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How do ankle fractures usually present?

Acute pain and swelling following trauma


MC injured wt bearing joint of the body, that has increasing incidence in the elderly and diabetic populations?

Ankle fractures


OA and fractures?

They are going to get OA

Primary ankle OA = 7-9%
Post-traumatic = 70-78%


What comprises the mortise of the ankle?

tibial plafond
Medial malleolus
Lateral malleolus


Stability in the ankle?

Bony articulation is more stable with dorsiflexion

A highly congruent joint


Lateral ligamentous complex?

Anterior talofibular ligament

Posterior talofibular ligament (strongest)

Calcanofibular ligament (limits inversion)


Anterior, posterior and inferior stability of the ankle joint?

Anterior-inferior tibiofibular ligament (AITFL)

Posterior-inferior talofibular ligament (PITFL) - volkmans tubercle

Inferior transverse ligament (ITL) (part of the PITFL?)


Ankle’s always swell, how does this affect treatment?

Medial, lateral and or posterior swelling can lead to infections and problems with the surgery so often must wait for the swelling to go down before cutting the pt


Common exam findings with ankle fx?

Swelling (medial, lateral, posterior)

Tenderness at fx site

Palpable gap on medial side (maybe)

External rotation or lateral displacement (maybe)


A distal fib (lateral malleolus) fx w tenderness over the medial deltoid ligament is presumed to be?

Unstable bimalleolar injury until proven otherwise


What must always be assessed with ankle fractures? Or any other fx for that matter

Assess circulation and innervation to posterior tibial, superficial peroneal and deep peroneal nerves distal to the fx

Lacerations assessed for open fractures


What radiology needs to be ordered for most ankle fx?



What is a mortise view?

15* internally rotated AP

The relationship of the tib, fib and talus are the clearest with the mortise view


Danis weber classifications?

Weber A: below the joint
- fibular fx is distal to ankle mortise

Weber B: at the joint
- fibula fx oblique and begins at the level of the ankle mortise and extends proximally

Weber C: “train wreck”
-tibiofibular syndesmosis disrupted with widening of the distal tibiofibular articulation
- medial malleolus fracture or deltoid ligament injury present


Danis webber A treatment?

Closed reduction with casting


Danis-weber B treatment?

Closed reduction and casting


Warning sign of badness for danis weber B?

stress exam reveals medial clear space widening > 5mm

Makes treatment more complicated


What is a manual stress view?

Assess the integrity of the deltoid ligament medial clear space

With Ankle in maximum dorsiflexion external rotation force is applied to the foot-mortise view is obtained


Radiology techs always want to pull on the ankle to get a stress view but what is the best way to do it?

Gravity has been shown to be equally effective and much less traumatic to the pt

(Hang the leg ff the table and get your x ray)


Danis-webber C treatment?

Open reduction with internal fixation (ORIF)


What are bimalleolar injuries?

Fractures of the lateral and medial malleolus or fracture of the distal fibula with disruption of the deltoid ligament


What fracture is associated with syndesmotic disruption?

Maissoneuve fracture


What is a tillaux fracture?

Avulsion injury of the lateral tibial articular surface (anterior or posterior) (ATFL)

More common in kids because in adults the ligament is weaker than the bone so the ligament gives out first


Trimalleolar injury

lateral malleolus, the medial malleolus, and the distal posterior aspect of the tibia (aka posterior malleolus)

May also include posterior dislocation of the ankle


Why are trimalleolar fractures a big deal?

They are highly unstable and hard to reduce


Initial treatment of all ankle fx?

Reduce dislocations (ASAP)

Non-weight bearing L&U splint

Call ortho


How is a closed reduction performed?

Anatomic reduction of the mortise using the Quigley maneuver (suspended great toe)


Well padded L and U splint with good proximal, distal and apex molds, ankle in neutral flexion


Ankle reductions hurt, what is an alternate to conscious sedation to perform the procedure?

PRC - intraarticular hematoma block

20ga needle into medial ankle, medial to the TA tendon , hematoma is aspirated and 12cc of lidocaine is injected in its place


How are weber a’s treated?

Stable fx

Like an ankle sprain can be immobilized or put in a non weight bearing or partial weight bearing cast


How are weber B and C or bimalleolar fractures treated?


Open reduction and internal fixation