Courtesy: Dr Jordi Sanchez Ballester, FRCS Orth, Liverpool, UK

Initial Clinical Assessment

History and Examination

A thorough history and clinical examination are essential in evaluating ankle injuries.

Typical Presentation

Painful, swollen ankle
History of inversion or eversion injury

Differential Diagnosis

When assessing ankle trauma, always consider:

Ligament injuries
Tendon injuries
Osteochondral lesions
Syndesmotic injuries
Fractures of the ankle and foot

Clinical Tip:
Avoid focusing solely on fractures—associated soft tissue injuries are commonly missed.

Ottawa Ankle Rules

Purpose

Used in emergency settings to determine the need for radiographs, thereby:

Reducing unnecessary imaging
Improving efficiency

Indications for Ankle X-ray

An X-ray is indicated if there is pain in the malleolar zone along with:

Bone tenderness at:
- Posterior edge/tip of lateral malleolus
- Posterior edge/tip of medial malleolus
Inability to bear weight for 4 steps

Key Questions in Ankle Fracture Evaluation

Once a fracture is identified, two critical questions guide management:

Is the fracture displaced or undisplaced?
Is the fracture stable or unstable?

Undisplaced Ankle Fractures

Epidemiology

Approximately 75% of ankle fractures are undisplaced

Definition

Talar alignment is maintained within the ankle mortise
Minor fibular rotation may be present, but mortise remains congruent

Key Indicator: Talar Shift

Significance

Indicates instability and displacement

Radiographic Criteria

Medial clear space > 4 mm
OR
Medial clear space > 2 mm more than superior clear space

Presence of talar shift = Displaced & unstable fracture

Stability of Ankle Fractures

Stable Fractures

Typically include:

Weber A or Weber B fractures
No medial tenderness
No medial swelling or bruising
Usually low-energy injuries

Medial Tenderness: Does It Always Mean Instability?

Not necessarily.

Explanation

Injury may involve only the superficial deltoid ligament
The deep deltoid ligament may remain intact
If deep deltoid ligament is intact – ankle remains stable

Biomechanics of Ankle Stability

Role of Deep Deltoid Ligament

Primary stabilizer of the ankle mortise
Prevents lateral talar shift

If Intact

Talus remains centered
Fracture may still be stable

If Ruptured

Talus shifts laterally
Leads to unstable fracture

Role of Weight-Bearing Radiographs

If Deltoid Ligament Intact

Weight-bearing tightens ligament
Mortise remains congruent

If Ruptured

Weight-bearing reveals talar shift
Confirms instability

Fibular Rotation: Important Clarification

Apparent external rotation on X-ray is often due to:
- Internal rotation of proximal fibula
- If mortise is congruent ? fracture is still undisplaced

Management of Undisplaced Stable Fractures

Example

Lateral malleolus fracture without medial tenderness

Treatment

Functional management
Pain control
External support

Options

Ankle brace
Stirrup splint
Tubigrip

Weight Bearing

Full weight bearing allowed

Healing & Follow-Up

Healing time: ~6 weeks
Routine follow-up often not required
Excellent union rates

Undisplaced but Potentially Unstable Fractures

Example

Lateral malleolus fracture with medial tenderness

Concern

Possible deep deltoid ligament injury

Investigation

Perform weight-bearing ankle X-ray

Interpretation

Stable

Mortise congruent
Deep deltoid intact

Unstable

Talar shift present
Deltoid ligament disrupted

Management

Stable on Weight-Bearing

Below-knee cast or walking boot
Weight bearing as tolerated
Healing: 5–6 weeks

If Displacement Develops

Indicates instability
Treatment: Open Reduction and Internal Fixation (ORIF)

Management of Displaced / Unstable Fractures

General Principle

Most unstable fractures require surgical fixation

Factors Influencing Decision

Skin condition
Swelling and blisters
Patient age
Comorbidities
Functional demands

Timing of Surgery

Immediate (Day 1)
OR
Delayed until swelling subsides

Indicator

Wrinkle sign suggests readiness for surgery

Surgical Fixation Techniques

Lateral Malleolus

Standard Fixation

One-third tubular plate
Often combined with lag screw

In Osteoporotic Bone

Locking anatomical plate preferred

Medial Malleolus

Key Points

Usually associated with other fractures
Isolated fractures are rare
Always rule out Maisonneuve fracture

Standard Fixation

Two partially threaded cancellous screws
Often with washers

Exceptions

Small avulsion fractures may not need fixation

Vertical Fractures

Problem

Screw fixation may cause shear displacement

Preferred Treatment

Buttress plate fixation

Syndesmotic Injuries

Common In

Weber C fractures
Always considered unstable

Fixation Options

Syndesmotic screw (1.5 cm above joint)
- One or two screws

Weight Bearing

Usually non-weight bearing for ~8 weeks

Screw Removal

Controversial:
- Remove at ~12 weeks
- Or leave in situ
- Broken screws are usually asymptomatic

Tightrope Fixation

Advantages

Allows physiological micromotion
No need for removal
Both screw and tightrope techniques are acceptable

Posterior Malleolus Fracture

Traditional Teaching

Fix if >25% articular involvement

Current Concept

Fragment size is less important

Key Factor

Syndesmotic stability

Importance

Attachment site of posterior inferior tibiofibular ligament

Displacement leads to:

Syndesmotic instability
Increased risk of post-traumatic arthritis

Indications for Fixation

Displacement >2 mm
Syndesmotic instability
Associated complex fractures

Preferred Approach

Posterolateral approach

Advantages

Direct visualization
Improved reduction
Allows buttress plating

Mason Classification (Posterior Malleolus)

Type 1

Small fragment
Treatment: Fibular fixation + syndesmotic stabilization

Type 2A

Posterolateral fragment
Treatment: Posterolateral plating

Type 2B

Posterolateral + posteromedial fragments
Treatment: Combined fixation

Type 3

Large fragment (pilon-like)
Treatment: Posteromedial approach

Evidence-Based Insight

Fixation improves:
- Functional outcomes
- Syndesmotic stability
- Slight increase in implant removal rates

Special Situations

Ankle Fractures in Diabetic Patients

Key Concern

Peripheral neuropathy

Risks

Fixation failure
Charcot arthropathy

Surgical Considerations

Stronger fixation
Locking plates
Additional syndesmotic screws

Postoperative Care

Prolonged non-weight bearing
Typically 2–3× longer than non-diabetic patients

Deltoid Ligament Repair

Usually Not Required

Indications

Persistent talar displacement after fixation
Interposed ligament blocking reduction
Significant medial instability

Technique

Repair using suture anchors

Hindfoot Nail in Elderly

Indication

Frail or very elderly patients

Advantages

Early weight bearing
Avoids repeated surgeries

Alternative Technique

Percutaneous Steinmann Pin Fixation

Inserted from tibia ? talus ? calcaneus
Removed after ~12 weeks

Benefits

Cost-effective
Technically simple

Key Takeaways

Always assess stability and displacement
Talar shift = instability
Weight-bearing X-rays are crucial
Most unstable fractures require ORIF
Posterior malleolus fixation depends on stability, not size
Special populations (e.g., diabetics, elderly) require modified strategies

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