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DR. Rahmatullah
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Highest incidence in elderly women
Incidence – 187 per 1 lakh people per year
Isolated malleolar fractures – 66 %
Bi malleolar fractures – 25%
Tri malleolar fractures – 5 to 10%
Open fractures – 2%
Incresed BMI is a risk factor.
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Complex hinge joint with complex ligamentous system
The plafond is concave in AP plane & convex in Lateral plane
Plafond is wider anteriorly to allow for congruency with the
wedge shaped talus
Talar dome is trapezoidal, with anterior aspect 2.5 cm wider than
posterior talus
Chaput's tubercle: insertion site of anterior tibiofibular ligament
on the anterolateral tibia
Wagstaffe's tubercle: insertion site of anterior tibiofibular
ligament on the anterior fibula
Volkmann's tubercle: tibial insertion of posterior tibiofibular
ligament at the posterolateral aspect of tibia
Anterior colliculus: located at anterior, inner aspect of medial
malleolus distally,
Insertion site of deltoid ligament.
Larger than posterior colliculus
Posterior colliculs: located at posterior, inner aspect of medial
malleolus distally,
Insertion site of deltoid ligament.
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SYNDESMOTIC LIGAMENT COMPLEX :
Exists between distal tibia & fibula
Composed of
1) Anterior Inferior TibioFibular Ligament
2) Posterior Inferior TibioFibular Ligament –
thicker & stonger
3) Transverse TibioFibular Ligament
4) Interosseous Ligament
SUPERFICIAL PORTION :
3 ligaments originates from anterior colliculus
1) Tibionavicular Ligament
2) Tibiocalcaneal Ligament
3) Tibiotalar Ligament – most prominent
 DEEP PORTION :
Originates on inter collicular groove and
posterior colliculus
1. Deep ant talotibial Ligamen
2. Deep post talotibial Ligament
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Not as strong as medial
complex
1)Ant Talofibular Ligament
-weakest of lat ligaments
2) Post Talofibular Ligament
-strongest of lat ligaments
3)Calcaneofibular Ligament
Stabilises subtalar joint &
limits inversion
Rupture of this ligament
causes POSITIVE TALAR
TEST
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These rules are used to
determine the need for
radiographs in patients
with an ankle injury.
Ankle X-ray series are
only required in case of:
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Bone tenderness along the
distal 6 cm of the posterior
edge of the fibula or tip of
the lateral malleolus.
Bone tenderness along the
distal 6 cm of the posterior
edge of the tibia or tip of
the medial malleolus.
Inability to bear weight for 4
steps both immediately
and in the emergency
department
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Tibiofibular overlap
should be>10mm
Tibiofibular clear space
<5mm
Talar tilt : difference in
width of medial &
lateral aspect of the
superior joint space
should be <2mm .
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The dome of talus
should be centered
under the tibia &
congruous with tibial
plafond
Posterior tuberocity #
& avulsion # of talus
can be identified
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Taken with foot in 15-20 degrees
of internal rotation that is
perpendicular to intermalleolar
axis
Medial clear space should be
equal to superior clear space,
should be <4mm, >4mm is
abnormal & indicates lateral talar
shift
Talocrural angle : angle
subtended between the inter
malleolar line and a line parallel
to the distal tibial articular
surface - 8 to 15 degrees.
- should be within 2 to 3 degrees
of un injured ankle.
Tibiofibular overlap should be >
1mm, <1mm is syndesmotic
injury
Talar shift >1mm is abnormal
Tibiofibular clear space should
< 6mm
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Normal ROM – dorsiflexion : 30 & plantar flexion –
45 degrees
Minimum of 10 degree of dorsiflexion & 20 degree
of plantar flexion are required for normal gait
Axis of ankle flexion runs between 2 malleoli,
which is externally rotated 20 degrees
Lateral talar shift of 1mm will decrease surface
contact by 40%, & 3mm shift results in >60%
decrease
Disruption of syndesmotic ligaments results in
decreased tibiofibular overlap & lateral talar shift
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Swelling, tenderness, variable deformity from a
limp to non ambulatory.
Check for Neurovascular status & extent of soft
tissue injury
Squeeze test – positive in high ankle sprains,
syndesmotic injuries
Dislocated ankle should be reduced & splinted
immediately
CT scan- specially for plafond #s
MRI –for ligament, cartilage, tendon injuries
BONE SCAN – for occult #, continued pain after
injury
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Takes into account
1) the position of the foot at the time of injury
2) the direction of deforming force
Based on cadaveric studies
Patterns may not always reflect clinical reality
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10-20% of malleolar #
Only type asso with
medial displacement of
talus
STAGE-I : Transverse
avulsion # fibula (or)
Rupture of talofibular
ligament
STAGE-II : - Vertical
medial malleolus #
-Transverse distal fibula #
-Medial plafond impaction
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40-70% of malleolar #
occurs with this mech.
STAGE-I : Disruption of
ant tibiofibular lig +/avulsion #
STAGE- II: Spiral # of
distal fibula
STAGE- III: Disruption of
post tibiofibular lig (or) #
of post malleolus
STAGE- IV: Transverse
avulsion # of medial
malleolus (or) rupture of
deltoid ligament
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5-20% of malleolar #
STAGE- I : Transverse
medial malleolus # (or)
rupture of deltoid
ligament
STAGE- II : Disruption of
ant tibiofibular lig +/avulsion #
STAGE- III : Spiral # distal
fibula at/above the level
of syndesmosis
STAGE- IV : Disruption of
post tibiofibular lig (or)
avulsion # of
posterolateral tibia
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5-20% of malleolar #
STAEGE- I : Transverse
fracture of medial
malleolus (or) rupture
of deltoid lig
STAGE- II : Rupture of
syndesmotic lig (or)
avulsion # with medial
injury
STAGE- III :
Transverse/laterally
comminuted # fibula
with medial injury
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Based on the level of fibular #
The more proximal, the greater risk of syndesmotic
disruption & instability
type A
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type B
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below level of the ankle joint
Tibio fibular syndesmosis intact
Deltoid ligament intact
Medial malleolus often fractured
usually stable : occasionally requires ORIF
at the level of the ankle joint, extending superiorly
and laterally up the fibula
tibiofibular syndesmosis intact or only partially
torn, but no widening of the distal tibiofibular
articulation
medial malleolus may be fractured or deltoid
ligament may be torn
variable stability
type C
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above the level of the ankle joint
tibiofibular syndesmosis disrupted with widening
of the distal tibiofibular articulation
medial malleolus fracture or deltoid ligament injury
present
unstable : requires ORIF
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1 - Disruption of the
medial ankle joint with
small bone avulsion
2 - Disruption of the distal
tibio-fibular syndesmosis
No fibular fracture is
visible at the ankle raising
the suspicion of a
proximal fibular fracture
Spiral fracture of the
proximal fibula
It is a pronation & external
rotation injury
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CURBSTONE # : Avusion fracture of posterior tibia is produced by a
trippling mechanism
LEFORTE – WAGSTAFFE # :
-Anterior fibular tubercle avulsion fracture by anterior tibiofibular
ligament
-Associated with Lauge-Hansen SER type #
THILLAUX – CHAPUT # :
- Anterior tibial tubercle avulsion fracture by anterior tibiofibular
ligament
- Counter part of Leforte-Wagstaffe #
VOLKMANNS TRIANGLE:
-Bony avulsion of posterior tibiofibular ligament from the tibia
HERSCOVICI CLASSIFICATION of medial malleolar fractures.
A - tip avulsions (anterior colliculus)
B - intermediate
C - level of plafond
D - above plafond (adduction fractures)
Posterior colliculus fracture :
- the fragment is nondisplaced because of stabilisation by
posterior tibial & flexor digitorum longus tendons
- supra malleolar spike clearly seen on external rotation views.
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Emergency room :
-Dislocated ankles should be reduced immediately. If reduction fails , go
for urgent surgical reduction
- open wounds, abrasions cleansed & dressed
- fracture reduction for displaced fractures
- splint application
STABLE FRACTURES
Ankles with perfect position of the talus and with no medial swelling and
tenderness are considered to be stable, follow-up x-ray 1 week after injury
to ensure there is no displacement.
if talus is perfectly centered but medial swelling and tenderness, take
stress x-rays.
- If there is no sign of talar shift, the ankle is considered to be stable.
removable walking boot or short-leg cast for 6 wks with crutches but bear
weight as tolerated
Sport activity limitation for 3 months
Nonoperative
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short-leg walking cast/boot
 indications
 isolated nondisplaced medial malleolus fx or tip avulsions
 isolated lateral malleolus fx with < 3mm displacement and no talar shift
 posterior malleolar fx with < 25% joint involvement or < 2mm step-off
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OPERATIVE :
 open reduction internal fixation
 indications
 any talar displacement
 displaced isolated medial malleolar fx
 displaced isolated lateral malleolar fx
bimalleolar fx and functional bimalleolar fracture
 posterior malleolar fx with > 25% or > 2mm step-off
 Bosworth fracture-dislocations (distal fibula # with posterior dislocation of
proximal fibular fragment behind posterior tibial tubercle )
open fractures
TECHNIQUE :
 goal of treatment is stable anatomic reduction of talus in the ankle mortise
 1 mm shift of talus leads to 42% decrease in tibiotalar contact area
 OUTCOMES :
 overall success rate of 90%
 prolonged recovery expected (2 yrs to obtain final functional result)
 worse outcomes with: smoking, decreased education, alcohol use, increased
age, presence of medial malleolar fracture
 ORIF superior to closed treatment of bimalleolar fxs
 in Lauge-Hansen supination-adduction fractures restoration of marginal
impaction of the anteromedial tibial plafond leads to optimal functional results
after surgery
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Isolated Medial Malleolus Fx Nonoperative
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short leg cast
 indications
 nondisplaced fracture
 tip avulsion fractures
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Operative
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ORIF
If they are displaced, thick periosteum usually folds into the
fracture site leading to nonunion.
 indications
 any displacement or talar shift
 technique
 lag screw fixation
 lag screw fixation stronger if placed perpendicular to fracture line
 antiglide plate with lag screw
 best for vertical shear fractures
 tension band fixation
 utilizing stainless steel wire
 Used when fragment is small & in osteroporotic fragments
 Adverse effect - posterior tibial tendon irritation
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4.0 mm partially threaded screws work well for most
patterns
Screws should be perpendicular to the fracture line and
parallel for maximal compression
Spread two screws for good stability
Ignore or excise small anterior colliculus fractures
Use fluoroscopy to be sure screws are clear of the joint
Beware supination adduction patterns with vertical fracture
lines and impacted medial dome fragments
Oblique fractures of posterior colliculus involve posterior lip
of the tibia.
- On the AP x-ray- double profile of the medial malleolus.
- better visualized on a slightly externally rotated AP x-ray
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Isolated Lateral Malleolus Fx Nonoperative
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short leg cast
 indications
 intact mortise,
 no talar shift,
 < 3mm displacement
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Operative
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ORIF
 indications
 if talar shift or > 3 mm of displacment
 can be treated operatively if also treating an ipsilateral
syndesmosis injury
 Techniques :
 open reduction and plating
 intramedullary retrograde screw placement
 isolated lag screw fixation
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Most commonly fixed with one third tubular plate
3 types of plate orientations : lateral, posterolateral, posterior
Avoid screw impingement on talofibular articular surface in lateral
plating
Posterior fibuar plating conditions : when # is more distal, dislocation
is posterior, osteopenic bone
- distal part of plate provides buttress & stabilise # even without
distal screws
- provides maximum stability
- m/c disadvantage of posterior antiglide plating – peroneal irritation
if the plate is too distal
when # is long, oblique, non comminuted - isolated lag screw fixation
Intra medullary screw or rod fixation :
- more limited approach
- particularly difficult in SER type #s
Severly comminuted fibula #s : seen in Pronation-Abduction injuries
- if asso with MM #, first fix MM that stabilises talus which reduces
fibula
- Bone grafting is not necessary
- the position of the talus in the mortise should be used as the ultimate
guide to accurate position of the distal fibula.
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Avoid injuring the superficial peroneal nerve with
anterolateral incisions
Make sure the distal fibula is fully out to length
Laterally comminuted pronation abduction patterns
are most difficult
For maximal stability place a plate posterior
Consider the location of syndesmosis fixation when
placing a fibular plate
Test the syndesmosis after lateral malleolar fixation
Beware in short distal segments, elderly patients with
osteopenic bone, diabetics
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For bimalleolar or trimalleolar fractures
Fix the fibula fracture before reducing and
fixing the medial malleolus.
When the fibula is laterally comminuted and
the medial malleolus fracture is large, we
reduce and fix the medial malleolus fracture
first.
posterior malleolar evaluation and possible
reduction and fixation as the last step in ankle
fixation.
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The superficial peroneal nerve is at risk during
the lateral approach to the fibula.
The sural nerve lies posterior to the fibula, and
during a posterolateral approach to the fibula,
it should be identified and protected
The deep peroneal nerve, the anterior tibial
artery and branches of the superficial peroneal
nerve are at risk when small incisions are made
for front-to-back posterior malleolar fixation
small increase in the medial clear space and valgus sag of
the talus might be apparent
- The talus is narrowest posteriorly leading to increased
space in the mortise in plantar flexion.
- absence of the deltoid allows the talus to rotate externally,
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 technique
 not necessary to repair medial deltoid ligament
 only need to explore it if you are unable to reduce the mortise
 Interposition of the deltoid ligament is one potential cause of
residual talar shift , but very unusual.
 The clinical outcome of these ankle fractures is not improved by
suturing the deltoid ligament
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External rotation lateral x ray view & CT scan are choice
Increased rotation and posterior subluxation of the talus with
positive posterior drawer test but have little effect on stability in
inversion or eversion
Trimalleolar fractures are known to have a worse prognosis
than bimalleolar fractures (23).
Large posterior malleolar fractures lead to poorer outcomes
Approach : direct ( posterior to anterior)
indirect (anterior to posterior)
most important factor in reducing and stabilizing the posterior
malleolus is accurate stable fixation of the associated fibular #
In trimalleolar #, first fix MM, LM & then fix post malleolus
When the fibula is reduced, the posterior malleolus is often
nearly reduced, and the talus is centered
After fibular fixation check posterior drawer test for posterior
stability
Non operative : short leg cast
 indications
 < 25% of articular surface involved
 evaluation of percentage should be done with CT, as plain radiology is unreliable
 < 2 mm articular stepoff
OPERATIVE : ORIF
 indications
 > 25% of articular surface involved
> 2 mm articular stepoff
 ipsilateral syndesmosis injury
 technique
 use posterolateral or posteromedial approach to the ankle joint to reduce and place
fixation
 decision of approach will depend on fracture lines and need for fibular fixation
 can use anterior to posterior lag screws to capture fragment (if nondisplaced)
 syndesmosis injury
 stiffness of syndesmosis restored to 70% normal with isolated fixation of posterior
malleolus (versus 40% with isolated syndesmosis fixation)
 stress examination of syndesmosis still required after posterior malleolar fixation
 posteroinferior tibiofibular ligament may remain attached to posterior malleolus and
syndesmotic stability may be restored with isolated posterior malleolar fixation
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Bosworth Fracture-DislocationOverview
rare fracture-dislocation of the ankle where the proximal
fibula fragment becomes entrapped behind the posterior
tibial tubercle and becomes irreducible
 posterolateral ridge of the distal tibia hinders reduction of
the fibula
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Operative
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open reduction and fixation of the fibula
 indicated in most cases
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Open Ankle Fx Operative
emergent operative debridement and ORIF
 external fixation
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Associated Syndesmotic Injury Overview
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suspect injury in all ankle fractures
 most common in Weber C fracture , L-H pronation type & AO type
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C pattern.
fixation usually not required when fibula fracture within 4.5 cm of
plafond
Higher fibula fractures >4.5cm result in syndesmotic widening
despite internal fixation of the fibula fracture and require
syndesmotic fixation
When there is a proximal fibula fracture and the talus is shifted or
when the talus is shifted without a fibula fracture, there is always a
syndesmosis injury with instability
Radiographically, syndesmosis instability should always be
suspected when fibula fractures are above the level of the ankle
mortise
Stress x-rays : ankle in the mortise position with external rotation
force
Pronation-abduction injuries completely tear the entire syndesmosis
and lead to greater instability than external rotation injuries
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Evaluation :
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measure clear space 1 cm above joint
 it has also been reported that there is no actual correlation
between syndesmotic injury and tibiofibular clear space or
overlap measurements
 lateral stress radiograph has more reliability than an AP/mortise
stress film
best option is to assess stability intra operatively with
abduction /external rotation stress of dorsiflexed foot
 the decision to fix or not to fix the syndesmosis must be
individualized in each case and preferably should be based
on direct stress testing of syndesmosis integrity after internal
fixation of other structures.
 instability of the syndesmosis is most in the anteriorposterior direction
 in the absence of a deltoid injury, fixing the syndesmosis is
unnecessary, and if a medial malleolar fracture is securely
fixed restoring the deltoid ligament, despite complete
disruption of the syndesmosis, tibial fibular fixation is not
needed (Boden SD, Labropoulos PA, McCowin P, et al.)
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 syndesmosis screw fixation
 indications
 widening of medial clear space
 tibiofibular clear space (AP) greater than 5 mm
 tibiofibular overlap (mortise) narrowed
 any postoperative malalignment or widening should be treated with
open debridement, reduction, and fixation
 technique
 length and rotation of fibula must be accurately restored
 open reduction required if closed reduction unsuccessful or
questionable
 one or two cortical screw(s) 2-4 cm above joint, angled posterior to
anterior 20-30 degrees
 lag technique not desired
 maximum dorsiflexion of ankle not required during screw placement
(can't overtighten a properly reduced syndesmosis)
 SER injury that shows mild syndesmosis diastasis, a single threecortex 3.5-mm screw is sufficient,
 In Maisonneuve's proximal fibula fracture with complete disruption
of the syndesmosis without a medial malleolus fracture, fixing the
syndesmosis will provide the entire stability of the ankle
 postoperative
 screws should be maintained in place for at least 8-12
weeks
 must remain non-weight bearing, as screws are not
biomechanically strong enough to withstand forces of
ambulation
 controversies
 3 or 4 cortices (3 – motion between tibia, fibula & 4- stable
fixation)
 3.5 mm or 4.5 mm screws
 implant material (stainless steel screws, titanium screws,
suture, bioabsorbable materials)
 need for hardware removal
 no differences seen in hardware breakage, loosening, or
removal at 1 year
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Use syndesmosis fixation when the medial clear space
widens on intraoperative stress views after the fibula is
fixed
The fibula must be accurately reduced to the tibia in all
views including the lateral
Use a 4.5-mm four cortex screw if the patient will weight
bear postoperatively
Do not remove syndesmosis screws before 3-4 months
postinjury
Achieve a perfectly symmetric tibiotalar clear space
Use syndesmosis fixation only without fixing the fibula
fracture when it is above the midfibula
Overcompressing the syndesmosis by applying a screw with
the ankle in plantar flexion or using a compression
technique should be avoided
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Polyglycolide or polylactide implants have been used most
commonly
Advantages : eliminating the need for hardware removal,
decreasing irritation over prominent screws and plates, and
allowing for gradual stress transfer from the implant to bone.
used as screws for the fibula, syndesmosis, and the medial
malleolus
Polylactide implants have excellent MRI compatibility
wound infection rate has been reported to be similar to that seen
with metallic implants
Chance of redisplacement – 0.9% with simple ankle #
- 8.2% with complex unstable ankle fractures
A local inflammatory granulomatous reaction to polyglycolide
has been reported in 4% to 50% of malleolar fractures, in the 3rd
or 4th postoperative month, is culture negative, that contains
polyglycolide debris
Polylactide implants degrade at a much slower rate than
polyglycolide implants
longer time to degrade significantly decreases the rate of
reaction to these implants
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NONUNION – m/c in medial malleolus
MALUNION – due to lateral malleolus shortening &
external rotation
WOUND PROBLEMS
INFECTIONS
POST TRAUMATIC ARTHRITIS
REFLEX SYMPATHETIC DYSTROPHY – rare, minimised
by anatomical restoration of ankle & early return of function
COMPARTMENT SYNDROME OF LEG, FOOT
TIBIOFIBULAR SYNOSTOSIS – asso with use of
syndesmotic screw, usually asymptomatic
LOSS OF REDUCTION – in 25% of unstable # treated non
operatively
LOSS OF ANKLE ROM