Diagnostics, classification
and treatment of malleolar
fractures. Pilon fractures.
What are malleolar fractures?
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Fractures of the ankle!!!
Anatomy???
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What makes up the ankle joint?
• Bones
• Soft tissues: ligaments and muscles
Bones
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Distal tibia (plafond
and medial
malleolus
Distal fibula (lateral
malleolus)
Talus (highly
congruent
articulation with
plafond)
• Truncated cone
Ligaments
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Medial stabilizers:
deltoid ligament (5 components)
Lateral stabilizers:
anterior talofibular ligament
posterior talofibular ligament
calcaneofibular ligament
Ligaments binding tibia and fibula together:
anterior and posterior inferior tibiofibular
ligaments
inferior transverse ligament
interosseous ligament (strongest)
Medial stabilizers

Deltoid
ligament
• 5 components
• Resists
abduction
Lateral stabilizers
Anterior
talofibular
ligament
Posterior
talofibular
ligament
Calcaneofibular
ligament
Syndesmosis
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Anterior
tibio-fibular
ligament
Posterior
tibio-fibular
ligament
Interosseus
ligament
Malleolar fractures: Diagnostics
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History
Clinical examination
• Observation: swelling, pain, deformity,
possible hematoma
• Physical examination: comparison of
temperature of both sides (possible
vessel injury)
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Radiological examination
CT if necessary
Malleolar fractures: Diagnostics

Radiological
examination
• AP and
lateral views
• May also use
a 30 degree
internally
rotated view
(mortise)
Malleolar fractures: what to look for
on x-ray
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Position of lateral and medial ankle
Dislocations
How parallel the surfaces of the tibia and
talus are with regard to one another
Position of the Weber tip of the lateral
ankle
Unevenness of the talar surface
(osteochondral fractures)
Distance between the medial ankle and
talus (if >4mm and the Weber tip is
displaced proximally subluxation of the
joint is probable)
Classification: Why classify??
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Aim of classification is demonstration
of different types of fractures and
their organization
Fracture classification aids in
determination of the best treatment
and also gives an idea of fracture
prognosis
Should be simple and useable
Classification of malleolar fractures
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Ankle fractures can be classified purely
along anatomical lines as monomalleolar,
bimalleolar, or trimalleolar.
Lauge-Hansen classification takes into
account the position of the forefoot
(pronation or supination) and the direction
of the force which causes the fracture
(abduction, adduction, outward rotation).
Weber classification of lateral ankle
fractures takes into account the level of
the fracture in a frontal view (AO
classification is similar to this).
Lauge-Hansen classification
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Supinationadduction injury:
with the forefoot in
supination, the
force acts in a varus
direction thus
adducting the foot.
• Transverse avulsiontype fracture of the
fibula below the
level of the joint or
tear of lateral
collateral ligaments
• Vertical fracture of
medial malleolus
Lauge-Hansen classification
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Supination-external
rotation injury: most
common. Forefoot in
supination and force in
direction of external
rotation further stresses
the forefoot.
• Disruption of the anterior
talofibular ligament
• Spiral oblique fracture of
the distal tibia
• Disruption of the posterior
tibiofibular ligament or
fracture of the posterior
malleolus
• Fracture of the medial
malleolus or rupture of the
deltoid ligament
3
Supination external rotation
Lauge-Hansen classification
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Pronation-abduction
injury: quite common,
besides forced abduction,
the forefoot is in
pronation.
• Transverse fracture of the
medial malleolus or rupture
of the deltoid ligament
• Rupture of the syndesmotic
ligaments or avulsion
fracture of their insertions
• Short, horizontal oblique
fracture of the fibula above
the level of the joint
Pronation-abduction
Lauge-Hansen classification
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Pronation-external rotation
injury: more rare, forefoot
in pronation with a forced
external rotation
• Transverse fracture of the
medial malleolus or disruption
of the deltoid ligament
• Disruption of the anterior
tibiofibular ligament
• Short oblique fracture of the
fibula above the level of the
joint
• Rupture of the posterior
tibiofibular ligament or
avulsion fracture of the
posterolateral tibia
Weber and AO classification
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Weber A: Fibula
fracture below
syndesmosis
AO:
• A1: isolated
• A2: with fracture
of medial
malleolus
• A3: with a
posteromedial
fracture
Weber and AO classification
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Weber B:
fracture of the
fibula at the
level of the
syndesmosis
AO:
• B1: isolated
• B2: with medial
lesion
(malleolus or
ligament)
• B3: with a
medial lesion
and fracture of
posterolateral
tibia
Weber and AO classification
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Weber C: fracture
of the fibula above
the level of the
syndesmosis.
AO:
• C1: diaphyseal
fracture of the
fibula, simple
• C2: diaphyseal
fracture of the
fibula, complex
• C3: proximal
fracture of the
fibula
Treatment of malleolar fractures
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With fractures of the ankle, only slight
variation from normal is compatible with
good joint function:
• The normal relationships of the ankle mortise
must be restored
• The weight-bearing alignment of the ankle
must be at a right angle to the longitudinal
axis of the leg
• The contours of the articular surface must be
as smooth as possible
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The best results are obtained by
anatomical joint restoration
Anatomical joint restoration
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Closed manipulation with plaster
casting (conservative treatment)
Open reduction and internal fixation
(operative treatment)
Conservative treatment
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Indications: nondisplaced fractures,
stable fractures (Weber
B, pronation-adduction
fractures)
Technique: reduction
using opposite to
mechanism of injury
Time: 6-8 weeks cast,
no weight-bearing for 3
weeks
Complications: when
swelling goes down,
cast becomes loose
and fracture can redislocate. Frequent
follow-up is necessary!!
Operative treatment
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Indications: all open
fractures, unstable
fractures, failure of
closed reduction
(retention?), displaced
fractures
If possible,
immediately. If not,
within 12 hours. After
this, bullae or skin
necrosis can develop
which further delay
surgery
Operative treatment
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Osteosynthesis
of lateral
malleolus
• Plate and
screws
• Interfragmental
screw in case of
diagonal
fracture
Operative treatment
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Osteosynthesis
of medial
malleolus
• Isolated medial
malleolus
fractures are
rare, look for
proximal fibular
fracture in
these cases
• Tension band
wiring
• Cancellous
screws
Operative treatment
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Osteosynthesis of
the Posterior
malleolus (2530% of articular
surface)
• Can often be
reduced with
closed reduction
• Cancellous screw
introduced from
the ventral surface
Operative treatment
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Injuries of the syndesmosis:
• Anterior syndesmosis ligament injuries are
associated with both pronation and supination
injuries
• Instability occurs when the interosseous
membrane is lesioned to the level of the lateral
malleolar fracture (only in Weber C or
pronation-external rotation injuries).
• Reduction and stabilization of the membrane
using temporary pinning or reduction clamp
and insertion of syndesmotic screw (for
anterior syndesmolysis)
• Reduction and stabilization of the Volkmann
triangle (for posterior syndesmolysis)
Operative treatment
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Syndesmosis lesions
• Hard to assess
radiographically
• May stabilize if lateral
and medial ankle are
fixed
• Cotton test (pull with
bone hook
intraoperatively)
• External rotation
under image
intensifier
• Instability: >1.52.0mm widening or
medial clear space >
4mm
Pilon fractures
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Pilon fractures = Intraarticular
fractures of the distal tibia
Pilon fractures =
Extraarticular fractures of
distal tibia which are closer to
joint than the diameter of the
tibia
Can be caused by low energy
rotational forces or by high
energy axial compressional
forces (car accidents or falling
from height).
Not frequent: make up about
1% of fractures
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Pilon fractures: Mechanism of
Relatively less
injury
malignant fracture
if the injury is
indirect, small
energy and usually
rotational. Less
connective tissue
damage, and
dislocation of
articular surface is
minimal.
Fracture is worse if
high energy, direct
trauma with force
either in axial
direction or as
torsion force. More
damage to bone,
cartilage and
connective tissues.
Pilon fractures: Diagnosis
Clinical examination: pain, swelling, loss
of function, determine amount of
connective tissue damage, circulation,
innervation
 X-ray
 Doppler sonography (in cases where
circulation is suspect)
 Angiography
 Intraoperatively often find other injuries
like impression fractures, ligament and
syndesmosis lesions.
Pay attention to compartment syndrome!!!
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Pilon fractures: Classification
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2 important classifications:
• AO classification
• Rüedi-Allgöwer classification
Pilon fractures: AO classification
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Type A: extraarticular distal
tibial fractures subdivided
into A1, A2, A3 depending on
amount of metaphyseal
comminution
Type B: partial articular
fractures in which a portion
of the articular surface
remains in continuity with the
shaft; subdivided into B1, B2,
B3 depending on the amount
of articular impaction and
comminution
Type C: complete
metaphyseal fractures with
articular involvement;
subdivided into C1, C2, C3
depending on extent of
metaphyseal and articular
comminution
Pilon fractures: Rüedi-Allgöwer
classification
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Type I: non-displaced
cleavage fractures that
involve the joint
surface
Type II: have
cleavage-type fracture
lines with
displacement of the
articular surface but
minimal comminution
Type III: are
associated with
metaphyseal and
articular comminution
Pilon fractures: tissue damage
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At time of injury in pilon fractures,
often soft tissues are seriously
damaged
Pressure to skin, abrasions, bullae,
and variable degrees of open injuries
can occur
Pilon fractures: Treatment
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Treatment is usually difficult due to
the fact that the injury is usually
caused by high energy forces that
lead to serious cartilage, bone and
soft tissue damage
The aim of treatment is painless,
complication-free, bony healing
It should be pointed out that in
some cases injuries are so serious
that treatment is limited to the
prevention of septic complications
and the preparation of a situation
where arthrodesis is possible.
Restoration of the articular surface,
stable osteosynthesis and early
mobilization decrease the risk of
post-traumatic arthrosis
Pilon fractures: conservative
treatment
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The only time conservative treatment
is utilized in pilon fractures is when
operative treatment is absolutely
contraindicated
In theory, non-displaced or displaced
but reducable fractures can be
treated conservatively.
Conservative treatment
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Plaster casting
• Following reduction cast reaches the top
of the thigh
• No weight-bearing for 6 weeks
• Cast remains for 12-16 weeks but in
some cases can change cast to PTB
(patella tendon bone) cast in the 6-8th
week depending on the fracture.
Conservative treatment
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Traction
• Following reduction we put a Steinman
nail into the calcaneus and pull the limb
with 3kgs weight
• Traction uses ligamentotaxis to help
reduction
• After 3 weeks the patient is put in a cast
without weight-bearing and the cast is
kept on for 8-16 weeks
Pilon fractures: operative treatment
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Open reduction internal fixation
Closed indirect reduction and
external stabilization
Minimal invasive osteosynthesis
External fixator
63 year old male patient
Operative treatment
49 year old male patient
After treatment
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Thrombosis prophylaxis
Functional treatment
Thank you for your attention