Internal Fixation of Ankle Fractures DJ3427 6-10 Objectives Review ankle anatomy Identify the indications & treatment goals for ORIF of ankle fractures Summarize the implant options DJ3427 Anatomy Formed by medial malleolus of tibia, and lateral malleolus (fibula) Talus sits in “mortise” Fibula Ankle Bones Tibia (as in “mortise & tenon”) Talus DJ3427 Anatomy Ankle Soft Tissues Ligaments connect ankle on medial & lateral sides Important for stability DJ3427 Anatomy Ankle Soft Tissues Fibula connected to tibia by fibrous band of tissue called syndesmosis Also important for stability DJ3427 Ankle Fractures DJ3427 Ankle Fractures History Twisting injury Immediate pain – lateral and/or medial Difficulty weight-bearing Physical examination DJ3427 Malleolar pain (posterior & anterior) Difficulty weight-bearing Swelling Neurovascular involvement Ankle Fractures Radiographs Ankle Series: AP, mortise, lateral “Rule out” other injuries: DJ3427 AP Mortise Osteochondral injuries Lateral process fracture Anterior calcaneus fracture Base of 5th MT fracture Lateral Ankle Fractures Classification Weber / AO Classification based on level of fibula fracture A – Below syndesmosis B – At syndesmosis C – Above syndesmosis DJ3427 Simple Classification: Stable & Unstable Stable fractures Most commonly involve medial or lateral side only Talus remains anatomic relative to tibia DJ3427 Simple Classification: Stable & Unstable Unstable fractures Disruption of 2 or more aspects of the mortise -bone and/or ligament Talus may sublux or be dislocated from tibia DJ3427 Stable Examples DJ3427 Unstable Examples DJ3427 Indications for Surgery Ankle Fractures Inability to obtain or maintain an anatomic mortise (unstable fracture pattern) Open fractures DJ3427 Basic Set-Up Ankle Fractures Supine position most common Occasionally prone for direct approach to posterior malleolus Bump beneath ipsilateral buttocks (allows easier approach to fibula) Tourniquet Prep / drape to above knee Pre-op antibiotics Fluoroscopy or X-ray DJ3427 General Considerations Small size of ankle bones = dictates implant sizes Multiple complex 3-D articulations Weight bearing structure subject to high stresses (2 – 5x body weight) DJ3427 General Considerations Limited soft tissue coverage DJ3427 Instrumentation Ankle Fractures DJ3427 Small fragment set Cannulated screws K-wires Cerclage wire Power Have mini-frag available Ankle Fracture Surgical Tx Type One malleolus Treatment Fix fibula with screw / TB wire / plate Bimalleolar Plate fibula, lag screw tibia (medial malleolus) Tri-malleolar Plate fibula, lag screw tibia, fix posterior if >20 - 25% articular surface involved DJ3427 Implant Considerations Lateral Malleolus One-third tubular plate & 3.5 mm cortex screws Lateral Posterior 3.5mm compression plate for unstable fractures DJ3427 Implant Considerations Lateral Malleolus Locking plates -- lateral or posterolateral Osteoporotic bone Unstable fractures Distal fractures DJ3427 Implant Considerations Lateral Malleolus Hook Plate Used to obtain purchase in very distal fibula fractures DJ3427 Implant Considerations Posterior Malleolus Posterior to anterior DJ3427 Anterior to posterior Implant Considerations Medial Malleolus Two partially threaded 4.0 mm cancellous screws K-wires Cerclage wire for tension band technique DJ3427 Syndesmosis Fixation Indications Syndesmotic instability after fixation of malleolus Consider if fibula fracture > 4 cm above joint line & Maisonneuve’s fracture Have bone hook on back table to check stability Have large frag screws & instruments available DJ3427 Implant Considerations Syndesmosis Surgeons choice of large or small fragment fully threaded screws, one or two Not inserted as lag screw, but as a positioning screw (threads engage all cortices) Secures position of fibula next to tibia allowing torn syndesmotic tissues to heal May be removed in 6 - 12 weeks DJ3427 Implant Considerations Syndesmosis Have pelvic forceps on back table May need longer plates than in small frag set: 1/3 tubular, compression or specialty fibula plate Bioresorbable screws DJ3427 Case #1 Age: 81 Gender: Female Cause of Injury: Fall Fixation: 3.5mm LCP Lateral Distal Fibula Plate DJ3427 Age: 64 Gender: Female Cause of Injury: Fall Fixation: 3.5mm LCP Lateral Distal Fibula Plate DJ3427 Case #2 Summary Reviewed ankle anatomy Identified the indications & treatment goals for ORIF of ankle fractures Summarized the implant options DJ3427 Thank You DJ3427