ANKLE FRACTURES
Classifications
1. Lauge-Hansen
Cadaveric study which relates the fracture pattern to an injury
mechanism
The first word in the designation refers to the foot’s position at the
time of injury; the second word refers to the direction of the
deforming force.
‘‘eversion’’ is a misnomer; it more correctly should be ‘‘external’’ or ‘‘lateral’’
rotation
Type of injury (foot Pathology
position/direction of force)
Supination/adduction Transverse # of fibula/tear of collateral
ligaments ± vertical # medial malleolus
Supination/eversion (external 1.Disruption of the anterior tibiofibular
rotation) ligament
2.Spiral oblique fracture of the distal
fibula
3.Disruption of the posterior tibiofibular
ligament or fracture of the posterior
malleolus
4.Fracture of the medial malleolus or
rupture of the deltoid ligament
Pronation/abduction 1.Transverse fracture of the medial
malleolus or rupture of the deltoid
ligament
2.Rupture of the syndesmotic ligaments
or avulsion fracture of their insertion(s)
3.Short, horizontal, oblique fracture of
the fibula above the level of the joint
Pronation/eversion 1.Transverse fracture of the medial
malleolus or disruption of the deltoid
ligament
2.Disruption of the anterior tibiofibular
ligament
3.Short oblique fracture of the fibula
above the level of the joint
4.Rupture of posterior tibiofibular
ligament or avulsion fracture of the
posterolateral tibia
Pronation/Dorsiflexion (Pilon) 1.Fracture of the medial malleolus
2.Fracture of the anterior margin of the
tibia
3.Supramalleolar fracture of the fibula
4.Transverse fracture of the posterior
tibial surface
2. AO/ Danis-Weber
Type Pathology
A Avulsion # fibula ± shear # of med malleolus
B Fibula # at level of syndesmosis ± # med malleolus/ tear of
deltoid ligament
C Fibula # above level of syndesmosis ± medial injury + tear of
ITFL and interosseous membrane
Maissoneuve’s fracture
Spiral fracture of proximal fibula associated with very unstable ankle
injury
Bosworth Fracture
A lesion described by Bosworth may be the cause of failure to reduce
a posterior fracture-dislocation of the ankle.
The distal end of the proximal fragment of the fibula may be displaced
posterior to the tibia and locked by the tibia’s posterolateral ridge; the
bone cannot be released
by manipulation because of the pull of the intact interosseous
membrane.
In these cases the fibula is exposed, and a periosteal elevator is used to
release the bone; considerable force may be necessary. The fibular
fracture then is fixed.
Bosworth fracture with entrapment of fibular behind tibia. A,
Anteroposterior view. B and C, Lateral views.
Rationale behind ORIF of ankle
fractures
Tibiotalar congruency
Ramsey and Hamilton (JBJS (B) 1976)
showed that a 1mm lateral shift of the
talus in the ankle mortice reduces the
contact area by 42%
Posterior malleolus fracture >33% leads
to a significant loss of tibiotalar contact
DeSouza (JBJS (A) 1985) showed 90%
satisfactory results could be obtained
even if up to 2mm of lateral
displacement was present
Generally
o Young ORIF if >1mm displacement or >2º talar tilt
o Old can accept up to 2mm of displacement
o Always take into account the ambulatory needs of the patient
and judge treatment accordingly
Surgical technique
Standard AO fixation
Interfragmentary screw and 1/3 tubular neutralisation plate for fibula
and lag screw fixation for medial malleolus
Syndesmosis screw is required if fibula is unstable at end of fixation
(engage 3 cortices and ensure the ankle is at 90º when inserting screw,
and that the screw is not lagged) Screw needs to be removed before
weight bearing can be commenced
Alternative fixation for Type B fractures of the fibula is the anti-glide
plate which has been shown to be biomechanically superior to a
lateral plate
Posterior malleolus fractures need to be fixed if there is > 25% of the
articular surface involved. This is often underestimated on lateral
radiographs.
Post-operative management
In studies comparing the effect of early movement vs immobilisation
and weight bearing vs non-weight bearing, the conclusion is that there
is no difference in the final result whichever regime is used.
Arthritis
Incidence increases with severity of injury
Degenerative changes in
10% of anatomically fixed
85% if not adequately reduced - changes apparent within 18 months
Klossner "Late results of operative and non-operative treatment of
severe ankle fractures" Acta Chir Scand Suppl. 293: 1-93, 1962
Prognosis
There is a reduction in the incidence of arthrosis in patients where an
anatomical reduction has been achieved (Phillips et al JBJS 67A: 67-78,
1985)
Prospective trial shows higher total ankle scores in those that are operatively
treated- especially so in those pts more than 50 yrs old
PILON / PLAFOND FRACTURES
(Pilon = Hammer / Plafond = Ceiling)
Reudi & Allgower Classification
(Ruedi TP, Allgower M: Clin Orthop 1979;138:105-110)
Type Pathology
I Undisplaced
II Displaced with joint incongruity
III Marked comminution with crushing of the
subchondral cancellous bone
Initial treatment
Reduction of any dislocation and covering of exposed wounds if
present
Assess neurovascular status
Check for evidence of compartment syndrome
Splint fracture which may require temporary skeletal traction
Investigations
X-ray plus CT
Timing of surgery
Type II and III - goal is to keep talus centred under the tibia while soft
tissue heal over 7 to 21 days
Study by M.Sirkin et al 1999, a series of pilon fractures underwent
immediate external fixation and ORIF of the fibula, and formal ORIF
of the tibial articular surface was performed on a delayed basis (avg.
delay 12-13 days); - using this protocol, no patient that presented with
a closed injury developed a full thickness skin necrosis and none
required secondary soft tissue coverage
The historically high rate of infection and skin necrosis following
ORIF of these injuries is most related to operative timing - in the
study by MJ Patterson and JD Cole (JTO 1999), all patients
underwent a two staged technique for the treatment of complex pilon
fracture - initially all patients underwent immediate fibular fixation
and placement of a medial fixator
Surgical options
1. ORIF
Medial and anterior incisions with full thickness flaps developed at
level of the periosteum. These incisions must be at least 7 cm apart to
protect the viability of the intervening skin bridge
Steps
1. Fibula # brought out to length and fixed with plate (DCP)
2. Tibial # exposed and reduced, held with temporary K-wires –
usually 4 main fragments
3. K-wires replaced with interfragmentary screws and fixed with
buttress plate
4. Closure of wounds – tension must be avoided and if present
close deep layers and return later for delayed 1º closure of skin
2. Fine wire fixation with circular frames
Using either the Ilizarov or hybrid external fixators
This can be combined with limited internal fixation of the tibia using
interfragmentary screws and fixation of the fibula
3. Trans-articular external fixation
Will align the tibia but will not address the central depression of the
joint surface.
Useful as first part of 2 -stage procedure (to allow soft tissue
management & CT & planning)
Outcomes
Operative treatment of high-energy pilon fractures will take an
average of 4 months to heal
75% of patients that do not develop wound complications may expect
a good result
Subsequent arthrodesis rate ~ 10%
Bourne et al " Pilon fractures of the distal tibia" CORR 240:42-46,
1989
o 36% satisfactory results in intra artic fracture treated with
closed means
o 76% satisfactory for operative treatment
o 32% at 4.5 yrs had undergone ankle arthrodesis for failed result
