Peggers’ Super Summary of Ankle Fracture fixation
Indications:
FRACTURE REASONS – all unstable fractures which include

Talar shift

Bimalleolar fractures

Weber c

Weber b with instability or shortening > 2mm

Open fractures

Syndesmosis disruption

>20% of posterior malleolus or > 2mm articular step or talar
subluxation
PATIENT REASONS

Patients unable to remain non weight bearing – there may be a
subgroup in which the hindfoot nail may be of benefit

Peripheral neuropathy
Examination:

Associated injuries
o
Talus
o
Calcaneous
o
5th MT base
o
Lisfranc

Neurovascular examination

Reduction of deformity

Skin assessment
Imaging

1cm above ankle joint there should be > 1mm tibia-fibula
overlap

Medial clear space <5mm initially or on stress views
Anatomy:
LATERAL ANKLE

Superficial branch of peroneal nerve – 6-8cm proximately from
tip crosses fibula

Sural nerve running posteriorly

Anterior inferior tibio-fibular ligament

Fibular calcaneal ligaments

Peroneal tendons
MEDIAL ANKLE

Spahenous nerve and vein – running anteriorly to MM

Tibialsis posterior tendon running directly behind MM

Deltoid ligament
POSTERIOR ANKLE

Sural nerve – posterolaterally

Achilles

FHL – only muscle belly at ankle level level

Medial n/v bundle MEDIAL to FHL
Preoperative Planning:
RADIOGRAPHICALLY

AP / LAT / Mortice at 200 IR

CT for posterior malleolus or Pillon
SOFT TISSUES

Operate before soft tissue swelling or blisters

Delayed ORIF after soft tissue resolves
Equipment

AO small fragment set

If osteoporotic low profile locking plate

3.5mm cortical and 4.0 cancellous screws

II and radiolucent table
Operative Room Planning
INTRODUCTION

Confirm Consent / Mark / WHO form / Abx at induction
POSITION

Supine

Tourniquet

Sand bag under ipsilateral hip

II on contralateral side
DRAPING

Antiseptic solution to Knee

Perforated drape

Glove over toes

Drape to mid lower leg
Surgical Approach
LATERAL

Mark outline of fibular and draw midline vertical line

Careful 6-8cm proximately for superficial peroneal nerve

Full thickness flaps direct lateral incision and AVOID using
retractors

Incise anteriorly to peroneal tendons and retract them
posteriorly (incising fascia off the peroneals will give access
for anteglide plate posteriorly)

Visualise fracture site and talar dome using periosteal elevators
or curette

Reduction forceps to reduce the fracture

NB failure to achieve reduction must use II to see if talus
fails to reduce – a medial incision may be used to remove
deltoid from joint space

A lag screw ideally placed posteriorly or through the
neutralisation plate are options

A lag screw is placed by over drilling near cortex 3.5mm
placing chimney pot in hole and 2.5mm far cortex

Tap

Measure hole

Countersink near cortex

Place cortical screw

Use neutralisation plate at side or as antiglide at back

3 screws must be used either side of the fracture site with distal
screws going into distal fibular as cancellous screws to avoid
penetration of articular surface
MEDIAL

Mark the outline to the MM and mark a central direct approach
to the MM curving anteriorly distally

Care to preserve the long saphenous nerve and vein

A periosteal elevator or curette explore the fracture site and
remove periosteum

Displace the MM to view talar dome

Wash and irrigate

Reduction forceps

Hold with k wire

II to confirm reduction

2x 4.0mm partially threaded cancellous screws with thread in
the distal metaphysis and dense old growth plate region

2x medial 4.0mm drill bits can be used to maintain reduction
with simultaneous holes whilst the other is converted into a
screw

NB Small MM fragment a tension band technique with a
proximal screw and wire can be used as an alternative
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Peggers’ Super Summary of Ankle Fracture fixation
POSTEROLATERAL

Can address the fibular and posterior malleolus with the same
incision

Mark the longitudinal vertical midpoint between the lateral
Achilles and the back of the fibular.

Dissection is between the Achilles and the peroneal tendons

CAREFUL to dissect the sural nerve

Dissect deeper between FHL and the peroneal tendons

FHL PROTECTS the medial n/v bundle

Fracture haematoma and periosteum clear

Lag screw and antiglide plate are typically used
REDUCTIONS TOOLS

Crab claw reduction forceps

Pointed reduction forceps
Syndesmosis Repair:
NB accurate fixation of the fibula in the incisura is vital

Stress ER views or cotton hook test are used to check the
syndesmosis

A clamp is used to hold the reduction during fixation

The inferior screw should be at the junction of the superior
margin of the tibia-fibula joint i.e. the inferior screw should be
in the physeal growth plate region at the flair of the lateral tibia

From the lateral approach the hands need to be dropped to 20300 as the fibular is posterior to the tibia

Controversies arise from 1 or 2 screws & 3 or 4 cortices
Unusual Repairs
Tilleaux Chaput

Anterolateral tibia from ligament avulsion use screw and
washer
Wagstaffe

Anterior fibula – use screw and washer or suture anchor
Reduced and stabilised with a 3.5 mm lag screw
Neutralised with 1:3 tubular plate, 7 holed amd 3.5 mm screws
Images satisfactory and saved
Posterior malleolar fragment too small to be fixed
Articular surface of the distal tibia well aligned
Syndesmosis stable on stressing
Closure in layers
Ethilon to skin
Local infiltration
cleaned and dressed
compression bandage
TQ down ´+ 46 mins
Back slab
´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´
Limb elevation
MonitorCSM
Antibiotics x 3 doses
Analgesics
Wound check 48 hrs
Closure






5/0 nylon mattress or vicryl rapide to skin
Join corners up 1st
Non adherent dressing
Splint the hand in intrinsic plus position to mid forearm
o
Wrist extended 100
o
MCPs flexed 800
o
IPJs fully extended
For extensor tendons apply volar splint
For flexors tendons apply dorsal splint to avoid over flexion or
extension of repairs
Operative Note
WEBER B FRACTURE LEFT ANKLE
ORIF
´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´
GA, supine position
TQ control Time ???
Lateral approach
Fracture exposed
Mobilise non weight bearing 6 weeks
Review 2 weeks
Evidence:
>20% posterior malleolus causes worse prognosis. Mont et al. J
Orthop Trauma 1992
>2mm shortening or lateral shift cause increase contact pressures.
Thordarson et al. JBLS (Am) 1997
Complications:
NB diabetics require double the time for non weight bearing to avoid
fracture fixation failure
Early

n/v or tendon damage

infection

failure
Late

removal of metal work

non or mal-union

stiffness

OA

CRPS
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