Courtesy: Prof Nabil Ebraheim, University of Toledo, Ohio, USA

Key Topics Covered

• Lateral malleolus fractures
• Medial malleolus fractures
• Posterior malleolus fractures
• Syndesmotic injuries
• Ankle fractures in diabetic patients

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Initial Clinical Assessment

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History and Examination

• Mechanism of injury (inversion / eversion)
• Painful, swollen ankle

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Differential Diagnosis

Always consider:

• Ligament injuries
• Tendon injuries
• Osteochondral lesions
• Syndesmotic injuries
• Foot fractures

Avoid missing associated injuries

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Ottawa Ankle Rules

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Indications for X-ray

Perform ankle X-ray if:

• Pain in malleolar zone AND
  • Tenderness at posterior edge/tip of malleoli
  • Inability to bear weight for 4 steps

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Purpose

• Reduce unnecessary imaging
• Improve emergency efficiency

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Key Questions in Evaluation

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1. Is the fracture displaced or undisplaced?

2. Is the fracture stable or unstable?

 These determine management

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Undisplaced Ankle Fractures

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Definition

• Talar alignment maintained
• Mortise congruent

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Key Indicator

 Presence of talar shift

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Talar Shift

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Radiographic Criteria

• Medial clear space > 4 mm
  OR
• 2 mm greater than superior clear space

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Significance

 Indicates instability

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Stability of Ankle Fractures

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Stable Fractures

• Weber A or B
• No medial tenderness
• No medial swelling

Usually low-energy injuries

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Important Concept

Medial tenderness – always instability

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Why?

• May involve only superficial deltoid ligament
• Deep deltoid may remain intact

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Biomechanics of Stability

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Deep Deltoid Ligament

• Primary stabilizer
• Prevents lateral talar shift

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If Intact

• Talus remains centered
• Fracture may be stable

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If Ruptured

• Talar shift occurs
   Unstable fracture

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Role of Weight-Bearing X-ray

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If Deep Deltoid Intact

• Ligament tightens
• Mortise remains congruent

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If Ruptured

• Talar shift seen
   Confirms instability

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Fibular Rotation: Key Insight

• Apparent external rotation may actually be:
  • Internal rotation of proximal fibula

 If mortise congruent — still undisplaced

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Management of Stable Undisplaced Fractures

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Example

• Lateral malleolus fracture without medial tenderness

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Treatment

• Functional management
• Pain control
• Ankle support

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Options

• Ankle brace
• Stirrup splint
• Tubigrip

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Weight Bearing

• Full weight bearing allowed

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Healing

• ~6 weeks

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Follow-Up

• Usually not required

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Undisplaced but Potentially Unstable Fractures

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Example

• Lateral malleolus fracture with medial tenderness

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Concern

• Possible deep deltoid injury

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Investigation

Weight-bearing X-ray

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Interpretation

Mortise Congruent

• Stable
• Treat conservatively

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Talar Shift Present

• Unstable
   Requires surgery

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Management

• Cast or boot
• Weight bearing as tolerated
• Monitor for displacement

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Management of Displaced / Unstable Fractures

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General Principle

 Most require ORIF

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Factors to Consider

• Skin condition
• Swelling / blisters
• Age
• Comorbidities
• Functional demand

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Timing of Surgery

• Immediate OR
• Delayed until swelling subsides

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Wrinkle Sign

 Indicates safe timing for surgery

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Fixation Techniques

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Lateral Malleolus

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Standard Fixation

• One-third tubular plate
• ± Lag screw

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Osteoporotic Bone

• Locking plate preferred

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Medial Malleolus

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Common Features

• Rarely isolated
• Always rule out Maisonneuve fracture

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Standard Fixation

• Two cancellous screws
• Often with washers

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Special Case: Vertical Fracture

• Shear forces present

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Preferred Treatment

 Buttress plate

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Syndesmotic Injuries

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Common in

• Weber C fractures

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Fixation

• Syndesmotic screw (1.5 cm above joint)

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Options

• One or two screws

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Weight Bearing

• Usually delayed (~8 weeks)

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Screw Removal

• Controversial

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Alternative: Tightrope

• Allows micromotion
• No removal required

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Posterior Malleolus Fracture

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Old Concept

• Fix if >25% articular surface

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Modern Concept

 Focus on syndesmotic stability, not size

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Indications for Fixation

• Displacement > 2 mm
• Syndesmotic instability
• Complex fractures

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Preferred Approach

 Posterolateral approach

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Advantages

• Direct visualization
• Better reduction
• Allows buttress plating

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Mason Classification

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Type 1

• Small fragment
• Treat with fibular fixation

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Type 2A

• Posterolateral fragment
• Plate fixation

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Type 2B

• Posteromedial + posterolateral
• Combined fixation

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Type 3

• Large pilon-type fragment
• Posteromedial approach

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Evidence

• Fixation improves outcomes
• Reduces instability

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Ankle Fractures in Diabetic Patients

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Key Concern

• Peripheral neuropathy

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Risks

• Fixation failure
• Charcot arthropathy

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Surgical Strategy

• Strong fixation
• Locking plates
• Additional syndesmotic screws

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Postoperative Care

• Prolonged non-weight bearing
• 2–3× longer than normal

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Deltoid Ligament Repair

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Usually Not Required

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Indications

• Persistent talar displacement
• Interposed ligament
• Severe instability

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Technique

• Suture anchor repair

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Special Techniques in Elderly Patients

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Hindfoot Nail

• Allows early weight bearing

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Alternative

• Percutaneous Steinmann pin
• Removed after ~12 weeks

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Advantages

• Low cost
• Simple technique

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Key Take-Home Points

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Assessment

• Always evaluate:
  • Displacement
  • Stability

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Critical Indicator

Talar shift = instability

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Management

• Stable fractures – conservative
• Unstable fractures – surgical

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Modern Insight

• Posterior malleolus fixation depends on stability, not size

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Special Populations

• Diabetics require:
  • Strong fixation
  • Prolonged protection