Ankle Fractures

Lauge-Hansen Classification:
- Based on cadaveric studies. - Patterns may not always reflect clinical reality. - Four patterns are recognized, based on “pure” injury sequences, each subdivided into stages of increasing severity.
- This system takes into account: Position of í foot at í time of injury & Direction of í force.

Supination-Adduction (SA) Pronation-Abduction (PA) Supination-External Rotation (SER) Pronation-External Rotation (PER)
- 10% to 20%. - 5% to 20%. - 40% to 75%. - 5% to 20%.
- Stage I: Transverse avulsion # of í fibula distal to í - Stage I: Transverse avulsion # of í medial - Stage I: Transverse avulsion # of í medial
level of í joint or rupture of í lateral collateral ligs. malleolus or a rupture of í deltoid ligament. malleolus or a rupture of í deltoid ligament
- Stage II: Rupture of í syndesmotic ligaments or - Stage I: Disruption of í anterior tibiofibular - Stage II: Disruption of í anterior tibiofibular
an avulsion # at their insertions. ligament é or éout avulsion # at its insertions. ligament é or éout avulsion # at its insertions.
- Stage II: Vertical # of medial malleolus. - Stage III: Transverse or short oblique # of í distal - Stage II: Spiral # of í distal fibula at í level - Stage III: Spiral # of í distal fibula at or above í
fibula at or above í level of í syndesmosis of í syndesmosis ώ runs from level of í syndesmosis ώ runs from
anteroinferior to posterosuperior. anterosuperior to posteroinferior
- Stage III: Disruption of í posterior tibiofibular - Stage IV: Disruption of í posterior tibiofibular
ligament or a # of í posterior malleolus. ligament or an avulsion # of í posterior malleolus.
- Stage IV: Transverse avulsion # of í medial
malleolus or a rupture of í deltoid ligament.

Fracture Variants:
Pronation-Dorsiflexion #: - Displaced # off í anterior articular surface, It is considered a pilon variant when a significant articular fragment presents.
Maisonneuve #: - External rotation-type injury é # of í proximal 1/3 of í fibula; it is important to distinguish it from direct trauma #s.
Curbstone #: - Avulsion # of Posterior tibia produced by a tripping mechanism.
LeForte-Wagstaffe #: - Avulsion # of Anterior fibular tubercle by í anterior tibiofibular lig. usually associated é Lauge-Hansen SER-type # patterns.
Tillaux-Chaput #: - Avulsion # of Anterior tibial margin by í anterior tibiofibular lig.
- Anterior colliculus #: Deep portion of í deltoid may remain intact.
Collicular #s:
- Posterior colliculus #: Usually nondisplaced because of stabilization by í posterior tibial & í flexor digitorum longus tendons; On external rotation view: Supramalleolar Spike.
Chip avulsion: - Small avulsions of Anterior or Posterior colliculus.

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Danis-Weber Classification: Based on í level of í fibular #: í more proximal í greater í risk of syndesmotic disruption & associated instability.
Type A: Type B: Type C:
- Fibula # below í syndesmosis - Fibula # at í level of syndesmosis - Fibula # above í syndesmosis
- Type A1: Isolated - Type B1: Isolated - Type C1: Diaphyseal # of í fibula, simple
- Type A2: é # of medial malleolus - Type B2: é medial lesion (malleolus or ligament) - Type C2: Diaphyseal # of í fibula, complex
- Type A3: é # of posteromedial tibia - Type B3: é medial lesion & # of posterolateral tibia - Type C3: Proximal # of í fibula

- Results from Supination of í foot - Results from External Rotation of í foot - Results from Pronation of í foot
- Equivalent to í Lauge-Hansen SA injury. - Equivalent to í Lauge-Hansen SER injury. - Equivalent to í Lauge-Hansen PER or PA Stage III injuries.
- May be associated é an oblique or vertical # of í medial malleolus. - 50% associated é disruption of í anterior syndesmotic ligament. - Associated é disruption of í syndesmosis & medial structures injury.
- May be associated é injury to í medial or í posterior malleolus.

Radiological Evaluation:
AP view: Lateral view:
- Tibiofibula overlap: of <10 mm is abnormal & implies syndesmotic injury. - Dome of í talus should be centered under í tibia & congruous é í tibial plafond.
- Tibiofibula clear space: of >5 mm is abnormal & implies syndesmotic injury. - Posterior tibial tuberosity #s can be identified, as well as direction of fibular injury.
- Talar tilt: A difference in width of í medial & lateral aspects of í superior joint space of >2 mm is - Avulsion #s of í talus by í anterior capsule may be identified.
abnormal & indicates medial or lateral disruption.
Mortise view:
- Taken é í foot in 15° to 20° of internal rotation to offset í intermalleolar axis.
- Medial clear space: > 4 to 5 mm is abnormal & indicates lateral talar shift.
- Talocrural angle: angle ( ) í intermalleolar line & a line parallel to í distal tibial articular surface should
be ( ) 8° to 15°. Angle should be éin 2° to 3° of í uninjured ankle.
- Tibiofibular overlap: < 1 cm indicates syndesmotic disruption.
- Talar shift: >1 mm is abnormal.

Stress view: - é í ankle dorsiflexed & í foot stressed in external rotation can be used to identify medial injury é an isolated fibula #.
CT scans: - Used to delineate bony anatomy, especially in ptns é plafond injuries.
MRI: - Used for assessing occult cartilaginous, ligamentous or tendinous injuries.
Bone scan: - Used in chronic ankle injuries, such as osteochondral injuries, stress #s, infection or reflex dystrophies.

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Treatment: Goal: Anatomic restoration of í ankle joint. Fibular length & rotation must be restored.
Emergency Room Nonoperative: Operative: ORIF
- CR for displaced #s to: Indications: Indications:
- ↓post-injury swelling - Nondisplaced, Stable #s é an intact syndesmosis. - Failure to achieve or maintain CR é amenable soft tissues.
- ↓ pressure on í ar cular car lage - Displaced #s after stable anatomic reduction. - Unstable #s result in talar displacement or widening of í ankle mortise.
- ↓ risk of skin breakdown - Unstable or Multiple trauma ptn é extreme medical risk for surgery. - #s require abnormal foot positioning to maintain reduction.
- ↓ pressure on NV structures. - Stable #: Short leg cast or removable boot & allow to bear weight - Open #s.
- CR of dislocated ankles before radiographic evaluation. as tolerated. Timing:
- Open wounds should be cleansed & dressed in a sterile fashion. - Displaced #s after stable anatomic reduction: Bulky dressing & - Once í ptn’s general medical condition, swelling about í ankle & soft
- After CR: Posterior splint é a U-shaped component for í 1st few days while tissue status allow.
- A well-padded posterior splint é a U-shaped component for swelling subsides → Long leg cast to maintain rota onal control for - Swelling & soft tissue issues usually stabilize éin 5 to 10 days after
# stability & ptn comfort. 4 to 6 wks é serial radiographic evaluation → If adequate healing í injury é elevation, ice, & compressive dressings.
- Postreduction radiographs for # reassessment. ptn placed in a short leg cast or # brace. Weight bearing is - Closed # é severe soft tissue injury or massive swelling: Reduction &
- Limb should be aggressively elevated é or éout í use of ice. restricted until # healing. stabilization é use of external fixation before definitive fixation.
Lateral malleolar #s: Medial malleolar #s: Posterior malleolar #s:
- Distal to syndesmosis: Lag screw or K-wires é tension banding. - Cancellous screws or a figure-of-eight tension band. - Indirect reduction & placement of an anterior to posterior lag screw
- At or above syndesmosis: Lag screws & plate. - Indications for operative fixation: or a posterior to anterior lag screw through a separate incision.
- Concomitant syndesmotic injury. - Indications for operative fixation:
- Persistent widening of í medial clear space after fibula reduction - Involvement of >25% of í articular surface
- Inability to obtain adequate fibular reduction. - >2 mm displacement
- Persistent medial # displacement after fibular fixation. - Persistent posterior subluxation of í talus.
Syndesmotic stabilization: Open #s:
- After fixation of í medial & lateral malleoli is achieved, í syndesmosis should be stressed - Require emergent irrigation & debridement in í operating room.
intraoperatively & held é a large-pointed reduction clamp. A syndesmotic screw is placed 1.5 to 2 cm - Stable fixation is important prophylaxis against infection & helps soft tissue healing.
above í plafond from í fibula to í tibia. - It is permissible to leave plates & screws exposed, but efforts to cover hardware, if possible.
- Controversy: Number of purchased cortices (3 or 4) - Size of í screw (3.5 or 4.5 mm) - Need for ankle - Tourniquet use should be avoided. - Antibiotic prophylaxis should be continued postoperatively.
dorsiflexion during syndesmotic screw placement. - Serial debridements for removal of necrotic, infected, or compromised tissues.
Indications for operative fixation: - Syndesmosis disruption - Fibula #s above í plafond. - Postoperative Management: Limb is placed in a bulky dressing incorporating a plaster splint.
- Very proximal fibula #s é syndesmosis disruption: Syndesmosis fixation éout direct fibula fixation. - Progression to weight bearing is based on í # pattern, stability of fixation, ptn compliance.
Comlications:
- Rare & usually involve í medial malleolus when treated closed, associated é residual # displacement, interposed soft tissue or lateral instability.
1. Nonunion:
- If symptomatic → ORIF, electrical s mula on or Excision if it is not amenable to internal fixation.
2. Malunion: - Lateral malleolus is usually shortened & malrotated. Medial malleolus may heal in an elongated position resulting in residual instability.
3. Wound problems: - Skin edge necrosis (3%); ↓ risk é minimal swelling, no tourniquet & good soft tissue technique.
4. Infection: - <2% of closed #s; leave implants in situ if stable, even é deep infection. One can remove í implant after í # unites.
5. Tibiofibular synostosis: - Associated é í use of a syndesmotic screw & is usually asymptomatic. 8. Posttraumatic arthritis: - Rare in anatomically reduced #s, ↑ Risk é articular incongruity.
6. Loss of reduction: - Up to 25% of unstable ankle injuries treated nonoperatively. 9. Reflex sympathatic dystrophy: - Rare in anatomically reduced #s & early return to function.
7. Loss of ankle ROM: - May occur. 10. Compartment syndrome: - Rare.

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 Plafond (Pilon) Fractures
Classification:
Rüedi & Allgöwer Classification: Based on severity of comminution & displacement of articular surface Mast Classification: Combination of í Lauge-Hansen & í Ruedi-Allgöwer classifications.

Type I: Nondisplaced cleavage # of í ankle joint Type A: Malleolar #s é significant posterior lip involvement (Lauge-Hansen SER IV injury)
Type II: Displaced # é minimal impaction or comminution Type B: Spiral #s of í distal tibia é extension into í articular surface
Type III: Displaced # é significant articular comminution & metaphyseal impaction Central impaction injuries as a result of talar impaction é or éout fibula #.
Type C:
- Most commonly used classification. - Prognosis correlates é increasing grade. Subtypes 1, 2 & 3 correspond to í Ruedi-Allgöwer classification.

Treatment:
Nonoperative: Nondisplaced # or minimally displaced #s or severely debilitated ptns. - Long leg cast for 6 wks followed by # brace & ROM exercises.
Operative:
- Indications: Displaced #s are usually treated surgically. - Goals:
- Time: May be delayed for 7 to 14 days to Optimization of soft tissue status & ↓ of swelling. - Maintenance of fibula length & stability.
- External fixation for high energy injuries provide Skeletal stabilization, restoration of length & partial - Restoration tibial articular surface.
# reduction while awaiting definitive surgery. - Bone grafting of metaphyseal defects.
- Associated fibula #s may undergo ORIF at í time of fixator application. - Buttressing of í distal tibia.
Surgical Tactic:
- Articular #: Reduction percutaneously or through small approaches assisted by a variety of reduction forceps é fluoroscopy to judge # reduction.
- Metaphyseal #: Stabilized é plates or é a nonspanning or spanning external fixator.
- Bone grafting: for metaphyseal defects.
ORIF: Joint spanning external fixation: Hybrid External Fixation:
- Plate fixation is í best way to achieve reduced articular surface. - Open #s or in ptns é significant soft tissue compromise. - A type of Nonspanning external fixator.
- To minimize complications of plating: - Reduction is maintained via distraction & ligamentotaxis. - Fracture reduction is enhanced using thin wires é or éout olives to
- Surgical delay until definitive surgical treatment using initial - If adequate reduction is obtained, external fixation may be used as restore í articular surface & maintain bony stability. It is especially
spanning external fixation for high energy injuries. definitive treatment. useful when internal fixation of any kind is contraindicated. There
is a reported 3% incidence of deep wound infection.
- Use small, low-profile implants. - Articulating versus Nonarticulating spanning external fixation:
- Avoid incisions over í anteromedial tibia. - Nonarticulating (Rigid) Ex. Fix.: Most commonly used, theoretically Arthrodesis:
- Use indirect reduction techniques to ↓ soft tissue stripping. allowing no ankle motion. - It is best done after # comminution has consolidated & soft tissues
- Use percutaneous techniques for plate insertion. - Articulating Ex. Fix.: allows motion in í sagittal plane, thus have recovered. It is performed as a salvage procedure after other
preventing ankle varus & shortening; application is limited, but treatments have failed & posttraumatic arthritis has ensued.
theoretically it results in improved chondral lubrication & nutrition
owing to ankle motion.
Postoperative Management:
- Initial splint placement in neutral dorsiflexion é careful monitoring of soft tissues. Early ankle & foot motion when wounds & fixation allow.
- Non–weight bearing for 12 to 16 wks, then progression to full weight bearing once radiographic evidence of healing.

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