Ankle Fracture

Question 1

Epidemiology

Answer 1

Younger males and older females

Account for around 10% of all fractures seen in trauma setting.

Question 2

What is the ankle comprised of?

Answer 2

Talus bone articulating within the mortise

Mortise is comprised of the tibial plafond and the medial malleolus + lateral malleolus.

Question 3

Where do the tibia and fibula join?

Answer 3

At the syndesmosis

Question 4

Explain the syndesmosis

Answer 4

A very strong fibrous structure comprised of anterior inferior tibiofibular ligament (AITFL) and the posterior inferior tibiofibular ligament (PITFL) and the intra-osseous membrane

Question 5

Define ankle fracture

Answer 5

A fracture of any malleolus (lateral, medial or posterior) +/- disruption to the syndesmosis.

Question 6

What is a fracture called where the tibial articular surface (the plafond) of joint is inovlved?

Answer 6

Pilon fracture

Question 7

How can ankle fractures be described?

Answer 7

Isolated lateral malleolus fracture

Isolated medial malleolar fracture

Bimalleolar fracture

Trimalleolar fracture

Question 8

What is the most common classification used?

Answer 8

Weber classification

Question 9

Explain Weber classification

Answer 9

Classifies lateral malleolus fractures and used in Emergency setting

Type A - Below the syndesmosis

Type B - At the level of syndesmosis

Type C - Above the level of the syndesmosis

Question 10

Explain degrees of severity related to Weber classification.

Answer 10

The more proximal injury => Higher likelihood of ankle instability

Type C fractures almost always need surgical fixation.

Question 11

What classification is more common in orthopaedic practice?

Answer 11

Lauge-Hansen classification

Question 12

Explain Lauge-Hansen classification

Answer 12

Based on ankle position at the time of injury and the deforming force involved

Much more detailed than Weber’s

Question 13

Clinical features

Answer 13

Ankle pain following a traumatic injury

Associated deformity

Can have neurovascular compromise and be open (typically over the medial side)

Question 14

Sometimes there is diagnostic uncertainty and the patient might be able to mobilise and have no visible deformity.

What can be used then?

Answer 14

Ottawa rules

Question 15

Explain Ottawa ankle rules.

Answer 15

Bone tenderness at the posterior edge or tip of the lateral malleolus or…

Bone tenderness at the posterior edge or tip of the medial malleolus or…

An inability to bear weight both immediately and in the ED for four steps.

If any of the features above is present X-ray must be undertaken.

Question 16

Ix

Answer 16

X-ray AP and lateral views

Check the joint space for uniformity ensuring there is no evidence of talar shift.

If there is complex ankle fractures, particularly where there is a displaced posterior malleolus fragment CT scan will be required for surgical planning.

Question 17

What is important to consider in X-rays.

Answer 17

That the ankle is in full dorsiflexion.

This because the talus is narrower posteriorly and can appear translated within the mortise if it is done in plantarflexion.

Question 18

Initial management

Answer 18

Immediate fracture reduction under sedation in ED to realign the fracture

Question 19

Once reduced what management should be done?

Answer 19

Ankle should be placed in a below knee back slab.

Post-reduction neurovascular examination must be done.

Repeat X-ray should be done

If the reduction is not adequate repeat reduction attempts are required.

Question 20

Indications of conservative management

Answer 20

Non-displaced medial malleolus fractures

Weber A or Weber B fractures without talar shift

Unfit for surgical intervention

Question 21

Indications of surgical intervention.

Answer 21

Displaced bimalleolar fractures or trimalleolar fractures

Weber C fractures

Weber B fractures with talar shift

Open fractures

Question 22

What surgical management is done?

Answer 22

ORIF to achieve stable anatomical reduction of the talus within the ankle mortise.

Question 23

Complications

Answer 23

Post-traumatic OA but is rather rare with appropriate reduction and fixation

Surgical site infection

DVT or PE

Neurovascular injury

Non-union

Mal-union