification expands on the Danis–Weber classification scheme, which is still in use and is perhaps the most rudimentary of the classification systems and is based simply on the level of the fibula fracture. The basic fracture types are shown.
View Original | Slide (.ppt)
This classification system is based upon the location of fracture lines and degree of comminution and serves to describe the severity and degree of instability associated with a particular fracture pattern. The AO-OTA classification expands on the Danis–Weber classification scheme, which is still in use and is perhaps the most rudimentary of the classification systems and is based simply on the level of the fibula fracture. The basic fracture types are shown.
View Original | Slide (.ppt)
This classification system is based upon the location of fracture lines and degree of comminution and serves to describe the severity and degree of instability associated with a particular fracture pattern. The AO-OTA classification expands on the Danis–Weber classification scheme, which is still in use and is perhaps the most rudimentary of the classification systems and is based simply on the level of the fibula fracture. The basic fracture types are shown.
View Original | Slide (.ppt)
This classification system is based upon the location of fracture lines and degree of comminution and serves to describe the severity and degree of instability associated with a particular fracture pattern. The AO-OTA classification expands on the Danis–Weber classification scheme, which is still in use and is perhaps the most rudimentary of the classification systems and is based simply on the level of the fibula fracture. The basic fracture types are shown.
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Lauge-Hansen Classification

An alternative classification system based on causative mechanism of injury was proposed by Ashurst and Bromer in 1922,17 and expanded by Lauge-Hansen in 1950 following cadaveric investigations.208 The Lauge-Hansen classification is shown in Figure 59-8. It employs two words and a number. The first word describes the position of the foot at the time of fracture (supination or pronation), the second the deforming force at the ankle (abduction, adduction, internal rotation, or external rotation). There are four resulting classes of injury: Supination external rotation (SER), pronation external rotation (PER), supination adduction (SAD), and pronation abduction (PAB). The number then refers to the progression through stages of bony and soft tissue injury (Fig. 59-8). The most common pattern of injury is SER (60%) followed by SAD injuries (20%) and then those occurring in pronation (20%).208,218,409 PAB fractures and PER fractures comprise 8% and 12% of ankle fractures respectively. Most, but not all, ankle fractures can be classified, with reported rates between 83%121 and 98.8%.409 The Lauge-Hansen classification historically indicated the process of closed manipulation required to reverse displacement and reduce the fracture, but in the era of surgical fixation this classification system remains helpful in directing management. 
Figure 59-8
Schematic diagram and case examples of Lauge-Hansen SER and SA ankle fractures.
 
A: A supinated foot sustains either an external rotation or adduction force and creates the successive stages of injury shown in the diagram. The SER mechanism has four stages of injury, and the SA mechanism has two stages. AP (B) and lateral (C) radiographs show an unstable SER stage IV ankle fracture with the characteristic oblique distal fibula fracture and a medial side injury. D: An AP radiograph of a SAD ankle fracture with a transverse fibula fracture and an impacted medial malleolar fracture. E: A pronated foot sustains either an external rotation or abduction force and creates the successive stages of injury shown in the diagram. The PER mechanism has four stages of injury, and the PAB mechanism has three stages.
A: A supinated foot sustains either an external rotation or adduction force and creates the successive stages of injury shown in the diagram. The SER mechanism has four stages of injury, and the SA mechanism has two stages. AP (B) and lateral (C) radiographs show an unstable SER stage IV ankle fracture with the characteristic oblique distal fibula fracture and a medial side injury. D: An AP radiograph of a SAD ankle fracture with a transverse fibula fracture and an impacted medial malleolar fracture. E: A pronated foot sustains either an external rotation or abduction force and creates the successive stages of injury shown in the diagram. The PER mechanism has four stages of injury, and the PAB mechanism has three stages.
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A: A supinated foot sustains either an external rotation or adduction force and creates the successive stages of injury shown in the diagram. The SER mechanism has four stages of injury, and the SA mechanism has two stages. AP (B) and lateral (C) radiographs show an unstable SER stage IV ankle fracture with the characteristic oblique distal fibula fracture and a medial side injury. D: An AP radiograph of a SAD ankle fracture with a transverse fibula fracture and an impacted medial malleolar fracture. E: A pronated foot sustains either an external rotation or abduction force and creates the successive stages of injury shown in the diagram. The PER mechanism has four stages of injury, and the PAB mechanism has three stages.
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A: A supinated foot sustains either an external rotation or adduction force and creates the successive stages of injury shown in the diagram. The SER mechanism has four stages of injury, and the SA mechanism has two stages. AP (B) and lateral (C) radiographs show an unstable SER stage IV ankle fracture with the characteristic oblique distal fibula fracture and a medial side injury. D: An AP radiograph of a SAD ankle fracture with a transverse fibula fracture and an impacted medial malleolar fracture. E: A pronated foot sustains either an external rotation or abduction force and creates the successive stages of injury shown in the diagram. The PER mechanism has four stages of injury, and the PAB mechanism has three stages.
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Figure 59-8
Schematic diagram and case examples of Lauge-Hansen SER and SA ankle fractures.
A: A supinated foot sustains either an external rotation or adduction force and creates the successive stages of injury shown in the diagram. The SER mechanism has four stages of injury, and the SA mechanism has two stages. AP (B) and lateral (C) radiographs show an unstable SER stage IV ankle fracture with the characteristic oblique distal fibula fracture and a medial side injury. D: An AP radiograph of a SAD ankle fracture with a transverse fibula fracture and an impacted medial malleolar fracture. E: A pronated foot sustains either an external rotation or abduction force and creates the successive stages of injury shown in the diagram. The PER mechanism has four stages of injury, and the PAB mechanism has three stages.
A: A supinated foot sustains either an external rotation or adduction force and creates the successive stages of injury shown in the diagram. The SER mechanism has four stages of injury, and the SA mechanism has two stages. AP (B) and lateral (C) radiographs show an unstable SER stage IV ankle fracture with the characteristic oblique distal fibula fracture and a medial side injury. D: An AP radiograph of a SAD ankle fracture with a transverse fibula fracture and an impacted medial malleolar fracture. E: A pronated foot sustains either an external rotation or abduction force and creates the successive stages of injury shown in the diagram. The PER mechanism has four stages of injury, and the PAB mechanism has three stages.
View Original | Slide (.ppt)
A: A supinated foot sustains either an external rotation or adduction force and creates the successive stages of injury shown in the diagram. The SER mechanism has four stages of injury, and the SA mechanism has two stages. AP (B) and lateral (C) radiographs show an unstable SER stage IV ankle fracture with the characteristic oblique distal fibula fracture and a medial side injury. D: An AP radiograph of a SAD ankle fracture with a transverse fibula fracture and an impacted medial malleolar fracture. E: A pronated foot sustains either an external rotation or abduction force and creates the successive stages of injury shown in the diagram. The PER mechanism has four stages of injury, and the PAB mechanism has three stages.
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A: A supinated foot sustains either an external rotation or adduction force and creates the successive stages of injury shown in the diagram. The SER mechanism has four stages of injury, and the SA mechanism has two stages. AP (B) and lateral (C) radiographs show an unstable SER stage IV ankle fracture with the characteristic oblique distal fibula fracture and a medial side injury. D: An AP radiograph of a SAD ankle fracture with a transverse fibula fracture and an impacted medial malleolar fracture. E: A pronated foot sustains either an external rotation or abduction force and creates the successive stages of injury shown in the diagram. The PER mechanism has four stages of injury, and the PAB mechanism has three stages.
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Supination External Rotation Fractures.
In the first stage of this injury (SER 1), the talus rotates within the mortise, pushing the tibia and fibula apart, and causing a rupture of the anterior-inferior tibiofibular ligament (AITFL). This represents a stable ankle sprain. In the second stage (SER 2), the fibula fractures at the level of the syndesmosis resulting in an oblique fracture line with a classic long posterior spike Figure 59-9). This is the equivalent of the AO/OTA type B fracture (Fig. 59-7). The ankle remains stable because the medial structures are intact, the lateral malleolar fracture is typically minimally displaced, and thus SER 2 fractures are treated nonoperatively. In the third stage (SER 3), the posterior tibiofibular ligament ruptures or a posterior malleolar fracture occurs. In the fourth and final stage (SER 4), the medial aspect of the ankle is injured and the ankle becomes unstable. This may be either a rupture of the deltoid ligament, or an oblique fracture of the medial malleolus (Fig. 59-8). Occasionally, both elements may be injured, the line of injury passing through both the deep deltoid ligament (attached to the posterior colliculus of the medial malleolus, which itself is left intact), and then through bone, resulting in an anterior colliculus fracture. SER 4 fractures are generally managed operatively. The oblique or spiral configuration of the fibula fracture lends itself to lag screw compression protected with a neutralization plate, or alternatively to nail stabilization. The oblique medial fracture is then most commonly treated with two parallel partially threaded cancellous lag screws placed orthogonal to the fracture. The integrity of the syndesmosis should be assessed and if found to be unstable, stabilized with a syndesmosis screw. 
Figure 59-9
AP and lateral radiographs of a supination external rotation (SER 2) fracture (AO/OTA B1.1).
 
Note the oblique fracture line with the long posterior spike. The talus is congruent.
Note the oblique fracture line with the long posterior spike. The talus is congruent.
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Figure 59-9
AP and lateral radiographs of a supination external rotation (SER 2) fracture (AO/OTA B1.1).
Note the oblique fracture line with the long posterior spike. The talus is congruent.
Note the oblique fracture line with the long posterior spike. The talus is congruent.
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Supination Adduction Fractures.
In the first stage (SAD 1), the adduction of the hindfoot results in either a talofibular ligament rupture (ankle sprain) or a transversely orientated avulsion fracture of the distal fibula, this being equivalent to an AO/OTA type A fracture (Fig. 59-7). This is a stable injury. In the second stage (SAD 2) the medial malleolus is sheared off resulting in a diagnostic vertical fracture line (Fig. 59-10). This is an unstable injury. The medial plafond may suffer impaction from the talus and radiographs should be scrutinuized carefully for this additional injury. In contradistinction to the other patterns of ankle fracture, surgical stabilization of an SAD 2 fracture begins with initial exposure of the medial malleolus. The area of impaction is exposed through the fracture and the joint is irrigated to remove osteochondral fragments. The impacted articular segment is reduced with a lever or punch and the defect is filled with graft or graft substitute if required (Fig. 59-10). The shear fracture is then typically stabilized with a buttress plate. The fibular fracture may subsequently be stabilized with a plate, a nail, or a tension band construct (Fig. 59-10). 
Figure 59-10
A supination-adduction (SAD2) fracture (AO/OTA A2.2).
 
A: The initial AP radiograph shows impaction of the medial plafond and an avulsion fracture of the fibula. B: An intraoperative radiograph. The impacted region must be reduced. This is achieved through the fracture using a punch or lever. Bone grafting of the defect may be required. C: At 6 months the fractures is united. Note the buttress plating of the shear fracture. A fibular nail has been used to stabilize the fibular fracture.
A: The initial AP radiograph shows impaction of the medial plafond and an avulsion fracture of the fibula. B: An intraoperative radiograph. The impacted region must be reduced. This is achieved through the fracture using a punch or lever. Bone grafting of the defect may be required. C: At 6 months the fractures is united. Note the buttress plating of the shear fracture. A fibular nail has been used to stabilize the fibular fracture.
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Figure 59-10
A supination-adduction (SAD2) fracture (AO/OTA A2.2).
A: The initial AP radiograph shows impaction of the medial plafond and an avulsion fracture of the fibula. B: An intraoperative radiograph. The impacted region must be reduced. This is achieved through the fracture using a punch or lever. Bone grafting of the defect may be required. C: At 6 months the fractures is united. Note the buttress plating of the shear fracture. A fibular nail has been used to stabilize the fibular fracture.
A: The initial AP radiograph shows impaction of the medial plafond and an avulsion fracture of the fibula. B: An intraoperative radiograph. The impacted region must be reduced. This is achieved through the fracture using a punch or lever. Bone grafting of the defect may be required. C: At 6 months the fractures is united. Note the buttress plating of the shear fracture. A fibular nail has been used to stabilize the fibular fracture.
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Pronation Abduction Fractures.
In the first stage (PAB 1), the abducting talus avulses the medial malleolus (resulting in a transverse fracture line) or causes a deltoid ligament rupture. In the second stage (PAB 2) the fibula is pushed laterally resulting in rupture of the AITFL or an avulsion fracture of the tubercle of Chaput. In the third stage (PAB 3) the fibula fractures under compression and bending, resulting in a comminuted fracture at or above the level of the syndesmosis (Fig. 59-11). Operative treatment of this fibular fracture differs from that of an SER 4 fracture in that lag screw fixation of the comminuted region is often not possible, and an alternative strategy of bridge plating with a small fragment DCP or equivalent, rather than a 1/3 tubular plate, or an intramedullary nail may be required. The medial fracture can be addressed with orthogonal cancellous lag screws as for the SER fracture, or with a tension band construct if the fragment is small. The integrity of the syndesmosis should be assessed. 
Figure 59-11
A pronation abduction (PAB3) fracture (AO/OTA C2.3).
 
A: The initial radiograph shows a medial malleolar fracture, a comminuted suprasyndesmotic fibular fracture and a diastasis. B: The medial malleolar fracture has been stabilized with two screws and the fibular fracture with a bridging plate. A diastasis screw has been inserted. C: An intramedullary nail can be used for the fibula.
A: The initial radiograph shows a medial malleolar fracture, a comminuted suprasyndesmotic fibular fracture and a diastasis. B: The medial malleolar fracture has been stabilized with two screws and the fibular fracture with a bridging plate. A diastasis screw has been inserted. C: An intramedullary nail can be used for the fibula.
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Figure 59-11
A pronation abduction (PAB3) fracture (AO/OTA C2.3).
A: The initial radiograph shows a medial malleolar fracture, a comminuted suprasyndesmotic fibular fracture and a diastasis. B: The medial malleolar fracture has been stabilized with two screws and the fibular fracture with a bridging plate. A diastasis screw has been inserted. C: An intramedullary nail can be used for the fibula.
A: The initial radiograph shows a medial malleolar fracture, a comminuted suprasyndesmotic fibular fracture and a diastasis. B: The medial malleolar fracture has been stabilized with two screws and the fibular fracture with a bridging plate. A diastasis screw has been inserted. C: An intramedullary nail can be used for the fibula.
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Pronation External Rotation Fractures.
In the first stage (PER 1), an isolated medial malleolar fracture (or deltoid rupture) is produced. In the second stage (PER 2), either the AITFL is ruptured or a tubercle of Chaput fracture occurs. In the third stage (PER 3), a fracture of the fibula occurs through torsion resulting in an oblique or spiral fracture. This differs from the SER fracture in that it is typically supra-syndesmotic (equivalent to an AO/OTA type C fracture) and that the long spike at the proximal extent of the fracture is anterior (i.e., the fracture line passes from distal posteriorly to proximal anteriorly). A PER 3 fracture is unstable and there is a high associated incidence of syndesmosis injury. The classic variant is the so-called Maisonneuve fracture (Fig. 59-12) which may not be diagnosed correctly unless suspected and looked for. Surgical stabilization of the fibular fracture is with a plate if it occurs within 5 or 6 cm of the syndesmosis, with or without a syndesmosis screw. Fractures above this level are most commonly treated with syndesmosis screw(s) alone. The medial malleolar fracture is commonly treated with cancellous lag screws. 
Figure 59-12
Maisonneuve fracture.
 
A: An AP radiograph of the ankle and tibia and fibula shows a PER 3 Maisonneuve fracture (AO/OTA C3.1). B: External rotation shows lateral displacement of the talus and widening of the syndesmosis.
A: An AP radiograph of the ankle and tibia and fibula shows a PER 3 Maisonneuve fracture (AO/OTA C3.1). B: External rotation shows lateral displacement of the talus and widening of the syndesmosis.
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Figure 59-12
Maisonneuve fracture.
A: An AP radiograph of the ankle and tibia and fibula shows a PER 3 Maisonneuve fracture (AO/OTA C3.1). B: External rotation shows lateral displacement of the talus and widening of the syndesmosis.
A: An AP radiograph of the ankle and tibia and fibula shows a PER 3 Maisonneuve fracture (AO/OTA C3.1). B: External rotation shows lateral displacement of the talus and widening of the syndesmosis.
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Despite the utility of the Lauge-Hansen classification system, later investigators have not been able to replicate the stages of injury described in the original experiments,136,245 and more recently an innovative study comparing the mechanism of injury as seen on “YouTube” movie clips and the subsequent x-rays of the same patient failed to find a strong correlation between mechanism and fracture pattern.204 In common with other classification systems, it does not does not provide reliable information regarding the presence or absence of syndesmotic rupture.121,270,409 Like most detailed classification systems, reproducibility is modest with interobserver variability of between 43% and 60% and intraobserver variability of between 64 and 82%.269,368 However, the classification system does have prognostic significance: The degree of articular damage has been shown to correlate with the stage of injury.215 

Eponymous Fractures

A number of eponymous terms have also survived by custom and common usage. A Volkmann’s fracture refers to a fracture of the posterior malleolus,387 although the fracture was first described by Earle, the grandson of Sir Percival Pott.94 A Maisonneuve fracture is a fracture of the proximal fibula associated with a medial malleolar fracture or deltoid ligament injury, accounting for 5% of all ankle fractures,287 although Maisonneuve actually described a number of fractures of both the proximal and distal fibula in association with a rotational injury.226 It is important to exclude this proximal fracture in rotational ankle injuries as it is highly unstable despite potentially normal ankle radiographs. The proximal tibia should be carefully palpated and, where there is tenderness, full-length views of the tibia and fibula should be obtained (Fig. 59-12). 

Clinical Assessment of Ankle Fractures

Assessment of an ankle fracture requires a detailed history, a thorough physical examination and radiographic imaging. Whilst the patient’s own account of a low-energy twisting injury may reveal little due to the speed of the event, an appreciation of the energy transfer involved is important as high-energy mechanisms indicate the likelihood of additional soft tissue complications, compartment syndrome,29,297,412 the presence of the more complex pilon fracture, or other associated injuries. Certain comorbidities in particular are of importance: Diabetes will not only require preoperative work-up and perioperative blood sugar management, but also indicates an increased likelihood of wound complications owing to immunologic and vascular impairment. Poorly controlled diabetics in particular are at risk of peripheral neuropathy, which may influence postoperative weight-bearing decisions. A history of smoking, alcohol abuse, and psychiatric illness similarly increases the likelihood of complications. Clinical examination begins with inspection for deformity, bruising, blistering, skin integrity, and color. A careful palpation of the limb then starts at the fibular head and progresses sequentially down the lateral aspect of the leg to the lateral malleolus and the soft tissues anterior and posterior to it before moving medially across the ankle joint to the medial malleolus and its adjacent soft tissue structures. Palpation of the skeleton of the foot will exclude commonly associated (or missed) injuries such as fractures of the metatarsals or lateral talar process, or disruption of the midtarsal (Lisfranc) articulation, which can occur following a similar mechanism. Palpation of the Achilles tendon and the Simmonds335 or Thompson’s367 test excludes rupture of this structure. A distal neurovascular assessment includes assessment of temperature and capillary refill. Skin marking of palpable dorsalis pedis and posterior tibial arterial pulsations at presentation will be helpful in later assessment if the condition of the limb deteriorates. The Ottawa ankle rules347 (Table 59-1) provide assistance in determining the need for x-ray. They offer a highly sensitive20,348 and cost-effective14,346,349 method of identifying those patients, presenting with ankle injuries, that are most likely to have sustained a fracture. Whilst Stiell346,347,348,349 has demonstrated the effectiveness of these rules in a number of centers, other authors have reported difficulties in disseminating the rules,53 and their applicability in certain patient groups such as diabetics has been questioned.65 
 
Table 59-1
Ottawa Ankle Rules
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Table 59-1
Ottawa Ankle Rules
Pain exists near one or both of the malleoli PLUS one or more of the following:
  •  
    Age >55 yr old
  •  
    Inability to bear weight
  •  
    Bone tenderness over the posterior edge or the tip of either malleolus
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Imaging and Other Diagnostic Studies for Ankle Fractures

Radiographs

The standard radiographs are an anteroposterior (AP) and a lateral projection of the ankle. Tenderness of the proximal fibula should be investigated with a full-length radiograph of the leg. A mortise view of the ankle taken in 15 degrees of internal rotation is also extremely helpful in assessing the lateral aspect of the ankle which is often poorly seen on the AP view because of the frustral shape of the talus and consequent overlap of the tibia, fibula, and talus (Fig. 59-13). 
Figure 59-13
These constitute a standard ankle trauma series.
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Figure 59-13
Anteroposterior (A), (B) mortise and (C) lateral radiographs of the ankle.
These constitute a standard ankle trauma series.
These constitute a standard ankle trauma series.
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Interpretation of the radiographs follows the sequence ABCS, and includes an assessment of technical adequacy and alignment (does this radiograph show the joint well enough for you to make a complete assessment?), the cortical outline and trabecular morphology of each of the bones, particularly the articular margins where irregularity of the cartilage articular surface, although not directly visible, can be inferred, and the contour of the overlying soft tissues. The relationship between the bony components of the ankle is critical, and a number of “normal” features are widely recognized (Table 59-2; Figs. 59-14 and 59-15). These empirical “normal” measurements must, however, be interpreted in the light of some scientific controversy and uncertainty. There is substantial variability in “normal” anatomy between individuals, and comparison views of the contralateral side are occasionally helpful. Absolute measurements are also affected by magnification, and the degree of axial rotation of the limb.127 Pneumaticos et al.298 have demonstrated that, for example, the size of the medial clear space more than doubles depending upon the rotational position of the limb, whilst other authors have found a significant increase in medial clear space with ankle plantar flexion.196,321 Moreover, the accuracy of plain radiographic measurements has been questioned in the light of CT studies that have shown that a number of assumptions based on the interpretation of a two-dimensional radiographs are simply not accurate.107,137,149,247,270 
Figure 59-14
Radiographic measurements.
 
See Table 59-2 for explanation. The ball sign is explained in Figure 59-15.
See Table 59-2 for explanation. The ball sign is explained in Figure 59-15.
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Figure 59-14
Radiographic measurements.
See Table 59-2 for explanation. The ball sign is explained in Figure 59-15.
See Table 59-2 for explanation. The ball sign is explained in Figure 59-15.
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Figure 59-15
 
A: The “ball” sign is described on the AP view as an unbroken curve connecting the recess in the distal tip of the fibula and the lateral process of the talus when the fibula is out to length. B: If the fibula is short and malreduced the ball sign is absent.
A: The “ball” sign is described on the AP view as an unbroken curve connecting the recess in the distal tip of the fibula and the lateral process of the talus when the fibula is out to length. B: If the fibula is short and malreduced the ball sign is absent.
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Figure 59-15
A: The “ball” sign is described on the AP view as an unbroken curve connecting the recess in the distal tip of the fibula and the lateral process of the talus when the fibula is out to length. B: If the fibula is short and malreduced the ball sign is absent.
A: The “ball” sign is described on the AP view as an unbroken curve connecting the recess in the distal tip of the fibula and the lateral process of the talus when the fibula is out to length. B: If the fibula is short and malreduced the ball sign is absent.
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Table 59-2
Radiographic Parameters that Should be Looked for on Radiographs of Ankle Fractures
Radiographic Feature Accepted Normal Parameter Notes
Medial clear space The joint spaces medial and superior to the talus should be equal. The medial clear space should be <5 mm, and no more than 2 mm greater than the tibiotalar clear space. These measurements are influenced by rotation, individual patient morphology, and the presence of ankle arthritis.
Tibiofibular clear space (syndesmosis A) 10 mm above joint line >5 mm Relatively constant with rotation
Tibiofibular overlap (syndesmosis B) 10 mm above joint line <5 mm on AP view and <1 mm on the mortise view Highly variable dependent on rotation
Fibular length The articular margins of the distal fibula and the lateral process of the talus on the mortise view should be parallel, and equal to the tibiotalar joint space. The “ball sign” (Fig. 59-15) is a confirmatory visual cue. Shortening of the fibula results in lateral and valgus subluxation of the talus
Talocrural angle Approximately 83 degrees, and symmetrical with contralateral ankle. A further measurement of fibular length.
Medial malleolus Less than 2 mm displacement Important where this results in talar shift.
Lateral malleolus displacement Less than 2 mm shortening, or displacement posteriorly or proximally Important where this results in talar shift. Isolated lateral malleolar fractures, although commonly displaced, are not usually an indication for surgery.
Posterior malleolus displacement The fragment must be less than 25% of the ankle joint seen on the lateral radiograph, and less than 2 mm displaced. The size may be underappreciated on plain x-ray.
 

Note: A diagrammatic representation of these parameters is shown in Figure 59-14 and the ’ball sign’ is explained in Figure 59-15.

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Whilst both a perfectly normal radiograph, and one with clear displacement, can usually be recognized with confidence, the importance of more subtle degrees of abnormality remain uncertain and controversial. Radiographic interpretation is often a clinical judgment made in the light of the individual circumstances of the injury, the clinical features present, and the state of health and functional requirements of the patient. 

Axial Imaging

Neither CT nor MRI is used frequently in the investigation of ankle fractures. CT scanning is helpful in characterizing joint displacement in pilon fractures, assessing the size of a posterior malleolar fragment, and in assessing the accuracy of the reduction of the syndesmosis postoperatively (Figs. 59-16 and 59-17). MRI has been used in the experimental setting to assess the integrity of the deep deltoid ligament where this is uncertain, but this is not common practice. Additional osteochondral lesions are not infrequently identified on MRI scans, but the importance of these remains uncertain. 
Figure 59-16
 
A: A suprasyndesmotic fibular fracture following ORIF. The fibula is imperfectly reduced but although there appears to be a satisfactory tibiofibular overlap (Syndesmosis B, Table 59-2) the tibiofibular clear space (Syndesmosis A, Table 59-2) is wide. B: A CT scan shows malreduction of the syndesmosis.
A: A suprasyndesmotic fibular fracture following ORIF. The fibula is imperfectly reduced but although there appears to be a satisfactory tibiofibular overlap (Syndesmosis B, Table 59-2) the tibiofibular clear space (Syndesmosis A, Table 59-2) is wide. B: A CT scan shows malreduction of the syndesmosis.
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Figure 59-16
A: A suprasyndesmotic fibular fracture following ORIF. The fibula is imperfectly reduced but although there appears to be a satisfactory tibiofibular overlap (Syndesmosis B, Table 59-2) the tibiofibular clear space (Syndesmosis A, Table 59-2) is wide. B: A CT scan shows malreduction of the syndesmosis.
A: A suprasyndesmotic fibular fracture following ORIF. The fibula is imperfectly reduced but although there appears to be a satisfactory tibiofibular overlap (Syndesmosis B, Table 59-2) the tibiofibular clear space (Syndesmosis A, Table 59-2) is wide. B: A CT scan shows malreduction of the syndesmosis.
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Figure 59-17
 
A: Anteroposterior and lateral radiographs of a trimalleolar fracture. B: A CT scan demonstrated that the posterior malleolar fracture involved about 30% of the tibial plafond. C: A 3D reconstruction demonstrating the size and morphology of the fracture. D: The prone position used for surgery. E: The incision is midway between the Achilles tendon and the fibula. The sural nerve and lesser saphenous vein are at risk and should be protected by blunt dissection through fat. F: the plane between FHL and the peronei is open exposing the posterior malleolar fracture. G: The fracture is reduced and stabilized with a K-wire. H: A buttress plate is then applied. I: The fibula fracture is secured with a posteriorly applied plate using the same incision. The peroneal tendons are retracted medially. J: The final construct.
A: Anteroposterior and lateral radiographs of a trimalleolar fracture. B: A CT scan demonstrated that the posterior malleolar fracture involved about 30% of the tibial plafond. C: A 3D reconstruction demonstrating the size and morphology of the fracture. D: The prone position used for surgery. E: The incision is midway between the Achilles tendon and the fibula. The sural nerve and lesser saphenous vein are at risk and should be protected by blunt dissection through fat. F: the plane between FHL and the peronei is open exposing the posterior malleolar fracture. G: The fracture is reduced and stabilized with a K-wire. H: A buttress plate is then applied. I: The fibula fracture is secured with a posteriorly applied plate using the same incision. The peroneal tendons are retracted medially. J: The final construct.
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A: Anteroposterior and lateral radiographs of a trimalleolar fracture. B: A CT scan demonstrated that the posterior malleolar fracture involved about 30% of the tibial plafond. C: A 3D reconstruction demonstrating the size and morphology of the fracture. D: The prone position used for surgery. E: The incision is midway between the Achilles tendon and the fibula. The sural nerve and lesser saphenous vein are at risk and should be protected by blunt dissection through fat. F: the plane between FHL and the peronei is open exposing the posterior malleolar fracture. G: The fracture is reduced and stabilized with a K-wire. H: A buttress plate is then applied. I: The fibula fracture is secured with a posteriorly applied plate using the same incision. The peroneal tendons are retracted medially. J: The final construct.
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Figure 59-17
A: Anteroposterior and lateral radiographs of a trimalleolar fracture. B: A CT scan demonstrated that the posterior malleolar fracture involved about 30% of the tibial plafond. C: A 3D reconstruction demonstrating the size and morphology of the fracture. D: The prone position used for surgery. E: The incision is midway between the Achilles tendon and the fibula. The sural nerve and lesser saphenous vein are at risk and should be protected by blunt dissection through fat. F: the plane between FHL and the peronei is open exposing the posterior malleolar fracture. G: The fracture is reduced and stabilized with a K-wire. H: A buttress plate is then applied. I: The fibula fracture is secured with a posteriorly applied plate using the same incision. The peroneal tendons are retracted medially. J: The final construct.
A: Anteroposterior and lateral radiographs of a trimalleolar fracture. B: A CT scan demonstrated that the posterior malleolar fracture involved about 30% of the tibial plafond. C: A 3D reconstruction demonstrating the size and morphology of the fracture. D: The prone position used for surgery. E: The incision is midway between the Achilles tendon and the fibula. The sural nerve and lesser saphenous vein are at risk and should be protected by blunt dissection through fat. F: the plane between FHL and the peronei is open exposing the posterior malleolar fracture. G: The fracture is reduced and stabilized with a K-wire. H: A buttress plate is then applied. I: The fibula fracture is secured with a posteriorly applied plate using the same incision. The peroneal tendons are retracted medially. J: The final construct.
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A: Anteroposterior and lateral radiographs of a trimalleolar fracture. B: A CT scan demonstrated that the posterior malleolar fracture involved about 30% of the tibial plafond. C: A 3D reconstruction demonstrating the size and morphology of the fracture. D: The prone position used for surgery. E: The incision is midway between the Achilles tendon and the fibula. The sural nerve and lesser saphenous vein are at risk and should be protected by blunt dissection through fat. F: the plane between FHL and the peronei is open exposing the posterior malleolar fracture. G: The fracture is reduced and stabilized with a K-wire. H: A buttress plate is then applied. I: The fibula fracture is secured with a posteriorly applied plate using the same incision. The peroneal tendons are retracted medially. J: The final construct.
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Management of Ankle Fractures

The vast literature on the treatment of ankle fractures is replete with small heterogeneous case series reporting the outcome of a bewildering variety of management strategies, using disparate outcome assessments. Critical review of this literature suggests that satisfactory outcomes can be obtained with a variety of treatments, but equally that the indiscriminate use of surgery does not necessarily improve outcomes and exposes the patient to additional complications. A satisfactory outcome after ankle fracture can be anticipated when the joint is congruent (the talus is placed anatomically under the plafond) and stable (it remains there until fracture healing). 

Isolated Lateral Malleolar Fractures

Truly isolated lateral malleolar fractures are stable, do not result in tibiotalar incongruence, and can be treated conservatively. Cadaveric studies show that an isolated fracture of the distal fibula does not result in abnormal ankle kinematics.249 Long-term cohort studies have universally reported good results. Bauer26 reported that 98% of patients with SER 2 fractures show no evidence of osteoarthritis at 30 years postinjury, and Kristensen and Hanson198 reported that 95% of patients have good functional outcomes at 21 years. Ongoing symptoms may be due to cartilage damage at the time of injury: Hinterman152 found that 60% of patients with isolated AO/OTA type B lateral malleolar fractures had chondral damage to the talus and 50% showed damage to the fibula. 
Management is aimed at allowing the patient to mobilize rapidly and return to normal function. A number of methods have been shown to be satisfactory including below-knee weight-bearing casts, elasticated bandaging,300 air stirrup devices,44,354 ankle braces44 and stabilizing shoes.415 No significant differences have been found in outcome beyond 3 months between these treatment options. Pragmatically, whichever is most convenient for both surgeon and patient is likely to result in good long-term function. 
The persistent minor radiographic displacement of the lateral malleolus seen in the majority of such patients does not impair clinical outcome.410 Despite this unambiguous clinical evidence, there remains occasional concern as to whether this equates to loss of normal mortise congruence. The SER 2 fracture has a typical oblique fracture line at the level of the syndesmosis with apparent external rotation, posterior translation, and shortening on plain radiographs (see Figs. 59-9 and 59-18A). Michelson and Harper addressed these concerns in a key investigation, using CT measurements of displacement.142,246 They showed that for these SER 2 injuries, the distal fibular fragment remains anatomically wedded to the talus, which in turn maintains its normal relationship with the tibial plafond. Distal talofibular and tibiotalar alignment is therefore normal. The cause of the apparent radiographic malalignment is actually internal rotation of the proximal fibular fragment rather than external rotation of the distal fragment. Moreover, whereas plain radiographs often appear to demonstrate several millimeters of displacement at the fracture site, on CT this is seen to be actually less than 1 mm of displacement, and this is clearly biomechanically unimportant. 
The other common group of isolated lateral malleolar fractures, the SAD 1 fracture, may be considered a part of the spectrum of ligamentous ankle injuries in adults and managed with functional bracing or casting: Outcomes are comparable to purely ligamentous injuries.138 

Lateral Malleolar Fractures Associated with Instability

The combination of a lateral malleolar fracture with failure of the deltoid ligament (one of the two variants of the SER 4 fracture) renders the ankle unstable. The diagnosis is made on the basis of obvious deformity of the ankle at the time of presentation or clear displacement of the talus on the presentation radiographs. Management is surgical reduction and fixation of the lateral malleolus with intraoperative assessment of the syndesmosis. Surgical repair of the medial deltoid injury, although at one time recommended,42 is unnecessary.22,139,414 

Occult Ankle Instability

Whilst a stable, isolated, lateral malleolar fracture (SER 2 injury) can be treated nonoperatively, the combination of a lateral malleolar fracture and a medial deltoid ligament rupture (SER 4 injury) may pose a diagnostic dilemma when there is no clear displacement on the initial plain radiographs (Fig. 59-18). 
Figure 59-18
A: An anteroposterior radiograph of an SER 4 injury showing no displacement.
 
However the gravity stress views shows displacement (B), confirming instability.
However the gravity stress views shows displacement (B), confirming instability.
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Figure 59-18
A: An anteroposterior radiograph of an SER 4 injury showing no displacement.
However the gravity stress views shows displacement (B), confirming instability.
However the gravity stress views shows displacement (B), confirming instability.
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The deltoid has both superficial and deep components and it is the deep component, attached to the posterior colliculus of the medial malleolus, that is widely considered to be crucial to talar stability.248,291 Assessment of the integrity of the deltoid is both clinical and radiographic. Clinical signs of medial swelling, bruising, and tenderness often accompany superficial deltoid ligament rupture, and may also indicate the presence of a deep deltoid injury and instability. These clinical signs are widely used to indicate the likelihood of mechanical instability,44,91,198,300,318,410 while the absence of these signs is often taken to indicate ankle stability.284 
In many centers a pragmatic “walking test” approach is taken. If there is no talar shift on radiographs taken a week after injury, the ankle has “proved” its stability. Alternatively, stability may be inferred from stress views or MRI images. The most common practice is to perform a stress radiograph, either manual or gravity-assisted. In the former, the patient is placed supine on the x-ray table with the leg held in 20 degrees of internal rotation to produce a mortise view. A firm but gently progressive external rotation force is applied to the forefoot and a radiograph is taken. The same effect can be achieved by placing the patient laterally on the x-ray table with the injured limb lowest and the foot hanging free from the end of the table (Fig. 59-19), with gravity thereby exerting the required external rotation force. The two examinations have been shown to produce equivalent results, and the gravity stress examination has the advantages of reducing the exposure of the surgeon to ionizing radiation and reducing discomfort for the patient.125,326 
Figure 59-19
 
During the gravity stress view, the patient is made to lie in the lateral decubitus position on the side of the affected ankle with the distal leg, ankle, and foot allowed to hang dependent off the end of the table while a mortise view is obtained. This patient positioning, in effect, acts to impart an external rotational force as in the manual stress view.
During the gravity stress view, the patient is made to lie in the lateral decubitus position on the side of the affected ankle with the distal leg, ankle, and foot allowed to hang dependent off the end of the table while a mortise view is obtained. This patient positioning, in effect, acts to impart an external rotational force as in the manual stress view.
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Figure 59-19
During the gravity stress view, the patient is made to lie in the lateral decubitus position on the side of the affected ankle with the distal leg, ankle, and foot allowed to hang dependent off the end of the table while a mortise view is obtained. This patient positioning, in effect, acts to impart an external rotational force as in the manual stress view.
During the gravity stress view, the patient is made to lie in the lateral decubitus position on the side of the affected ankle with the distal leg, ankle, and foot allowed to hang dependent off the end of the table while a mortise view is obtained. This patient positioning, in effect, acts to impart an external rotational force as in the manual stress view.
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Although conceptually attractive, evidence for the usefulness of stress views remains elusive at present. Principally, there is considerable uncertainty as to how much widening is indicative of instability. An absolute medial clear space of between 4 and 5 mm is often quoted as the upper limit of normal.83,96,141,291 However, the absolute size of the patient,236 their gender,174 the degree of magnification of the image and the rotation of the radiograph298 will all affect this assessment. Alternatively, an increase in the medial clear space from a baseline value (the superior clear space or contralateral ankle have been used) of up to 3 mm has been proposed289 although again this is empirical and can be affected by factors such as ankle arthrosis. Finally a combination of the two methods with an absolute medial clear space of 4 or 5 mm, which is also an increase on baseline, has been used by some authors.125,192,236,326 It has been widely assumed that ankles with medial clear space values less than these empirical values on stress examination are stable, whilst ankles with greater degrees of translation are unstable and should be advised to undergo surgery. 
There is increasing evidence, however, that such stress-test measurements do not equate with clinical stability or outcome. No specific cut-off value for medial clear space has been shown to equate to deltoid ligament rupture when detected with arthroscopy.327 A key study by Egol et al.96 reported on 101 patients who had apparently stable isolated lateral malleolar fractures and underwent manual stress views. Sixty-six patients were considered to have had positive stress tests as judged by an absolute medial clear space of more than 4 mm. Thirty-six of these also had clinical signs of medial injury and were empirically judged to have unstable injuries and underwent stabilization; it is not possible to judge how many of these were truly unstable. The most interesting group were the 30 patients who had positive stress tests but no clinical signs. This group were offered the option of surgery or functional treatment. Twenty chose functional treatment, and 10 chose operative treatment. Their functional results at 7 to 10 months were identical and no patient developed functional instability. The fact that 66% of the initial cohort were considered to be radiographically unstable suggests that a cut-off of 4 mm on stress radiographs is likely to be too stringent a criterion, and the clinical outcomes of this cohort appear to confirm this. Another study, of a cohort of 155 patients with apparent SER 2 fractures undergoing gravity stress testing, and using a medial clear space of 4 mm as the cut-off, found 79% of patients to have positive stress radiographs. As all of these patients were successfully treated nonoperatively with good outcomes, these were deemed to be false-positives. When the cut-off was increased to 6 mm, 19% remained false-positive and even when there was a requirement for the medial clear space to be greater than 6 mm and greater than a baseline value, 15% were false-positives. The role of stress tests remains undefined. 
Investigators have also assessed the usefulness of clinical indicators of deltoid injury such as medial bruising and swelling. When stress-test measurements are taken as the “gold standard” indicators of instability, these clinical findings appear to add little additional information. The presence of tenderness has been shown to have a positive predictive value of less than 50%, and the absence of tenderness has been shown to have a negative predictive value of just 66%.83 Moreover, the absence of combined tenderness and bruising has a negative predictive value of 39%. When judged by a stress test, there is a 61% chance of missing instability if the absence of these clinical signs is used as the criterion.96 However, given that a positive stress test seems not to relate closely to true instability, the low negative predictive value of clinical signs of medial injury, which have been calculated in relation to these stress views as the “gold standard,” may have been overstated83: That is, it seems likely that the absence of medial tenderness, swelling, or bruising probably is a good indicator of functional ankle stability, as previous outcome studies have long assumed.44,91,198,300,318,410 
To assess the relationship between clinical signs, deltoid injury and outcome further, Koval et al.192 subsequently reported on a group of 21 patients with lateral malleolar fractures who were clinically suspected of having an associated medial-sided injury. They underwent manual stress views, and all were shown to have between 5 and 8 mm of absolute medial clear space and therefore had a positive stress radiograph. All 21 patients underwent MRI scanning and all were found to have superficial deltoid ruptures. Two also had complete deep deltoid ruptures and were advised to undergo surgery. The remaining 19 had only partially ruptured deep deltoid ligaments despite the abnormal clear space and were advised to have conservative management with full weight bearing in a removable boot. Each was kept under review for a year and went on to make a full recovery. Thus the presence of medial clinical signs appears to have low positive predictive value for instability. 
It therefore seems that functional instability cannot be gauged simply from clinical or radiographic measurements and that the integrity of the deep ligament may not be the crucial factor determining functional stability as previously thought. This is entirely consistent with our progressive understanding of ankle biomechanics and the concept of dynamic stability. Further research is required to define the natural history of these injuries and to determine which patients require surgery, and which will ultimately prove to have adequate functional stability and a benign outcome without surgery. 

Author’s Preferred Management

Patients with an apparently isolated lateral malleolar fracture and a congruent mortise on their initial radiographs are provided with a functional brace and allowed to mobilize fully weight bearing regardless of the presence or absence of medial-sided bruising or swelling. They are reviewed at 1 and 6 weeks postinjury with AP and lateral radiographs. Neither stress views nor MRI are used routinely. If any talar shift is revealed, the patient is advised to undergo operative fixation of the fibula (but not the deltoid ligament). Otherwise they are discharged to physiotherapy rehabilitation at 6 weeks. 

Isolated Medial Malleolar Fractures

Pankovitch described injuries to the medial osteoligamentous complex of the ankle based on anatomical and clinical investigation. These included fractures of the anterior colliculus with or without deep deltoid ligament rupture, fractures of the posterior colliculus, supracollicular fractures (further subdivided into vertical, oblique, and transverse) and avulsion chip fractures.288,289 Herscovici150 suggested a simpler classification based upon the level of the medial malleolar fracture. 
Although in 1945 Muller recommended screw fixation of all medial malleolar fractures,260 isolated medial malleolar fractures can generally be managed nonoperatively. Herscovici et al.,150 reviewed the functional and radiographic outcomes of 57 patients with isolated medial malleolar fractures, 3 years after injury. Immobilization consisted of a below-knee non–weight-bearing cast for 6 weeks followed by progressive weight bearing and physiotherapy. In this cohort, despite many of the fractures showing initial displacement of up to 6 mm, only two fractures (3.5%) went on to nonunion. Despite several cases of medial malleolar malunion, no patient showed any evidence of displacement of the ankle mortise or osteoarthritis. Pankovitch et al.289 also reported good outcomes with isolated anterior colliculus fractures associated with a deep deltoid ligament tear when managed nonoperatively, although this injury only represented a small number of the patients in their cohort. More recently Tornetta et al.378 also reported that anterior collicular fractures fared better with conservative than operative management. 

Author’s Preferred Management

Undisplaced or minimally displaced isolated fractures of the medial malleolus are managed nonoperatively with 6 weeks in a plaster of functional brace with full weight bearing as tolerated. Where there is significant displacement, or where the fracture enters the joint through the tibial plafond, we advocate reduction and fixation to avoid a displaced nonunion. 

Bimalleolar Fractures

Conservative Treatment

As for all ankle fractures, where the talus can be reduced anatomically under the mortise and held there until fracture healing, a good result can be anticipated. Accordingly, Lloyd in 1939219 opined that fixation of ankle fractures in general was unnecessary and in 1952 Cox et al.76 concurred that only “in a rare instance it may be necessary to attack the fibular fracture operatively”: Indeed several authors then199,401 and since105,317 have reported acceptable results with conservative treatment. Wei et al.396 published their results of 19 conservatively managed unstable bimalleolar and trimalleolar ankle fractures at an average of 20 years postinjury. Their patients had been 17 to 79 years of age at the time of injury, and were placed in an above-knee cast for 6 weeks followed by a below-knee cast for a further 6 weeks, and subjected to close surveillance. After 20 years only two of their patients were “mildly symptomatic,” and they reported AOFAS score between 87 to 100, with a mean of 98 points. These findings were substantiated by Joy et al.176 who studied 118 unstable fractures up to 7 years after injury. The majority of these had been treated nonoperatively, and the 40% treated operatively had only undergone isolated medial-sided screw fixation or deltoid repair. Despite the heterogeneity of their patient group, by careful study of their postoperative radiographs they were able to show that anatomical reduction of the talus under the plafond resulted in a good clinical result in 85% of cases. Conversely, where reduction was poor, the clinical result was poor in two-thirds of cases. The principal drawback of this strategy is practical: Several authors have shown that maintaining reduction is difficult42,164,230,401 and a prolonged casting regime might now be considered burdensome. However, the principle demonstrated here is clear: With accurate reduction and vigilant monitoring a good anatomical and clinical result can be obtained with nonoperative management.87,317 

Fixation of Medial Malleolus Only

If isolated fractures of the lateral malleolus are stable, then it might be assumed that fixation of a medial malleolar fracture would restore the same mechanical environment and be sufficient treatment for bimalleolar fractures; indeed fixation of the medial malleolus alone was considered adequate for many years.242,260 However, in 1977 Yablon et al.407 observed that fixation of the medial malleolus alone often resulted in incomplete fibular and talar reduction and the later development of posttraumatic arthritis. They memorably stated that the “displacement of the talus faithfully follows that of the lateral malleolus” and demonstrated, in both a cadaveric model and in surgical patients, that open reduction of the lateral malleolus more predictably restored tibiotalar congruence and resulted in a satisfactory clinical outcome. 
At the same time, Svend-Hansen also reported that 16 of a cohort of 29 (55%) patients with bimalleolar ankle fractures, treated by fixation of the medial side only, experienced unsatisfactory results after a mean of almost 5 years,358 also emphasizing the difficultly of obtaining and maintaining ankle joint reduction. Pankovich289 in his clear description of the subtypes of medial-sided injury demonstrated why anterior collicular fractures might remain unstable despite fixation: Although the competence of the superficial deltoid is re-established by fracture fixation, the deep deltoid, which is attached to the posterior colliculus and has ruptured at the time of displacement, remains incompetent. Tornetta377 undertook a study of ankle stability confirming this variation. He performed a stress radiograph intraoperatively following medial malleolar fixation, but before lateral malleolar fixation. He demonstrated that a quarter of fractures remained unstable. Thus fixation of the medial malleolus only in a bimalleolar ankle fracture can re-establish stability in only three-quarters of cases. 

Fixation of Medial and Lateral Malleoli

Several studies have compared surgical fixation with conservative treatment. Yde411 retrospectively reviewed the results of their patients in 1980 and reported good results in 20% of their conservatively treated fractures compared to 92% of those operatively treated. Pettrone295 described a similar retrospective cohort and reported that conservative treatment and fixation of the medial malleolus alone gave similar results, but better results were obtained after combined fixation of both the medial and lateral malleoli. A small number of prospective RCTs have also been reported. Bauer et al.25 randomized 111 patients with displaced AO/OTA type A or B fractures to operative or nonoperative management; short-term results showed a significant benefit to those treated with surgical fixation but at final follow-up, 7 years postinjury, there was no significant difference between groups. Makwana et al. reported better functional outcomes and range of movement in their patients randomized to operative treatment but equal levels of satisfaction and pain.228 Phillips reported the results of a randomized trial in 1985, and although follow-up was only 51%, reported significantly better results in (predominantly SER 4) fractures treated with internal fixation than with conservative management.296 Hughes164 also found better results in AO/OTA type B and C fractures when treated surgically, a result replicated by Colton66 in PER 3 and 4 fractures. 

Author’s Preferred Management

Bimalleolar fractures are by definition unstable injuries and the vast majority should be treated by reduction and internal fixation. However entirely undisplaced fractures, particularly in the elderly or infirm, can be treated nonoperatively with a cast or brace provided the patient is kept under close clinical and radiographic review until union has occurred. 

Posterior Malleolar Fractures

The significance of a posterior malleolar fracture (see Fig. 59-25) is controversial. Whilst many have found that the presence of a posterior malleolar fracture is associated with poor outcomes45,168 others have found poorer outcomes only in the short term362 and others have not found any predictive value in terms of functional outcome295 or late osteoarthritis.222 
Figure 59-25
Percutaneous fixation of the posterior malleolus.
 
A, B: Initial AP and lateral radiographs showing a posterior malleolar fragment involving almost 50% of the tibial plafond. C: The posterior malleolus is percutaneously reduced using a periosteal elevator. The scalpel shows the position of the stab incision for the anterior-to-posterior screws. D: The fracture has been stabilized with two AP screws and a fibular nail.
A, B: Initial AP and lateral radiographs showing a posterior malleolar fragment involving almost 50% of the tibial plafond. C: The posterior malleolus is percutaneously reduced using a periosteal elevator. The scalpel shows the position of the stab incision for the anterior-to-posterior screws. D: The fracture has been stabilized with two AP screws and a fibular nail.
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Figure 59-25
Percutaneous fixation of the posterior malleolus.
A, B: Initial AP and lateral radiographs showing a posterior malleolar fragment involving almost 50% of the tibial plafond. C: The posterior malleolus is percutaneously reduced using a periosteal elevator. The scalpel shows the position of the stab incision for the anterior-to-posterior screws. D: The fracture has been stabilized with two AP screws and a fibular nail.
A, B: Initial AP and lateral radiographs showing a posterior malleolar fragment involving almost 50% of the tibial plafond. C: The posterior malleolus is percutaneously reduced using a periosteal elevator. The scalpel shows the position of the stab incision for the anterior-to-posterior screws. D: The fracture has been stabilized with two AP screws and a fibular nail.
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The most frequently expressed concerns regarding posterior malleolar fractures have centered around the risk of posterior talar subluxation and the reduction in the contact area of the ankle joint potentially leading to osteoarthritis. A number of recommendations have been made concerning the size of fragment that should be considered significant.240,323 Posterior talar subluxation is thought to occur due to the loss of the posterior malleolus as a stabilizing structure. Whilst a number of cadaveric studies have found that loss of up to 50% of the posterior malleolus does not correlate with significant posterior instability in the presence of intact medial and lateral structures,110,140,306 this may not apply to clinical situations in which these associated injuries are present. 
A reduction in joint contact area after fracture has been confirmed experimentally, however the extent of this is surprisingly modest: A fracture involving 25% of the joint as seen on the lateral radiograph results in no significant decrease, a 33% fracture reduces contact area by only 15% and a 50% fracture by around 30%.145,224 Even in large (50%) fractures, these reductions in contact area do not, moreover, seem to be associated with any increase in peak contact stress: In an unconstrained and loaded cadaveric model with a 50% fracture, contact stresses were not increased but were seen to be redistributed away from the area of injury to more anterior and lateral locations.110 The relationships between contact area, contact stress, surface shear, and clinical osteoarthritis remain unclear, and chondral damage at the time of injury may be the principle, but as yet unquantified, prognostic factor.374 
Evidence that surgical reduction and fixation can improve clinical outcomes has been varied and conflicting. McDaniel and Wilson240 found better clinical and radiographic results were achieved when patients with fractures involving over 25% of the joint surface were managed operatively in their small series of 15 cases. This may relate to the inability to achieve anatomical reduction in any of their conservatively treated cases, with residual posterior subluxation in half of these. Conversely, when Harper and Hardin143 retrospectively reviewed 38 patients with posterior malleolar fractures also involving over 25% of the joint surface they found that the outcomes (including reduction, union, complications, and late osteoarthritis) for operative and nonoperative management were the same. Furthermore, Donken et al.90 reviewed 19 patients 20 years after an apparently isolated posterior malleolar fracture treated nonoperatively, and reported uniformly good subjective, objective, and radiographic results. As a result surgical practice is varied with some surgeons fixing all fractures involving greater than 25% of the joint surface and others citing ankle stability as the key in their decision making.122 
The interpretation of these studies, and clinical decision-making in individual cases, is made considerably more difficult because the ability to define the size of the posterior fragment based purely on plain radiographs has been shown to be prone to error. Macko et al.224 found that measurement on the lateral x-ray significantly underestimated the size of the fragment due to the obliquity of the fracture to the x-ray beam whilst Ferries107 found both underestimation and overestimation of fracture size on lateral x-rays when compared with CT findings. Indeed Haraguchi et al.137 have suggested that all posterior malleolar fractures may benefit from preoperative CT scanning in order fully to appreciate the fracture pattern. 

Author’s Preferred Management

Ankle fracture involving more than 25% of the posterior malleolus should be managed operatively. The majority of cases are stabilized with percutaneous anterior to posterior screws. Large or irreducible fragments are treated with posterior plating. Both procedures are described below. 

Syndesmotic Injuries

The syndesmosis is ruptured in ankle fractures (Fig. 59-20) as a result of a torsional movement of the talus which forces the tibia and fibula apart or as a result of a severe abduction force (Fig. 59-11). However, the ligaments are rarely visualized or subject to MRI scanning, and their integrity is surmised from radiographic diastasis of the syndesmosis. Diastasis requires the rupture of three strong ligaments and the interosseous membrane (Fig. 59-3) and therefore represents a very substantial insult to the ankle. Not surprisingly, this injury often results in a poor long-term outcome, with or without surgical treatment.98,182 
Figure 59-20
 
A: An anteroposterior radiograph showing a diastasis following a rotational injury. B: Intraoperative view of the incision over the syndesmosis. The periarticular clamp is applied to the medial and lateral malleoli through separate stab incisions. The heavy K-wire placed in the distal fragment is used as a joystick. C: Intraoperative view of the syndesmosis showing the diastasis. D: Intraoperative view of the syndesmosis showed that it has been reduced and compressed. Note the congruent articular surfaces that come together to form three lines in a “Mercedes-Benz sign.” E: An intraoperative mortise view. A single 3.5-mm screw has been placed at the upper border of the syndesmosis. Note the “fibular nipple”: A radiographic extension of the articular surface of the fibula which runs confluently into the line of the tibial plafond, in a similar manner to the Shenton line at the hip.
A: An anteroposterior radiograph showing a diastasis following a rotational injury. B: Intraoperative view of the incision over the syndesmosis. The periarticular clamp is applied to the medial and lateral malleoli through separate stab incisions. The heavy K-wire placed in the distal fragment is used as a joystick. C: Intraoperative view of the syndesmosis showing the diastasis. D: Intraoperative view of the syndesmosis showed that it has been reduced and compressed. Note the congruent articular surfaces that come together to form three lines in a “Mercedes-Benz sign.” E: An intraoperative mortise view. A single 3.5-mm screw has been placed at the upper border of the syndesmosis. Note the “fibular nipple”: A radiographic extension of the articular surface of the fibula which runs confluently into the line of the tibial plafond, in a similar manner to the Shenton line at the hip.
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A: An anteroposterior radiograph showing a diastasis following a rotational injury. B: Intraoperative view of the incision over the syndesmosis. The periarticular clamp is applied to the medial and lateral malleoli through separate stab incisions. The heavy K-wire placed in the distal fragment is used as a joystick. C: Intraoperative view of the syndesmosis showing the diastasis. D: Intraoperative view of the syndesmosis showed that it has been reduced and compressed. Note the congruent articular surfaces that come together to form three lines in a “Mercedes-Benz sign.” E: An intraoperative mortise view. A single 3.5-mm screw has been placed at the upper border of the syndesmosis. Note the “fibular nipple”: A radiographic extension of the articular surface of the fibula which runs confluently into the line of the tibial plafond, in a similar manner to the Shenton line at the hip.
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Figure 59-20
A: An anteroposterior radiograph showing a diastasis following a rotational injury. B: Intraoperative view of the incision over the syndesmosis. The periarticular clamp is applied to the medial and lateral malleoli through separate stab incisions. The heavy K-wire placed in the distal fragment is used as a joystick. C: Intraoperative view of the syndesmosis showing the diastasis. D: Intraoperative view of the syndesmosis showed that it has been reduced and compressed. Note the congruent articular surfaces that come together to form three lines in a “Mercedes-Benz sign.” E: An intraoperative mortise view. A single 3.5-mm screw has been placed at the upper border of the syndesmosis. Note the “fibular nipple”: A radiographic extension of the articular surface of the fibula which runs confluently into the line of the tibial plafond, in a similar manner to the Shenton line at the hip.
A: An anteroposterior radiograph showing a diastasis following a rotational injury. B: Intraoperative view of the incision over the syndesmosis. The periarticular clamp is applied to the medial and lateral malleoli through separate stab incisions. The heavy K-wire placed in the distal fragment is used as a joystick. C: Intraoperative view of the syndesmosis showing the diastasis. D: Intraoperative view of the syndesmosis showed that it has been reduced and compressed. Note the congruent articular surfaces that come together to form three lines in a “Mercedes-Benz sign.” E: An intraoperative mortise view. A single 3.5-mm screw has been placed at the upper border of the syndesmosis. Note the “fibular nipple”: A radiographic extension of the articular surface of the fibula which runs confluently into the line of the tibial plafond, in a similar manner to the Shenton line at the hip.
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A: An anteroposterior radiograph showing a diastasis following a rotational injury. B: Intraoperative view of the incision over the syndesmosis. The periarticular clamp is applied to the medial and lateral malleoli through separate stab incisions. The heavy K-wire placed in the distal fragment is used as a joystick. C: Intraoperative view of the syndesmosis showing the diastasis. D: Intraoperative view of the syndesmosis showed that it has been reduced and compressed. Note the congruent articular surfaces that come together to form three lines in a “Mercedes-Benz sign.” E: An intraoperative mortise view. A single 3.5-mm screw has been placed at the upper border of the syndesmosis. Note the “fibular nipple”: A radiographic extension of the articular surface of the fibula which runs confluently into the line of the tibial plafond, in a similar manner to the Shenton line at the hip.
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The interosseous membrane is known to be important in weight transmission through the fibula.337 Syndesmotic diastasis left untreated may result in persisting instability, pain, and progressive osteoarthritis.59,212,395 Pettronne et al.,295 in a carefully conducted study of ankle fracture outcomes, demonstrated a poorer overall outcome at 5 years in patients with radiographic evidence of syndesmosis widening, and it is widely accepted that diastasis must be identified at the outset and treated with surgical stabilization. 
Patients at particular risk of persistent syndesmotic instability include the PER fracture with a deltoid ligament rupture (i.e., the high AO/OTA type C fracture or Maisonneuve fracture). However, Boden,38 in his classical cadaveric study, demonstrated that where the medial-sided injury is a malleolar fracture, fracture fixation results in the syndesmosis becoming stable, a finding confirmed by further cadaveric studies.52,313 Clinical studies treating patients according to this protocol have found good long-term results without syndesmotic fixation in these circumstances.59,408 It should be borne in mind, however, that fixed fractures of the anterior colliculus associated with a ruptured deep deltoid ligament may be an exception to this rule.289,377 The proximal fibula fracture itself does not require fixation, indeed surgical exploration at this level carries a risk of damage to the common peroneal nerve. 
The level of the fibular fracture is a helpful but not infallible indicator of stability: Boden38 classically demonstrated that when cadaveric PER fractures, with associated deltoid rupture and syndesmotic injury, are created more than 3 to 4.5 cm proximal to the ankle, syndesmotic fixation was required to re-establish stability. However, this was based on the assumption that the syndesmosis (specifically the interosseous membrane) was torn up to the level of the fibular fracture. Nielson et al.271 have subsequently demonstrated by MRI assessment of the syndesmosis that this relationship is not constant. Indeed it has been found that even with a deltoid ligament tear fractures occurring up to 5 cm proximal to the ankle joint can be treated nonoperatively with an equally satisfactory outcome both functionally and radiographically at 1 year.182,285 Thus, although high fibular fractures are often unstable, the precise level of the fibular fracture cannot be used to judge the degree of syndesmotic injury. 
Measurements taken from plain radiographs (Fig. 59-14) have been suggested to correlate with syndesmotic rupture: The most commonly used are a tibiofibular clear space (“syndesmosis A”) of greater than 5 mm and a tibiofibular overlap (“syndesmosis B”) of less than 5 mm on the AP view or of less than 1 mm on the mortise view.144 The tibiofibular clear space is the most reliable of these parameters.144,298 Further assessment of these measurements within the normal population, however, has found a large variation in values with a mean tibiofibular clear space of 3.8 mm in females and 4.6 mm in males.34,280 As an alternative it has been suggested that an increase in the tibiofibular clear space in comparison to the contralateral ankle may be more accurate. No consensus on this has been reached and disappointingly cadaveric models have suggested that no predictable increase in measurements on plain radiography can be found on sectioning of the syndesmotic ligaments,35 and clinical experience shows that some normal individuals have such a shallow incisura that they have no radiographic tibiofibular overlap whatsoever. Given the limitations of plain radiography, axial imaging has been evaluated and shown to demonstrate disruptions not evident on plain radiographs.121 CT studies have shown wide variation in the shape of the syndesmosis with a deep concave incisura in some and a limited curve in others.101 MRI has been shown to provide a more accurate assessment of syndesmotic injury149,270 which correlates well with direct arthroscopic assessment.274,359 MR arthrography may add further accuracy.263 Such investigations, however, are expensive and are not commonly performed. 
Intraoperative stress testing with fluoroscopic assessment of the ankle joint can be performed in a variety of ways. Cotton73 described applying a lateral force to the heel to displace the fibula laterally. A similar result can be obtained by directly pulling the fibula laterally with a hook (hook test) or a reduction clamp. Alternatively, an external rotation stress test can be performed. The various intraoperative stress tests correlate poorly with one another and have limited sensitivity when compared to a 7.5 Nm external rotation test performed with a standardized instrument.283 As one would expect given the marked limitations of plain AP radiographs in assessing the syndesmosis, and the uncertainty regarding the applicability of stress tests in distinguishing between SER 2 and SER 4 fractures, the rate of “positive” intraoperative tests also varies depending entirely upon the position of the foot and the criteria chosen.148,169,283,285,342 Stoffel et al.351 compared the hook and external rotation tests reporting the most useful measurement of syndesmotic rupture to be the hook test. They found that the application of an external rotation force resulted in consistent increases only in the medial clear space but that this increase in medial clear space was also seen with deltoid ligament sectioning even when the syndesmosis was left undamaged.351 Jenkinson et al.169 reported that the standard external rotation test identified patients with syndesmotic injury not previously recognized on plain radiography. Lui223 found that arthroscopy diagnosed cases of syndesmotic rupture missed by stress radiography, but neither author sought to correlate their findings with functional instability. Finally Beumer et al. found in cadaveric experiments that all clinical tests resulted in radiographic “abnormalities” that could occur without any anatomical injury.35,33 Which intraoperative test to use is therefore a matter of surgeon preference: It appears that the hook test is currently the most popular with 64% of orthopedic surgeons reporting it their first choice.254 
SER fractures are generally considered to be at low risk of syndesmotic instability following stable fixation, because this type of injury is unlikely to have disrupted the interosseous ligament of the syndesmosis, or the interosseous membrane above. However, instability has been reported by a number of authors: Stark et al.342 reported that 93 of 238 (39%) patients with unstable SER 4 ankle fractures had instability on intraoperative stress testing, and postulated that this resulted from stretching or transection of the ligament. However, the limitations of these stress tests themselves are gradually becoming clearer (see below) and the true level of syndesmotic instability after SER fractures remains uncertain. Cadaveric attempts to investigate the importance of syndesmosis injury should also be interpreted with caution as these have investigated the effect on pressure distribution following forceful subluxation of the talus. This experimental design may be flawed because clinically it is clear that a syndesmotic injury does not necessarily result in dynamic talar instability; as demonstrated by the stability seen in axial loading186 and dynamic loading249 cadaveric studies and clinical outcome studies.182 
Establishing a confident diagnosis of syndesmotic instability is of great practical importance because the decision to perform surgical stabilization exposes the patient to additional risks. Fanter et al.104 showed a risk of vascular injury in a cadaveric study and Kennedy et al.182 compared patients with PER fractures treated with and without syndesmosis screws in a randomized trial and demonstrated a worse radiographic outcome amongst those treated with a screw. Malreduction (Fig. 59-16) has a significant effect on outcome: Follow-up of patients with syndesmotic fixation at a minimum of 2 years shows that malreduction of the syndesmosis results in significantly worse functional outcomes than anatomical reduction.319 Long-term outcome studies have also shown that patients with malreduction of the syndesmosis, either persistent diastasis despite fixation or distal tibiofibular synostosis, have significantly worse functional results.399 Malreduction is notoriously difficult to recognize intraoperatively, partly due to anatomical variation259 and partly due to the limitations of two-dimensional intraoperative fluoroscopy which has been shown to be unable to detect rotation of the distal fibula within the syndesmosis of up to 30 degrees.233 Malreduction may therefore require CT evaluation120 to be recognized (Fig. 59-16) although the criteria for a “normal” reduction remain uncertain.259 

Author’s Preferred Management

Where there is clear widening of the syndesmosis with talar instability we advise surgical stabilization. Where the fibular fracture is within the distal third we prefer to fix the fibular fracture as an aid to reduction of the syndesmosis, and to ensure that the distal fragment does not angulate when the syndesmosis screw is tightened. In this situation we prefer to use a fibular nail to avoid extensive dissection, particularly as the fibula is usually comminuted and requires to be bridged. Furthermore we have found that once the distal fragment has been secured to the nail with the AP screw it is relatively easy to manipulate the fragment into position using the jig as a handle. Where the fracture is in the middle or proximal third of the fibula we do not expose or fix the fracture directly. Like most authors we have found it difficult to judge the mortise reduction fluoroscopically and we prefer an open reduction as described below. 
It should be remembered that many ankle fractures are treated nonoperatively. An algorithm to facilitate the decision as to whether to operate on an ankle fracture is shown in Figure 59-21
Figure 59-21
An algorithm detailed when surgery should be undertaken on ankle fractures.
 
When deciding on surgery the age and medical condition of the patient should be taken into consideration.
When deciding on surgery the age and medical condition of the patient should be taken into consideration.
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Figure 59-21
An algorithm detailed when surgery should be undertaken on ankle fractures.
When deciding on surgery the age and medical condition of the patient should be taken into consideration.
When deciding on surgery the age and medical condition of the patient should be taken into consideration.
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Ankle Fracture Fixation Techniques

Fibular Fixation of Ankle Fractures

Plating

The AO doctrine in the 1970s for early movement achieved by open reduction and rigid internal fixation led to rapid popularization of the use of a lag screw protected by a laterally placed neutralization plate261 (Fig. 59-22A). Early results achieved with this technique were good both clinically and radiographically164,227 and it has remained the “gold standard” for 50 years. Since then fibular plating has diversified to include buttress, bridging, and compression techniques, with locking, compression, or third tubular plates, via open or minimal incisions. 
Figure 59-22
 
A: A lateral malleolar facture treated with an interfragmentary screw and a one-third tubular neutralization plate. B: A dorsally placed one-third tubular plate. C: A one-third tubular plate applied using a bridging technique with minimal soft tissue stripping at the fracture site. D: Three interosseous screws used to reconstruct a long spiral fibular fracture in a younger patient with good bone.
A: A lateral malleolar facture treated with an interfragmentary screw and a one-third tubular neutralization plate. B: A dorsally placed one-third tubular plate. C: A one-third tubular plate applied using a bridging technique with minimal soft tissue stripping at the fracture site. D: Three interosseous screws used to reconstruct a long spiral fibular fracture in a younger patient with good bone.
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Figure 59-22
A: A lateral malleolar facture treated with an interfragmentary screw and a one-third tubular neutralization plate. B: A dorsally placed one-third tubular plate. C: A one-third tubular plate applied using a bridging technique with minimal soft tissue stripping at the fracture site. D: Three interosseous screws used to reconstruct a long spiral fibular fracture in a younger patient with good bone.
A: A lateral malleolar facture treated with an interfragmentary screw and a one-third tubular neutralization plate. B: A dorsally placed one-third tubular plate. C: A one-third tubular plate applied using a bridging technique with minimal soft tissue stripping at the fracture site. D: Three interosseous screws used to reconstruct a long spiral fibular fracture in a younger patient with good bone.
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However experience with plating has revealed a number of limitations. The thin soft tissues over the distal fibula, and the subcutaneous location of the lateral plate, predispose to wound dehiscence and infection. Rates between 5.5%324 and 26%154 have been reported with higher rates in elderly13 and diabetic patients.238 The thin soft tissues in this region may also result in late metalwork irritation and the requirement for secondary removal surgery in up to 50% of patients.13,241 The incision also puts at risk the superficial peroneal and sural nerves, both of which have highly variable anatomy.163 
With a laterally sited plate, the distal metaphyseal screws are necessarily unicortical and cancellous and risk articular surface penetration. Structural failure may be a problem in osteopenia: Beauchamp et al.28 reported stable fixation in only 54% of elderly patients with porotic or comminuted bone. 
To reduce some of these problems Brunner and Weber48 described dorsal buttress plating (Fig. 59-22B) in 1982. The posterior to anterior screws reduce the chance of intra-articular penetration and allow bicortical purchase, whilst the dorsal location of the plate gives increased soft tissue coverage and the more posteriorly placed incision reduces the chance of damage to the superficial peroneal nerve.311 Good clinical and radiographic outcomes have been reported,279,382,402,403 and the construct is certainly biomechanically stronger in vitro,253,322 but comparative clinical studies have failed to show a clear advantage over conventional lateral plating.206 Moreover, peroneal tendon irritation occurs in up to 43% of patients, and in 30% of patients visible tendon lesions are present at the time of plate removal.279,394 It appears that dorsal buttress plating largely exchanges the wound complications associated with lateral plating for peroneal tendon complications. 
Certain configurations such as pronation abduction fractures result in regional comminution that prevent lag screw compression, and in this situation the comminuted segment has to be grafted or bridged (Figs. 59-11 and 59-22C). Graft augmentation was described by Limbird and Aaron 216 in 1987 who treated eight patients with graft and a one-third tubular plate bridging the comminuted region. In all cases anatomical reduction was achieved and there were no cases of infection or osteoarthritis. Extraperiosteal bridge plating allows indirect fracture reduction, secondary bone healing, and theoretically reduces the damage to the periosteal blood supply of comminuted fracture fragments. In a cohort of 31 patients treated with this technique Siegel and Tornetta332,333 reported good clinical and radiographic outcomes and no episodes of nonunion. The mortise must be reduced either fluoroscopically or under direct vision, and accurate restoration of length and alignment of the fibula may be challenging. 
Although locking plates have a superior in vitro load-to-failure in osteoporotic ankles,185,413 comparative clinical studies have not confirmed a definite advantage. Schepers et al.324 reported that the rate of wound complications following locked plating was 17.5% compared to 5.5% after conventional plating: The bulkier size and technical difficulty of locking plates may currently negate their biomechanical advantage. 
MIPO techniques may reduce damage to a vulnerable soft tissue envelope,197 a potential advantage in the ankle. Hess et al.151 reviewed their results in 20 patients with distal fibular fractures describing a small 2 to 3 cm wound distally and 3 to 4 cm wound proximally. They experienced no soft tissue complications but there were three cases of nonunion. Inevitably, they describe the technique as highly challenging. 
A variety of strategies have been described for reinforcing the fixation of ankle fractures, particularly in osteoporotic bone. Biomechanical studies have shown that lateral plate fixation can be augmented by passing one or more screws into the tibia93,286 and this tibio-pro-fibular technique is a particularly attractive option for patients with osteoporotic bone or peripheral neuropathy. Assal et al. described using a traditional lateral plating technique augmented by both polymethylmethacrylate cement injection into the proximal fragment screw holes and an intramedullary axial wire. In a cohort of elderly patients allowed early weight bearing they described no failures of fixation.19 Koval et al. described a similar technique of augmentation of lateral plating but with intramedullary Kirschner wires (K-wires). In clinical and biomechanical studies they reported good results with no failures of fixation in the 20 patients treated with this technique and a construct that had twice the resistance to torsional force of traditional constructs.194 

Operative Technique

The patient is placed supine with a bolster under the ipsilateral hip to allow the foot to lie vertically. A tourniquet is applied and, after exsanguination, inflated to 250 mm Hg. A radiolucent box or platform holding the injured ankle above the level of the other side is helpful, allowing lateral fluoroscopy without the need to move the limb. This also opens up a greater arc of movement for instruments. A simple radiolucent box in a Mayo stand cover is ideal. The lateral malleolus is addressed first through a longitudinal incision placed directly over the fibula and centered on the fracture. Blunt dissection is performed through subcutaneous fat to avoid damage to the superficial peroneal nerve. The fracture is identified and periosteum and ligamentous attachments are debrided back from the fracture edges by 1 to 2 mm: Just far enough to visualize the fracture clearly. The fracture itself is distracted gently to allow irrigation and curettage of clot and small bone fragments. Reduction is achieved and held by the application of a serrated “lobster claw” clamp. There are a number of maneuvers that may assist with this reduction. Firstly, a gentle torsional movement with the reduction clamp may be sufficient to walk the two fractured surfaces out to length and into place. If more force is necessary, distraction and inversion of the foot and ankle will assist in regaining fibular length. Finally, if required, a pointed reduction clamp can be applied to the metaphysis of the distal fragment in the AP plane, and used to apply direct longitudinal traction. The next stage is to place a lag screw across the fracture in an orientation as close to orthogonal as possible. The serrated clamp is not infrequently found to obstruct either the starting point or anticipated exit point of the drill and screw, and may first need to be replaced with a pointed reduction clamp in a slightly different orientation. The lag screw may be placed in either an AP or a posteroanterior direction. A 3.5-mm gliding hole is drilled first, and a 2.5-mm pilot hole is then drilled through a centering device, followed by countersinking, measuring, and screw placement. A one-third tubular plate is selected of sufficient length to allow the placement of three screws above and below the fracture. Often a seven-hole plate is needed to avoid conflict with the lag screw. The plate is precontoured and then applied to the bone with three bicortical screws in the proximal diaphysis, and three cancellous screws in the distal metaphysis. These distal screws are unicortical and extend to, but not through, the second (subarticular) cortex. Their pull-out strength can be improved by varying their orientation, typically in a triangular construct. Alternatively, the tip of the plate can be bent sharply to allow a long screw to be placed in a retrograde manner (Fig. 59-23). 
Figure 59-23
The technique of tension band wiring of the medial malleolus.
 
A: An SER 4 (AO/OTA B2.2) fracture in an 85-year-old woman with osteoporosis. The medial malleolar fragment is small and fragile. B: A long axial intramedullary screw has been placed in the distal fibula to provide stability. The distal end of the plate has been bent to facilitate the placement of this screw. The medial malleolus has been reduced and initially secured with two K-wires placed orthogonally across the fracture. A malleable tension band wire has been placed through the deltoid ligament immediately deep to the K-wires, with the aid of an intravenous cannula, and looped over a proximal screw and washer which was then tightened to bone. C: An AP follow-up radiograph at 3 months. Note how the fibular fixation was completed with a triangular construct of distal screws in the metaphysis to maximize pull-out strength. The construct has been strengthened further by passing one screw across the syndesmosis into the tibia. On the medial side the bone fragment was compressed with the TBW and the K-wires were then bent over and hammered into bone.
A: An SER 4 (AO/OTA B2.2) fracture in an 85-year-old woman with osteoporosis. The medial malleolar fragment is small and fragile. B: A long axial intramedullary screw has been placed in the distal fibula to provide stability. The distal end of the plate has been bent to facilitate the placement of this screw. The medial malleolus has been reduced and initially secured with two K-wires placed orthogonally across the fracture. A malleable tension band wire has been placed through the deltoid ligament immediately deep to the K-wires, with the aid of an intravenous cannula, and looped over a proximal screw and washer which was then tightened to bone. C: An AP follow-up radiograph at 3 months. Note how the fibular fixation was completed with a triangular construct of distal screws in the metaphysis to maximize pull-out strength. The construct has been strengthened further by passing one screw across the syndesmosis into the tibia. On the medial side the bone fragment was compressed with the TBW and the K-wires were then bent over and hammered into bone.
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Figure 59-23
The technique of tension band wiring of the medial malleolus.
A: An SER 4 (AO/OTA B2.2) fracture in an 85-year-old woman with osteoporosis. The medial malleolar fragment is small and fragile. B: A long axial intramedullary screw has been placed in the distal fibula to provide stability. The distal end of the plate has been bent to facilitate the placement of this screw. The medial malleolus has been reduced and initially secured with two K-wires placed orthogonally across the fracture. A malleable tension band wire has been placed through the deltoid ligament immediately deep to the K-wires, with the aid of an intravenous cannula, and looped over a proximal screw and washer which was then tightened to bone. C: An AP follow-up radiograph at 3 months. Note how the fibular fixation was completed with a triangular construct of distal screws in the metaphysis to maximize pull-out strength. The construct has been strengthened further by passing one screw across the syndesmosis into the tibia. On the medial side the bone fragment was compressed with the TBW and the K-wires were then bent over and hammered into bone.
A: An SER 4 (AO/OTA B2.2) fracture in an 85-year-old woman with osteoporosis. The medial malleolar fragment is small and fragile. B: A long axial intramedullary screw has been placed in the distal fibula to provide stability. The distal end of the plate has been bent to facilitate the placement of this screw. The medial malleolus has been reduced and initially secured with two K-wires placed orthogonally across the fracture. A malleable tension band wire has been placed through the deltoid ligament immediately deep to the K-wires, with the aid of an intravenous cannula, and looped over a proximal screw and washer which was then tightened to bone. C: An AP follow-up radiograph at 3 months. Note how the fibular fixation was completed with a triangular construct of distal screws in the metaphysis to maximize pull-out strength. The construct has been strengthened further by passing one screw across the syndesmosis into the tibia. On the medial side the bone fragment was compressed with the TBW and the K-wires were then bent over and hammered into bone.
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Intramedullary Nailing of Ankle Fractures

Intramedullary fixation offers a minimally invasive approach to the distal fibula with little palpable metalwork (Figs. 59-10 and 59-11). Initially popular intramedullary implants, such as Rush nails, were smooth devices with no fixation to bone and were predisposed to backing out, therefore not controlling fibular length or preventing talar shift.102,276,303 Despite this, Pritchett303 reported functional outcomes that were good or fair in 76% of a cohort of elderly patients with no complications, a better result than those treated with plates. Radiographic results were less satisfactory, however, with only 40% of cases showing good reduction on postoperative radiographs. 
To reduce the problems with backing out, Ray et al.310 used a threaded intramedullary screw and reported good results in patients with minimal fracture comminution. A similar technique was described by Lee et al.210 using a fully threaded, headless, cannulated screw with variable thread pitch, resulting in good radiographic and clinical results in 95.7% and 91.3% of cases respectively. 
Comparisons of intramedullary devices with lateral plating techniques have been encouraging. Lee et al.209 reviewed 47 patients with Gustilo type I or II open ankle fractures; half were treated with an intramedullary Knowles pin and the others with a conventional lateral plate based on surgeon choice. Both groups had similarly high rates of anatomical reduction of around 96% but there were significantly fewer soft tissue complications in the Knowles pin group. However, the device has a bulky extraosseous tip and a large number of patients in both groups required later removal of metalwork. Similar results were seen when the same comparison was undertaken in a cohort of elderly patients treated in the same manner.211 Additional work by Brown46 reported similarly good clinical and radiographic results but again 55% of patients described discomfort over the tip resulting in a 40% rate of removal of metalwork. Subsequent biomechanical studies have found no significant differences between this intramedullary device and conventional lag screw and lateral plate techniques.24 
The Inyo nail is conceptually unique: A tapered triflanged stainless steel nail which can be inserted into the distal fibula through either an open or a closed technique and then augmented with an interlocking nail to prevent migration. McLennan and Ungersma243,244 reported results in two separate cohorts of 75 patients, with a mean age of 40 years. Good radiographic results were obtained in 83% of patients with 88% of patients achieving good functional results. In comparison with conventional lateral plating they found patients reported less pain, quicker return to usual activities and decreased metalwork tenderness. There were significantly lower rates of osteoarthritis and metalwork removal in the patients treated with the Inyo nail than those treated with a plate. There have been no further reports of its use. 
The IP-XS nail is a device implanted after open reduction and secured with multiple K-wires. Gehr et al.123 reported the results of 194 ankle fractures treated with this nail finding good or excellent results in 92% at a mean follow-up of 15 months. There were however a number of soft tissue complications and no further studies have been reported. 
Percutaneously inserted fibula-specific nails offer further potential. Ramasamy308 reported his experiences with the Biomet fibular nail in a small cohort of eight osteopenic patients over the age of 50 years: Early functional outcomes were promising with 88% achieving excellent subjective scores. However, 25% of patients did have evidence of osteoarthritis on evaluation of radiographs after a mean of 26 months, and one mechanical failure occurred. Rajeev et al.307 also investigated the use of the Biomet fibular nail in 24 elderly, osteoporotic, predominantly female, patients. After a mean follow-up of 7 months they reported a mean Olerud and Mollander score of 57 and no postoperative complications. Both of these studies were limited by the inability to place a screw across the syndesmosis with this nail, resulting in some failure of fixation with lateral talar subluxation. 
The Acumed fibular nail does allow for the placement of a screw across the syndesmosis, controlling fibular length, angulation, and rotation. Appleton et al.16 described their results in patients with significant comorbidities that had sustained unstable ankle fractures. They obtained good clinical and radiographic results in their cohort of 37 patients with a mean Olerud and Mollander score of 87, and few complications. Younger364 has also reported good results with arthroscopy as an aid to reduction and Bugler et al.50 reported good clinical and radiographic outcomes in a larger cohort of 105 patients. White398 has recently presented the results of a randomized trial comparing this nail with standard plate fixation in patients aged over 65, and has shown good radiographic and functional results and a significant advantage in favor of the nail in terms of wound-related complications. 

Operative Technique

The technique of fibular intramedullary nailing is shown in Figure 59-24. The patient set-up is as for fibular plating but a tourniquet is required only if a subsequent open medial malleolar fracture fixation is contemplated. The ankle mortise is reduced with ligamentotaxis. A small cortical step of 2 to 3 mm at the fracture is acceptable provided the mortise reduction is anatomical. Modest angular and translational deformities can usually be reduced with the nail as described below. Very occasionally more substantial deformity may need to be addressed by placing a reduction clamp across the fracture via a minimal access incision. To place the nail, a 10-mm longitudinal incision is made beginning 10 mm distal to the tip of the fibula and proceeding distally. A 1.6-mm guidewire is delivered to the very tip of the fibula and driven into the center of the metaphysis of the distal fragment (Fig. 59-24A, B). Correct placement of the guidewire along the longitudinal axis of the distal fragment is critical, especially where there is residual angular displacement as this allows subsequent fracture realignment. In particular, a medial start point will tend to displace the lateral malleolus laterally resulting in talar subluxation. The cannulated drill is passed over the guidewire to prepare the distal segment, and then exchanged for a hand reamer to prepare the diaphyseal segment. The nail is then implanted in 20 degrees of external rotation (Fig. 59-24C). This is essential to allow later placement of the syndesmosis screw into the center of the tibia, if one is required (Fig. 59-24D). Using the jig, an AP distal locking screw is now predrilled and placed with the screw tip at, but not penetrating, the dorsal cortex. The jig can now be manipulated to finalize the reduction of the distal fragment. Most commonly light back-taps on the jig are required to regain normal fibular length, and occasionally additional internal rotation will complete the reduction. Finally, the lateral-to-medial screw is implanted to maintain fibular length and rotation, and to secure the crucial lateral buttress against talar subluxation (Fig. 59-24D). AP and lateral locking screws can then be inserted (Fig. 59-24E). This is best achieved by placed the lateral-to-medial screw across the syndesmosis. The wounds are closed with sutures or steristrips. The patient is allowed full weight bearing the following day. The syndesmosis screw does not usually require removal. 
Figure 59-24
The technique of fibular intramedullary nailing.
 
A, B: The guidewire is placed centrally within the metaphysis of the fibula. C: After preparing the intramedullary canal the nail is inserted. D: A syndesmosis screw can be inserted if required. E: AP and lateral locking screws can be inserted.
A, B: The guidewire is placed centrally within the metaphysis of the fibula. C: After preparing the intramedullary canal the nail is inserted. D: A syndesmosis screw can be inserted if required. E: AP and lateral locking screws can be inserted.
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Figure 59-24
The technique of fibular intramedullary nailing.
A, B: The guidewire is placed centrally within the metaphysis of the fibula. C: After preparing the intramedullary canal the nail is inserted. D: A syndesmosis screw can be inserted if required. E: AP and lateral locking screws can be inserted.
A, B: The guidewire is placed centrally within the metaphysis of the fibula. C: After preparing the intramedullary canal the nail is inserted. D: A syndesmosis screw can be inserted if required. E: AP and lateral locking screws can be inserted.
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Other Fixation Techniques for Ankle Fractures

In carefully selected younger patients with good bone stock and simple oblique fracture patterns, two to four lag screws can be used in isolation without a neutralization plate (Fig. 59-22D), thus minimizing potentially irritating metalwork: Good clinical outcomes have been reported by several authors.184,241,379 Inevitably, poor surgical execution will affect results, and peroneal tendon irritation from the tip of excessively long lag screws has been reported.132 More importantly, cautious patient selection is crucial and the specific patient and fracture types that are appropriate for this biomechanically less robust construct remain to be defined. 
An alternative technique of cerclage wiring with a syndesmotic staple involves a minimal degree of dissection and very little prominent metalwork, and was popularized by Cedell in the 1960s,56,55 with subsequent variations reported by other authors.7,23,278 It remains popular in Scandinavia although little recent work has been published. Olerud et al.276 reported the technique to be unsatisfactory in unstable fractures. Moreover the load-to-failure has been shown to be only 60% that of conventional plating.95 
Biodegradable implants may reduce late hardware-related problems. However, these devices are more challenging to use, producing less mechanical compression88 and a less stable construct compared with conventional screws.5 Although promising early outcomes have been reported with biodegradable intramedullary fixation,314 concerning rates of osteolysis, sterile wound sinuses, and malunion in 26% of cases, suggest that the early degradation of these implants remains problematic particularly with the use of polyglycolide implants.41,117 
A list of potential pitfalls encountered in the treatment of lateral malleolar fractures and their prevention is shown in Table 59-3
 
Table 59-3
Lateral Malleolar Fractures
View Large
Table 59-3
Lateral Malleolar Fractures
Potential Pitfalls and Preventions
Pitfall Preventions
Pitfall #1
Clinically there is a fracture but no abnormality is seen on radiographs Examine the deltoid ligament distal to the medial malleolus and the proximal fibula to exclude a Maisonneuve fracture
Pitfall #2
Is ankle joint unstable? Assess congruence of the mortise on initial and follow-up radiographs. If congruent use walking test and reassess
Pitfall #3
Bone very osteoporotic or comminuted, skin in poor condition or diabetic patient Consider IM fibular nail
Pitfall #4
Postoperative joint incongruent, abnormally wide medial clear space present Fibula malreduced. Check length and/or rotation. Revise surgery
Pitfall #5
Failure to reduce the syndesmosis Syndesmotic reduction is notoriously hard to assess without comparing postoperative axial images of both ankles. Closed reduction is more likely to be successful if the fibular fracture is reduced and the foot held in neutral, but an open reduction is more accurate
Pitfall #6
Distal screws penetrate talus Use unicortical cancellous screws distally
Pitfall #7
Painful hardware or peroneal tendon irritation Remove plate
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Medial Malleolar Fixation

A number of surgical techniques for fixation of the medial malleolus have been described. Selection depends upon the size and integrity of the fragment. Options include screw fixation (in a number of forms), tension band wiring, and plate fixation. The most commonly used technique is with unicortical lag screws (Fig. 59-11), augmented with washers where the fragment is comminuted or soft.261,358 Typically, two parallel 4-mm partially threaded cancellous screws are used, inserted perpendicular to the fracture line. Where the fragment is too small to accept two screws, one screw and a K-wire will afford some rotational stability. It remains unclear what the optimal screw length is but an overly long screw with threads in metaphyseal bone may have little grip.312 Avoidance of screw penetration of the joint is ensured on the AP fluoroscopy image which is collinear with the medial joint space (because of the frustral shape of the talus): An internally rotated mortise view will not demonstrate this clearly.126,128,315 Awareness of screw orientation in the sagital projection is also important: Femino et al.106 examined 10 cadaveric limbs and found that insertion of a screw in the posterior colliculus resulted in tendon abutment in all specimens and tendon damage in half. 
Unicortical screws have occasionally been observed to undergo pull-out failure in poor bone. Bicortical screws provide a significantly greater resistance to pull-out299 and maximum torque before screw stripping.312 These may either cross the lateral tibial cortex116,299 or the medial tibial cortex proximal to the fracture.202 Clinical results have been encouraging. A retrospective cohort study, using screw lengths of 60 to 105 mm, found a significantly lower rate of screw loosening in the patients with bicortical fixation and no episodes of metalwork removal or nonunion.312 Another retrospective cohort in patients over 55 years did, however, report a complication rate of 17% including nonunion, malunion and symptomatic metalwork.187 
Bioabsorbable polylactide screws have been used for fixation of medial malleolar fractures with comparable results to stainless steel screws. Bucholz et al. undertook a RCT comparing the two and found similar levels of complications and similar patient-reported outcomes. The rate of metalwork removal was higher in patients with stainless steel screws (18% vs. 4%) but there was one inflammatory reaction in the bioabsorbable screw group.49 
The concept of tension band wire (TBW) fixation of fractures was first described by Lord Lister in 1883. Tension band wiring of the medial malleolus can achieve good compression and security, particularly in the face of small fragments or fragile bone63,124 (Fig. 59-23). Biomechanical studies have shown TBW constructs to be stronger under tension than unicortical cancellous screws,116,171,281 and good long-term functional and radiolographic outcomes have been achieved with the technique.177,281 Ostrum281 reported on a cohort of 32 patients after a 1 year follow-up. There were no cases of nonunion and one case of malunion. The main limitation of this technique is symptomatic metalwork, with a reported rate of 7%.281 In an attempt to reduce this incidence a fiber wire suture has been reported as an alternative to the stainless steel wire commonly used, but does not appear to have the same biomechanical strength.116 
The medial malleolar component of SAD fractures typically comprises a vertical fracture line with a degree of plafond impaction. Fixation of this medial malleolar fragment requires control of the vertical shear forces acting on the fracture and a buttress plate over the apex of the medial malleolar fracture has typically been used (Fig. 59-10). Biomechanical studies, however, have suggested that the use of screws alone may be sufficient. Toolan et al.376 in a large cadaveric study found that lag screws placed perpendicular to the osteotomy (and parallel to the plafond) were significantly stronger than an antiglide plate. Dumigan et al.92 in their comparison using synthetic bones found that two 3.5-mm parallel fully threaded cortical screws placed 1 cm proximal and parallel to the tibial plafond resulted in the stiffest construct when a transverse load was applied, simulating loading in external rotation, although plate fixation with two screws both proximal and distal to the fracture site was found to be the stiffest construct under offset axial loading conditions. There are no clinical studies in the published literature comparing these constructs but McConnell and Tornetta have reported their outcomes with this injury mechanism. They report that 42% of their patients seen over a 5-year period with vertical shear medial malleolar fractures were found to have associated plafond impaction. The nine patients that they describe underwent fixation with screws (two cases) or antiglide plates (six cases) followed by immobilization non–weight-bearing for 8 to 10 weeks. After a mean of 2.4 years of follow-up good clinical and radiographic outcomes were achieved.237 
K-wire fixation alone of medial malleolar fractures has previously resulted in disappointing results potentially due to their inadequate biomechanical properties.281 An alternative is the use of threaded K-wires. Biomechanical testing has resulted in equivocal results with no difference in strength to cancellous screws with offset axial loading but with lower pull-out strength.316 Clinical results have been more encouraging; Koslowsky reported the results of 76 patients with medial malleolar fractures treated in this manner. There were no episodes of nonunion or construct failure and good functional outcomes. A large number of this cohort developed posttraumatic osteoarthritis but this may have been related to their other injuries.191 
An alternative technique that has been proposed for small fractures is the use of a contoured T-plate, able to provide rigid fixation to the small comminuted fracture fragments. A small case series of three patients found good radiologic outcomes11 and encouraging biomechanical results have been achieved by the same group.10 Loveday et al.221 report the use of a suture anchor in similar situations. 
In summary, medial malleolar fractures may be managed by any of a number of techniques all with acceptable published outcomes. Further work will help to refine the choice of operative intervention for particular injuries. 

Operative Technique

The patient is set up as described for fibular fixation. The medial malleolus is most commonly approached through a longitudinal incision placed directly over the malleolus. Where there is individual preference for a hockey-stick incision, this is generally convex anteriorly, beginning just anterior to the malleolus. The skin is incised and then blunt dissection is performed down to bone in order not to injure the great saphenous vein and nerve. The fracture is usually transverse in orientation, and should be distracted with an instrument to allow removal of bone debris, and inspection of the talus. A flap of periosteum from the proximal tibial fragment is commonly found to have been pulled into the fracture and this requires to be extracted. A temporary fixation of the fracture is performed using a small reduction clamp, and a small drill hole is placed just proximal to the fracture to allow seating of one of the points of the clamp. The other point is placed at the tip of the malleolar fragment. The fracture is reduced by a combination of progressive compression with the reduction clamp with one hand, and manual correction of translation with the other. Placing the index finger over the anterior corner of the fragment and pushing posteriorly and laterally, so that the anterior surface is flush, is usually sufficient to obtain anatomical reduction, which is then confirmed fluoroscopically. Definitive fixation is with two parallel 4-mm cancellous screws, with washers in osteoporotic bone. The screws cross the fracture orthogonally and are typically 35 mm long—longer screws do not have a longer thread and there is no advantage in placing the thread further from the relatively dense subchondral bone. Where the fragment is too small, comminuted, or fragile to accept two lag screws, one screw and a threaded wire may be sufficient, but the author’s preference in this situation is to use a TBW. 
The set-up, approach, and fracture reduction for a TBW are as above. Two parallel 1.6-mm K-wires are driven orthogonally across the fracture and into the distal tibia to a depth of approximately 30 mm (Fig. 59-23). A 30-mm small fragment cortical screw with a washer is placed approximately 20 mm proximal to the fracture. The screw is orientated orthogonal to the surface of the tibia in the coronal plane, and so lies obliquely in the metaphysis. A 1.2-mm flexible wire is placed around the K-wires and screw in a figure-of-eight. To maximize compression and minimize progressive loosening during recovery it is important to place this wire against the bone of the distal fragment (rather than placing it superficial to the deltoid ligament) and this is achieved by first passing a 14-guage intravenous cannula through the deltoid ligament so that it lies tightly in the “axilla” formed between the cortex of the fragment and the K-wires. The wire is then placed into the cannula opening and pushed through the ligament using the cannula as a guide. The K-wires are then cut and bent through 180 degrees and are impacted over the flexible wire. Again, the metalwork should lie against the bone, and a longitudinal incision in the deltoid ligament will help the wire to pass through the ligament to bone. 
A list of potential pitfalls encountered in the treatment of medial malleolar fractures and their prevention is shown in Table 59-4
 
Table 59-4
Medial Malleolar Fractures
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Table 59-4
Medial Malleolar Fractures
Potential Pitfalls and Preventions
Pitfall Preventions
Pitfall #1
Very small or osteoporotic fragment Use K-wires and tension band wiring technique
Pitfall #2
Supination adduction injury. Vertical fracture line Correct any plafond impaction and then use antiglide plate or two cancellous screws placed parallel to joint
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Posterior Malleolar Fixation

Reduction of posterior malleolar fractures (Fig. 59-25), as in other intra-articular fractures, must be anatomical as nonanatomically fixed posterior malleolar fractures have been shown to have a higher rate of osteoarthritis.168 Fixation options include open (Fig 59-17) or percutaneous (Fig. 59-25) reduction with screw fixation, in either an AP or posteroanterior direction, or posterior buttress plate fixation. Little comparative clinical or biomechanical evidence is available but good results have been obtained with both techniques.1,39,114,362,380 Postoperatively, patients may be permitted to weight bear. In a small clinical study Papachristou290 reported good functional outcomes following early weight bearing in a cast during the postoperative period. 

Operative Technique

The operative technique is illustrated in Figure 59-25. We advise surgery where the plain lateral radiograph suggests the fragment involves greater than 25% of the articular surface. CT scanning is not routinely performed. Surgery is performed under general anesthesia in the supine position with a tourniquet. Although several authors emphasize that posterior malleolar reduction is made easier by fixing the fibula first, we have found that the lateral plate often obscures fluoroscopic assessment of the reduction of the posterior malleolus and prefer to deal with this first. The posterior malleolus can often be reduced simply by placing the heel on a radiolucent box and dorsiflexing the foot. If this fails, a small incision is made superomedially and after careful blunt dissection, a periosteal elevator is inserted, placed on the posterior surface of the tibia, and used to push the fracture apex distally into a reduced position (Fig. 59-25). The reduction is then held and carefully assessed fluoroscopically in both AP and lateral planes: The lateral view may not reveal a rotational malreduction that is visible in the AP projection. Fixation is with two anterior-to-posterior, percutaneously inserted, partially threaded 4-mm cancellous screws, placed just above the articular surface. Only rarely is an open reduction performed in this setting, but if required the patient is placed prone and the posterolateral interval is used to expose and fix the posterior malleolus with a buttress plate. The fibula is fixed through the same incision with a posterior plate. 

Surgical Stabilization of the Syndesmosis

Syndesmotic stabilization can be achieved with the use of screws, suture techniques, staples,234 and bolt fixation.86 Screw fixation is most widely practiced, with 51% of orthopedic surgeons using 3.5-mm screws, penetrating four cortices (67%) with equal numbers of surgeons preferring one or two screws (44% each).27 Fourteen percent of surgeons are reported to use a suture routinely.27 
Biomechanical testing has reported conflicting results. Xenos406 found that two screws conferred significantly greater strength to the syndesmosis than one, whereas Thompson et al.365 found no significant difference when comparing syndesmotic fixation with a 3.5-mm screw to a 4.5-mm screw. Hansen et al.133 found 4.5-mm screws were able to withstand shear stress better than 3.5-mm screws. Biomechanical testing has not demonstrated a difference between the use of screws spanning either three or four cortices in strength32 or range of movement following fixation.273 
Clinical studies have also not demonstrated the superiority of any particular technique. Wikerøy et al.399 found no difference in functional results at 8 years between those fixed with one screw spanning four cortices or two tricortical screws. Høiness et al.,156 although reporting significantly better short-term functional outcomes in those with two 3.5-mm tricortical screws in comparison to those with one 4.5-mm screw spanning four cortices, reported that by 1 year there was no significant difference between groups. Interestingly Moore et al.257 found good outcomes with fixation spanning either three or four cortices but reported a higher rate of recurrence of the diastasis when weight-bearing instructions were ignored by patients with three cortex only fixation. Finally four-cortex fixation exposes the patient to an additional risk of complications with case reports of posterior tibial tendon tear caused by damage from the tip of the screw.203 Pragmatically, small fragment screws have a smaller head that is less likely to cause irritation later, whilst if elective removal is anticipated, the larger head of the standard fragment screw will be easier to locate, particularly if the procedure is performed under local anesthesia in the outpatient setting. 
The position of the screw has also been a matter of debate; McBryde et al.235 found that a screw placed 2 cm proximal to the ankle affords more stability than a more proximal screw whilst Kukreti et al.201 found no difference in functional outcomes in patients with screws placed at or just proximal to the syndesmosis. 
The use of bioabsorbable screws across the syndesmosis has been reported with good functional and radiographic results.8,161,180,336,371 A cadaveric biomechanical study found a 5-mm bioabsorbable screw to have equal strength to a 5-mm stainless steel screw.77 Of note, none of the clinical studies report osteolysis or foreign body reaction although irritation due to incompletely absorbed screw heads has been reported.8,180 
An alternative option for syndesmotic fixation is the use of a suture or wire construct held in place by cortical metal buttons. Early reports of the use of this method found good clinical results but lower pull-out strength on biomechanical testing.328 Some investigators have reported equal biomechanical properties with sutures or screws on application of an external rotation force372 whilst others have reported significantly increased syndesmosis widening on external rotation with the suture compared to a screw.115 The semirigid nature of this device may more closely approximate the uninjured syndesmosis: Some biomechanical reports suggest movement at the syndesmosis during cyclical loading is similar to that seen in intact syndesmoses,188,363 although other investigators have reported nonphysiologic movement at the syndesmosis with both screws and suture constructs.338 A number of small studies have looked at the use of a commercially available device, the “Ankle TightRope,” with generally good results. Small cohort studies with follow-up of up to 2 years have reported good functional and radiologic results that are equivalent to, or in some cases better than, equivalent cohorts treated with screws.72,84,264,305 The major complications with the device have been related to the suture knot, problems with inflammation,400 irritation,305 osteolysis,84 sinus formation,264 and fracture through the suture tract.153 
Given the difficulty in identifying syndesmotic anatomy with two-dimensional fluoroscopy, it is not surprising that closed reduction results in a malreduction in around half of cases.293 Open reduction allows a more predictable result, although the rate of malreduction remains surprisingly high at around 15%.250,319 
The position of the foot whilst the syndesmosis screw is inserted has been the subject of controversy. It was initially suggested that because of the shape of the talus, and to prevent overtightening of the screw and subsequent stiffness of the ankle, that the screw should be inserted with the ankle in dorsiflexion. Olerud275 reported that for each 10-degree increase in plantarflexion during insertion, a 1-degree residual deficit in dorsiflexion would result. However, an important cadaveric study has refuted this notion, finding no reduction in range of movement even when a syndesmosis screw was inserted in maximum plantarflexion.381 
Following fixation there has long been a tradition of removal of screws that cross the syndesmosis42,64 due to concerns regarding a return to normal movement267 and the inherent risk of screw fracture with this movement. Current practice amongst orthopedic surgeons appears to be for routine screw removal with 65% of surgeons reporting this to be their practice.27 However, the evidence for this is limited with only one small cohort study reporting improvements in functional scores following screw removal.252 In contrast a large number of studies have found the reverse. Many authors have found no difference in range of movement158 or functional outcomes30,85,98,162 between those with intact, removed or broken screws, whilst others have reported better outcomes in those with fractured131 or loose screws in comparison to those with intact syndesmosis screws.231 Moreover, removal of syndesmosis screws places the patient at risk of complications. In a cohort of 76 patients Schepers et al.325 reported an infection rate of 9.2%, a recurrence of the diastasis in 6.6% of patients with screw removal at a mean of around 3 months postoperatively and an overall complication rate of 22.4%. Others have confirmed this loss of reduction particularly when performed before 3 months postinjury139 although this has not always been found to result in an unstable ankle mortise175 or affect functional outcomes.162 A rare complication of tibial fracture following syndesmosis screw removal has also been reported.61 
The other important decision is whether to allow patients to weight bear in the initial postoperative phase. Photodynamic studies have shown significant alterations in force distribution in the tibia and fibula after syndesmotic disruption which persists after screw fixation and in cadaveric studies application of axial force resulted in recurrence of the diastasis.344 However, in a clinical study Hooper158 described good outcomes with early weight bearing describing only loosening of the syndesmosis screw that did not appear to affect functional outcome. 
In summary, current evidence for the diagnosis of syndesmosis injuries, selection of patients for surgery, and both operative and postoperative management encompasses a wide range of conflicting results and opinion with few areas that do not require further investigation. 

Operative Technique

The operative technique is shown in Figure 59-20. Occasionally the syndesmosis can be reduced closed and screws placed percutaneously with a high degree of confidence in the reduction. Our preference, however, is to perform an open reduction. The patient is placed supine as described for fibular fixation. Using the image intensifier, the distal tibiofibular joint is identified and a 2.5-cm longitudinal incision is placed directly over it. The skin is incised and blunt dissection is performed down to the retinaculum which is then incised longitudinally in line with the skin incision. The displaced joint is usually identified easily after clearance of hematoma. The joint margins of the distal tibiofibular joint are cleared to allow assessment of reduction, and the lateral aspect of the talar dome is visualized and inspected. The reduction itself is most conveniently performed by placing a heavy 2-mm K-wire percutaneously into the distal fragment to act as a joystick. This allows the distal fragment to be brought out to length, and rotated anteriorly into the incisura fibularis. The foot is held in a neutral position to confirm reduction and during fixation. The reduction is confirmed visually by the presence of a congruent “Mercedes-Benz”–shaped articular margin between the tibia above, the talus medially and the fibula laterally (Fig. 59-20). Temporary stabilization is performed with a large periarticular reduction clamp, and checked fluoroscopically. Definitive fixation is performed percutaneously with a single small fragment position screw through three cortices and just reaching, but not penetrating, the medial tibial cortex. The patient is instructed to remain non–weight-bearing for 8 weeks and then enters unrestricted progressive physiotherapy. The screw is not removed routinely. 
An algorithm for the treatment of surgically managed ankle fractures is shown in Figure 59-26
Figure 59-26
An algorithm of the suggested management of surgically treated ankle fractures.
Rockwood-ch059-image026.png
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Perioperative Management Considerations for Ankle Fractures

Timing of Surgery

Many authors have recommended delaying surgery until any traumatic edema has settled to avoid soft tissue complications, particularly in patients with fracture blisters353 (Fig. 59-27), although direct evidence for this is lacking.190 On the contrary, Høiness et al.155 have reported increased rates of wound infection and longer hospital stay in patients undergoing late fixation when compared with patients undergoing early operation, a finding confirmed by others,43,54 and Mont et al.255 reported that a delay in surgery was a predictor of significantly poorer clinical outcomes. Furthermore Fogel et al.112 found increased difficulty in achieving an anatomical reduction and James et al.165 found increased costs in patients treated with delayed fixation. If edema is a concern then methods to reduce the edema preoperatively have been proposed. Thordarson et al.,369 in a RCT, found a significant reduction in ankle edema when patients were managed with the use of a pneumatic pedal compression device in addition to the usual ice, elevation and immobilization a finding confirmed by Stöckle.350 Mora et al.,258 in another RCT found that a combined compression and cryotherapy device resulted in significant reduction in preoperative ankle swelling. 
Figure 59-27
 
A, B: Hemorrhagic fracture blisters are unusual after a simple ankle fracture but represent a breach in the dermis. Consideration should be given to decompression of these blisters and allowing the region to re-epithelialize over a period of around 10 days (C, D) before undertaking open reduction and internal fixation. In contrast, nonhemorrhagic blisters represent a shear injury with an intact dermis and are generally considered safe to operate through.
A, B: Hemorrhagic fracture blisters are unusual after a simple ankle fracture but represent a breach in the dermis. Consideration should be given to decompression of these blisters and allowing the region to re-epithelialize over a period of around 10 days (C, D) before undertaking open reduction and internal fixation. In contrast, nonhemorrhagic blisters represent a shear injury with an intact dermis and are generally considered safe to operate through.
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Figure 59-27
A, B: Hemorrhagic fracture blisters are unusual after a simple ankle fracture but represent a breach in the dermis. Consideration should be given to decompression of these blisters and allowing the region to re-epithelialize over a period of around 10 days (C, D) before undertaking open reduction and internal fixation. In contrast, nonhemorrhagic blisters represent a shear injury with an intact dermis and are generally considered safe to operate through.
A, B: Hemorrhagic fracture blisters are unusual after a simple ankle fracture but represent a breach in the dermis. Consideration should be given to decompression of these blisters and allowing the region to re-epithelialize over a period of around 10 days (C, D) before undertaking open reduction and internal fixation. In contrast, nonhemorrhagic blisters represent a shear injury with an intact dermis and are generally considered safe to operate through.
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The use of a fibular nail (Fig. 59-24) may obviate many of these concerns by allowing percutaneous fracture fixation. Alternatively, in very low-demand patients with very compromised soft tissues, the use of a retrograde calcaneotalotibial nail (Fig. 59-28) may provide immediate stability without the need for fracture exposure.399 
Figure 59-28
 
A: The appearance of the soft tissues after an ankle fracture in an 84-year-old woman with dementia and very low functional demands. B: A retrograde calcaneotalotibial nail has been used to stabilize the fracture. C: Stab incisions were used to insert the nail and locking screws.
A: The appearance of the soft tissues after an ankle fracture in an 84-year-old woman with dementia and very low functional demands. B: A retrograde calcaneotalotibial nail has been used to stabilize the fracture. C: Stab incisions were used to insert the nail and locking screws.
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Figure 59-28
A: The appearance of the soft tissues after an ankle fracture in an 84-year-old woman with dementia and very low functional demands. B: A retrograde calcaneotalotibial nail has been used to stabilize the fracture. C: Stab incisions were used to insert the nail and locking screws.
A: The appearance of the soft tissues after an ankle fracture in an 84-year-old woman with dementia and very low functional demands. B: A retrograde calcaneotalotibial nail has been used to stabilize the fracture. C: Stab incisions were used to insert the nail and locking screws.
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Tourniquet Use

Tourniquets allow a bloodless surgical field, however a number of studies have described the potential disadvantages to their use. Konrad et al.189 conducted a RCT comparing those operated on with and without the use of a tourniquet and reported a better range of motion and reduced postoperative pain and swelling in the patients treated without. Maffulli et al.225 in another RCT found a significantly lower rate of wound complications and a more rapid return to work in patients managed without the use of a tourniquet although operating time was significantly longer. 

Thromboprophylaxis

Lower limb trauma and joint immobilization are both known to predispose to venous thromboembolism130 (VTE). Conservatively treated ankle fractures appear to be at low risk, although emotive case reports tend to raise awareness of this rare problem.58 Patil et al.292 found no symptomatic DVTs or pulmonary emboli (PEs) in 100 consecutive patients with stable fractures, and only a 5% rate of asymptomatic DVTs on duplex ultrasonography when patients were reviewed after 6 weeks of cast immobilization, and concluded that this rate does not justify chemical thromboprophylaxis which carries significant inherent risks and difficulties of its own.262 
Following operative fixation of ankle fractures, rates of symptomatic DVT of between 0.05%340 and 0.12%166 have been reported, with an associated risk of PE of between 0.17%166 and 0.34%.340 With these low rates of venous thromboembolic complications it is difficult to provide a strong argument for universal chemical thromboprophylaxis in this patient group. Moreover, the efficacy of prophylaxis has not been demonstrated: An RCT of prolonged dalteparin or placebo has found no significant difference in rates of DVT in patients following operatively treated ankle fractures.207 Nonetheless, most national guidelines do recommend that patients with operatively treated ankle fractures are managed with chemical thromboprophylaxis.103,268 
Certain risk factors have been found to correlate with higher incidences of VTE in patients with ankle fractures. Multiple comorbidities,166,340 obesity,330 open fractures,340 associated injuries (higher ISS)330 and age over 50166,330,340 have all been reported to be associated with increased incidence. The benefits of chemical thromboprophylaxis in these groups of patients may be greater. However, Hansen et al.134 found that despite low molecular weight heparin prophylaxis these patients remained at high risk of developing VTE. 

Postoperative Management of Ankle Fractures

Immobilization

A number of different methods of immobilization have been investigated including soft bandaging, functional bracing and casting, whilst the time to initiation of weight bearing and active movements has also been debated. Conclusive evidence of the benefits of one form of immobilization over any other is lacking. Whilst some comparisons of functional bracing and cast immobilization favour functional bracing,97 others have reported marginally better results with cast immobilization, citing concerns regarding wound problems with functional bracing.213 Other authors have simply found no major differences.60 Critics of cast immobilization have reported a significant loss of bone mineral mass following lower limb cast immobilization in previously fit adolescents57 and significant muscle atrophy on MRI.304 comparisons of soft bandaging with casting have been similarly equivocal. Søndenaa et al.339 found a better range of movement in patients managed without immobilization at 6 weeks but no significant differences thereafter, a finding echoed by Finsen109 and Tropp.384 
Weight bearing in plaster following ankle fracture fixation for most patients has long been shown to be safe with no increase in major complications,3,2,51,109,135,386 indeed the Cochrane database identifies this fact as one of the few areas of surgical treatment that has been well investigated. Weight bearing in an orthosis (thus allowing for early active movement) also appears safe.4,60,147,334,384 There are no studies considering outcomes following weight bearing without immobilization, presumably because this would represent a practical difficulty for most patients. Studies reporting good outcomes with patients managed with early weight bearing have often excluded certain patient groups, particularly patients unable to comply fully with guidance3,4,6,386 and those with potentially unstable fixation109,386 and as a result extrapolation of this evidence to all patients with ankle fractures may not be justified. Patients with dementia, neuropathy, IV drug abuse and excessive alcohol consumption may not be suitable for early weight bearing. There is some evidence suggesting that following fixation of the syndesmosis patients are best managed with a period of non–weight-bearing mobilization (see above). 
Early active movement of the ankle appears to be safe although once again no significant long-term benefits have been shown over a period of immobilization.4,89,97,109,147,339 Following immobilization no convincing benefits of manual therapy,217 passive stretching or a specific training plan272 as part of a program of physiotherapy has been demonstrated. 

Driving

Patients should be warned of the risks of driving after ankle fracture, particularly after right-sided injury. Waton et al. investigated patients immobilized following ankle fracture in a driving simulator. They found that whilst immobilized in a cast or functional brace there is a significant increase in total brake reaction time.277 Even healthy volunteers immobilized in a cast or functional brace have been shown to have increased braking distances.383,392 Patients should therefore be strongly encouraged not to drive during their period of immobilization. Despite this, a small minority of patients admit to driving whilst immobilized in a below-knee cast.183 
After release from immobilization patients still have an increased total braking and travel time compared to normal controls, but by 9 weeks postoperatively this impairment appears to have resolved.99 Therefore it appears that at 3 weeks after removal of their cast patients can safely resume driving. Under United Kingdom law this is a matter for the patient and patients should be encouraged to assess their own “fitness to drive.”388 
Authors preferred treatment: Although return to driving is largely a matter between the patient and their insurer, we advise patients that a pragmatic guide to the return of adequate neuromuscular control to brake safely is the ability to descend stairs in a reciprocal manner with one foot on each step. 

Complicated Patient Groups

There are a number of patient groups who need to be considered separately because of the potential complications inherent in the treatment of ankle fractures. They are listed in Table 59-5 which also lists the particular complications that may occur in these groups. 
 
Table 59-5
Risk Factors After Ankle Fracture
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Table 59-5
Risk Factors After Ankle Fracture
Diabetes
  •  
    Requires perioperative management with close glucose monitoring
  •  
    Wound dehiscence/infection in up to 32%111
  •  
    Charcot neurarthropathy—increases risk of construct failure during fracture healing: Consider an extended period (8–10 wks) of protected weight bearing71
Obesity Increases risk of fixation failure by up to three times40
Smoking Increases risk of deep infection by six times266
Stopping smoking after ankle fracture reduces this risk265
Alcohol Wound dehiscence/infection four times higher in alcohol abusers375
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Diabetics

A number of the long-term complications of diabetes may impact upon ankle fracture management including impaired wound and fracture healing and peripheral neuropathy. Because of the incidence of diabetes within most developed populations, a significant body of work has been undertaken on the impact of diabetes on ankle fracture management and outcomes. 
Some surgeons have reported extremely high rates of complications in diabetics who sustain ankle fractures. McCormack and Leith238 reported a 42% complication rate in their diabetic patients in comparison to no complications in their controls; they also reported a 10.5% rate of death amongst the operatively treated diabetics. Blotter et al.37 reported an overall complication rate of 43% amongst operatively treated diabetic patients in comparison to 15% in controls and Flynn111 reported a significantly higher infection rate in diabetic patients (32%) than controls (8%) with even higher rates in the cohort of patients that were noncompliant with diabetic management. Extremely high levels of infection have been seen in open ankle fractures with White et al.397 reporting a 64% rate of wound infection and a 42% rate of amputation. This can have a significant impact on the costs associated with the care of diabetic patients with ankle fractures with Ganesh et al.118 estimating a $2000 excess per patient. As would be expected, patient-reported outcomes are significantly poorer in diabetics.100 
Well-controlled, uncomplicated diabetics may have a better outcome: Larger studies have found no significant difference in infection rates when all diabetics are considered together, whereas subgroup analysis of patients with the complications of diabetes has revealed a significantly higher rate of complications after ankle fracture.173,405 The major risk factor seems to be neuroathropathy, which is perhaps not surprising given the importance of neuromuscular control of ankle stability.246 Costigan et al.71 reported a rate of complications of 14% in their cohort of operatively treated diabetic patients, again finding significantly higher rates in patients with associated peripheral neuropathy and vascular disease; interestingly no difference was found between insulin dependent and non-insulin dependent diabetics. 
Diabetics are also at risk of failure of fixation in the postoperative period as a result of reduced proprioceptive joint control (Charcot neuroathropathy). Patients may not be inhibited sufficiently by pain, and neuromuscular control of joint stability may be impaired resulting in greater forces being transferred to the fracture fixation leading to mechanical failure. This neuroarthropathy is common in diabetics69,200,357,366 and frequently the diagnosis is only made postoperatively.173 Patients presenting late with ankle fractures have a higher rate of Charcot changes (64%) than those presenting early (22%).157 
Empirically most authors recommend that patients with diabetic complications should be managed with prolonged periods of immobilization non–weight-bearing, of up to 8 weeks.71 Augmentation of fixation with Steinmann pins across the subtalar and ankle joints has also been suggested.167,172 There are however no comparative studies of fixation options and postoperative protocols. 

Obesity

The impact of obesity on outcome after ankle fracture is controversial. Some have found no difference in complication rates or patient-reported outcomes in obese patients in comparison to controls,352 whilst others have reported significant differences. Bostman et al.40 reported that 5.6% of obese patients experienced failure of fixation in comparison to 1.8% of nonobese patients and recommended a prolonged period of time non–weight-bearing to reduce these risks. 

Elderly

Elderly patients, in particular elderly women, make up a large proportion of patients presenting with ankle fractures. The optimum management of ankle fractures in elderly patients has been extensively debated in the literature and there remains a large variation in rates of operative fixation of ankle fractures in elderly patients across the United States193 with increasing age associated with significantly lower rates of operative intervention. 
Early reports of poor outcomes of operative treatment in elderly patients28,320 with high rates of complications particularly in postmenopausal women due to poor bone quality, may have discouraged operative intervention in elderly patients. However a number of studies since have shown that elderly patients with unstable fractures can be successfully treated with operative fixation9,12,195,404 with reports of comparable outcomes13,82 and rates of complications54,282 to younger patients. Indeed an RCT of patients over 55 with unstable ankle fractures found better subjective and objective outcomes in operatively managed patients.228 
A number of authors have investigated the optimum management of ankle fractures in the super elderly. Fong et al.113 experienced significant complications in their cohort of 17 patients over the age of 80 leading them to conclude that compliance with postoperative instructions may be the most challenging factor when dealing with this group of patients, whilst Shivarathre et al.331 reported good outcomes in their cohort. No prospective comparative studies have been undertaken. In frail patients with compromised soft tissues percutaneous methods may be more appropriate: Good clinical outcomes have been reported with use of fibular246 and calcaneotalotibial nails214 (Fig. 59-28). 

Smoking and Alcohol

Patients who smoke have a significantly higher rate of complications, particularly deep wound infections,266 and significantly worse long-term outcomes.36 However, smoking cessation after fracture is beneficial in reducing complication rates.265 
Those who drink alcohol to excess also appear to be at higher risk of complications. Tonnesen et al.375 compared 90 patients who drank to excess with 90 controls all presenting with unstable ankle fractures. Following fixation the alcoholic patients had a far higher rate of complications (33% to 9%) including wound infection (15% to 4%) and a significantly longer hospital stay. Kankare et al. attempted to compare biodegradable internal fixation with metallic fixation in an RCT in alcoholic patients, however, significantly higher rates of failure of fixation in the biodegradable group resulted in early cessation of the study. They report that noncompliance and loss to follow up were a major problem in studying this group of patients.178 

Management of Expected Adverse Outcomes and Unexpected Complications in Ankle Fractures

The complications associated with ankle fractures and their treatment are listed in Table 59-6. Most patients have good outcomes following ankle fracture but there are a range of potential complications. Assessment of the frequency at which these occur depends on the patient and injury groups evaluated. Whilst rates of wound infection of up to 32%111 have been reported in diabetic patients and high rates of fixation failure reported in elderly patients,28 for most patients recovery will be completed without complication. 
 
Table 59-6
Complications Following Ankle Fractures
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Table 59-6
Complications Following Ankle Fractures
Early
Wound infection/dehiscence 1–10% Superficial infections can often be treated with antibiotics and dressings. Deep infections may respond to suppression antibiotics until the fracture has united but then usually require surgery to debride the wound and obtain bacteriologic specimens. Exposed hardware may require removal and the use of a spanning external fixator until the infection is eradicated
Loss of reduction 0–2%. This is most common in conservatively treated, unstable fractures. In surgically treated fractures this may be related to inadequate initial reduction, inadequate fixation, poor bone stock, peripheral neuropathy or psychiatric illness. Malunion increases the risk of osteoarthritis
Thromboembolism DVT 3%, PE 0.3%. Chemoprophylaxis is of uncertain efficacy
Late
Symptomatic hardware Varies depending on the type and location of the fixation device. Removal is effective in 50%
Osteoarthritis Rare in low-energy fractures but up to 30% of unstable patterns. May take several decades to become evident. Higher when anatomical reduction of the mortise is not achieved, other cases probably related to chondral injury at time of injury. May require functional bracing or an arthrodesis
Nonunion Most commonly encountered after nonoperative treatment. Often asymptomatic, but if painful may require (revision) fixation and possibly bone grafting
Compartment syndrome Rare, associated with high-energy fractures
Neuroma The superficial peroneal, sural, and saphenous nerves are all at risk in the subcutaneous layer and injury may result in a patch of anesthetic, or worse, dysesthetic skin
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Osteoarthritis of the ankle is most commonly caused by trauma with 39% of cases in a recent series found to be secondary to ankle fracture.385 AO/OTA type C fracture patterns, high BMI, dislocation, and increased age are risk factors for the development of osteoarthritis.222 Assessing those at risk is a major challenge as osteoarthritis may occur even following perfect reduction, presumably because of cartilage damage at the time of injury.76 
An interesting study by Stufkens et al. found that cartilage damage was a predictor of posttraumatic osteoarthritis at a mean of almost 13 years follow-up. No correlation was found between the number of lesions and the outcome but worse outcomes were found with deeper lesions and those on the anterior or lateral talus or the medial malleolus.355 A further investigation of the articular cartilage assessment using arthroscopy found the most common site of damage to be the talus followed by the distal tibia and fibula and finally the medial malleolus.152 Further long-term outcome studies may be necessary particularly as we now know that osteoarthritis following ankle fracture may take a number of years to become apparent, with Horisberger finding a mean time from ankle fracture to end-stage osteoarthritis of 21 years.385 
As might be expected, postoperative complications have been shown to result in significantly worse patient-reported outcomes. Høiness et al.154 found a significant difference in patient-reported outcomes when those with minor, major and no postoperative complications were compared. Interestingly, Horisberger160 was also able to demonstrate a correlation between complications and development of osteoarthritis. 
Less common complications include CRPS,76 compartment syndrome,18,297,412 and pulmonary embolism.58,390 Whilst these are significant complications, their rarity is highlighted by the small number of case reports. The most common complications of wound infection, symptomatic metalwork, and failure of fixation remain the biggest challenges in the management of ankle fractures. Removal of metalwork results in an improvement in patient-reported outcomes in only 50% of patients.47 

Outcomes of Ankle Fractures

A number of factors have been shown to affect outcome following ankle fracture, many of which have been already discussed. Poorer outcomes and increased rates of complications have been reported in patients presenting with fracture dislocations in comparison to those without,21,54,59,181,85 in those with fractures involving the medial malleolus in comparison to those with medial ligamentous injuries,59,356,361 and in older, female and diabetic patients.100 A small study looking to correlate patient-related outcomes with surgeon’s perceptions of positive results found good correlation.108 
Sport is the third most common cause of ankle fractures75 and hence return to sport is a frequent concern of patients. Porter et al. assessed the outcomes in 27 operatively treated patients who sustained their fracture whilst playing sport. At a mean of 2.4 years postinjury all athletes except one had returned to their previous level of competition.301 In contrast, Shah et al.329 found that only 62% of their patients had returned to their prior level of sporting activity 5 years after injury. Moreover, Colvin et al.67 reviewed patients who reported that they had participated in sport prior to their injury (but who were not necessarily playing sport at the time of injury) and found that by 1 year only 24.5% of patients had returned to full sporting activity. These different results may relate to the different demographics of the cohorts: 70% of Porter’s patients were male and had a mean age of 18 years, whereas Colvin’s group were 55% male and had a mean age of 43 years. 
In summary, most patients do well following an ankle fracture. Eighty-eight percent are pain free or have only mild pain at 1 year, and 90% have no restrictions or only mild recreational limitations. A substantial improvement is generally seen between 6 months and 1 year after injury.100 

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