ANKLE FRACTURE

INTRODUCTION

Epidemiology
 Ankle fractures represent 10% of all fractures
 The second most common lower limb fractures after hip fractures
 The mean age at injury is 45 years, significantly older than that of patients
sustaining isolated ankle sprains
 These are typically low-energy injuries with the majority occurring due to
simple falls or sport

Timothy O. White and Kate E. Bugler. “Ankle Fractures” in Court-Brown, Charles M., Heckman, James D.,
McQueen, Margaret M., Ricci, William M., Tornetta, Paul, III, McKee, Michael D. 2015. Rockwood and Green’s
Fracture in Adults 8th ed.
INTRODUCTION

 high incidence of ankle fractures is increasing sharply.

 Incidence amongst younger males has appeared to remain static whilst the
increase in elderly women has continued
 The mechanism of injury has been changed with a reduction in fractures
occurring because of severe trauma and a concomitant increase in the
proportion of fractures caused by sporting activity in males

Timothy O. White and Kate E. Bugler. “Ankle Fractures” in Court-Brown, Charles M., Heckman, James D.,
McQueen, Margaret M., Ricci, William M., Tornetta, Paul, III, McKee, Michael D. 2015. Rockwood and Green’s
Fracture in Adults 8th ed.
RISK FACTOR

 Obese women over the age of 55 years were significantly more likely to
sustain an ankle fracture than non obese women.
 Patients with a greater percentage increase in weight since the age of 25
were also significantly more likely to sustain an ankle fracture.
 Patients with an unstable ankle fracture were far more likely to be obese
(29%) than patients with stable ankle fractures (4%)

Timothy O. White and Kate E. Bugler. “Ankle Fractures” in Court-Brown, Charles M., Heckman, James D.,
McQueen, Margaret M., Ricci, William M., Tornetta, Paul, III, McKee, Michael D. 2015. Rockwood and Green’s
Fracture in Adults 8th ed.
 ANATOMY

 Ankle joint complex

 Ankle joint
 Subtalar joint
 Inferior tibio-fibular joint
 ANATOMY

 The ankle joint is a three-bone joint with a

larger talar articular surface than matching
tibiofibular articular surface

Timothy O. White and Kate E. Bugler. “Ankle Fractures” in Court-Brown, Charles M., Heckman, James D.,
McQueen, Margaret M., Ricci, William M., Tornetta, Paul, III, McKee, Michael D. 2015. Rockwood and
Green’s Fracture in Adults 8th ed.
ANATOMY

 Mortise view
(A)
 inferior-
superior view
of the
tibiofibular side
of the joint (B)
 superior–
inferior view of
theO. talus
Timothy (C)E. Bugler. “Ankle Fractures” in Court-Brown, Charles M., Heckman, James D.,
White and Kate
McQueen, Margaret M., Ricci, William M., Tornetta, Paul, III, McKee, Michael D. 2015. Rockwood and
Green’s Fracture in Adults 8th ed.
TALOCRURAL ARTICULATION
(MORTISE)

Neumann. Kinesiology of the Musculoskeletal System 2nd ed.

2010.
ANATOMY
Tibiofibular syndesmotic ligaments

Timothy O. White and Kate E. Bugler. “Ankle Fractures” in Court-Brown, Charles M., Heckman, James D.,
McQueen, Margaret M., Ricci, William M., Tornetta, Paul, III, McKee, Michael D. 2015. Rockwood and
Green’s Fracture in Adults 8th ed.
ANATOMY

Jon C. Thompson, Frank H. Netter, Carlos A. G. Machado, John A. Craig. Basic Science. Netter Concise
Orthopaedic Anatomy 2rd ed. 2010. 1(27): 1-27.
ANATOMY
The deltoid ligament and its individual components

Timothy O. White and Kate E. Bugler. “Ankle Fractures” in Court-Brown, Charles M., Heckman, James D.,
McQueen, Margaret M., Ricci, William M., Tornetta, Paul, III, McKee, Michael D. 2015. Rockwood and
Green’s Fracture in Adults 8th ed.
 ANATOMY
The lateral ligamentous complex of the ankle and
its individual components

Timothy O. White and Kate E. Bugler. “Ankle Fractures” in Court-Brown, Charles M., Heckman, James D.,
McQueen, Margaret M., Ricci, William M., Tornetta, Paul, III, McKee, Michael D. 2015. Rockwood and
Green’s Fracture in Adults 8th ed.
BIOMECHANIC

Neumann. Kinesiology of the Musculoskeletal System 2nd ed.

2010.
BIOMECHANIC

Neumann. Kinesiology of the Musculoskeletal System 2nd ed.

2010.
BIOMECHANIC

 Inherent stability of the ankle is important:

 It is the primary articulation responsible for the transmission
of forces from the ground to the remainder of the lower
extremity.
 It is subjected to greater forces per square cm than any
other joint of the body:

FORCES
- Hip = 2-3 X body weight
- Knee = 3 - 4 X body weight
- Ankle = 5 - 7 X body weight

CONTACT AREA
Claire L Brockett and Graham J Chapman. Biomechanics of the Ankle. 2016.
- 1100 mm2
Orthopaedics And Trauma 30:3
ANKLE STABILITY

 The ankle is most stable in dorsiflexion, with

increasing plantar flexion there is more
anterior talar translation (drawer) and talar
inversion (tilt)
 The ATFL is the main talar stabiliser and the
CFL acts as a secondary restraint

Neumann. Kinesiology of the Musculoskeletal System 2nd ed.

2010.
ANKLE STABILITY

 The tibiocalcaneal and tibionavicular control abduction of

the talus
 The calcaneofibular controls adduction
 The anterior tibiotalar and anterior talofibular ligament
control plantar flexion
 Posterior tibiotalar and the posterior talar fibular ligament
resist dorsiflexion
 Both the anterior tibiotalar and the the tibionavicular
control external rotation and with the anterior talofibular
internal rotation of the talus
 The anterior talofibular is the primary stabilizer of the
ankle joint

Neumann. Kinesiology of the Musculoskeletal System 2nd ed.

2010.
 PHYSICAL EXAM
Inspection
-deformity, ecchymosis, swelling, perfusion

ROM (normal)
-30 to 50 degrees plantar flexion
-20 degrees dorsiflexion
-25 degrees inversion and eversion
-15 degrees of adduction
-30 degrees of abduction
Palpation
-individual ligaments (MCL,LCL, syndesmotic) and tendons
-the joints above and below the ankle
-important: proximal fibula (“Maisonneuve fracture”) and the base of the
fifth metatarsal ("dancer's fracture").
Clues to a probable ankle fracture include :
swelling, hematoma formation, and tenderness to pressure over the
medial and/or lateral malleolus or over the proximal head of the fibula.
Dtsch Arztebl Int 2014; 111: 377−88
 SPECIAL TESTS

Anterior Drawer
-integrity of the ATFL
-grasp the heel with one hand and apply a posterior force to the
tibia with the other hand, while drawing the heel forward.
-laxity is compared with the opposite (uninjured) ankle.
-positive test: a difference of 2 mm subluxation compared with the
opposite side or a visible dimpling of the anterior skin of the
affected ankle (suction sign)
Squeeze Test
-tests the integrity of the syndesmotic ligaments
-examiner places his hand 6 to 8 inches below the knee and
squeezes the tibia and fibula together
-positive test: results in pain in the ankle, which indicates injury of
the syndesmotic ligament
SPECIAL TESTS

 Cotton test : applying a lateral force to the heel to

displace the fibula laterally
 Hook test : directly pulling the fibula laterally with a
hook or a redcution clamp
 External rotation stress test
 Imaging and Diagnostic
Modalities

OTTAWA ANKLE RULES

To manage the large volume of ankle injuries of patients

who presented to emergency certain criteria has been
established for requiring ankle radiographs.

Pain exists near one or both of the malleoli PLUS one or more of the
following:

•Age > 55 yrs old

•Inability to bear weight
•Bone tenderness over the posterior edge or tip of either malleolus

BMJ 1995; 311: 594–7

ANTEROPOSTERIOR VIEW
Quantitative analysis
◦ Tibiofibular overlap
◦ <10mm is abnormal - implies
syndesmotic injury
◦ Tibiofibular clear space
◦ >5mm is abnormal - implies
syndesmotic injury
◦ Talar tilt
◦ >2mm is considered abnormal

Consider a comparison with

radiographs of the normal side if
there are unresolved concerns of
injury
J Bone Joint Surg Am. 1983 Jun;65(5):667-
MORTISE VIEW

•Abnormal findings:
–Medial joint space
widening ( > 5 mm)
–Talocrural angle: <8 or >15

degrees
–Tibia/fibula overlap:<1mm
Consider a comparison with
radiographs of the normal side if
there are unresolved concerns of
injury
J Bone Joint Surg Am. 1983 Jun;65(5):667-
77
EVALUATION: RADIOGRAPHIC
MORTISE VIEW

FIBULAR LENGTH:
1. Shenton’s Line of the ankle
Weber SICOT 1981
2. 2. The dime test
 LATERAL VIEW
•Posterior mallelolar fractures
•AP talar subluxation
•Distal fibular translation &/or
angulation
•Syndesmotic relationship
•Associated or occult injuries
– Lateral process talus
– Posterior process talus
– Anterior process calcaneus
EVALUATION: RADIOGRAPHIC
OTHER IMAGING
MODALITIES

 Stress Views
 Gravity
 Manual

 CT
 Articular involvement
 Posterior malleolus

 MRI
 Ligament and tendon injury
 Talar dome lesions
 Syndesmosis injuries
STABLE VS UNSTABLE

 The ankle is a ring

 Tibial plafond
 Medial malleolus
 Deltoid ligaments
 calcaneous
 Lateral collateral ligaments
 Lateral malleolus
 Syndesmosis
 Fracture of single part usually stable
 Fracture > 1 part = unstable
UNDERSTANDING ANKLE
FRACTURES

• Classification systems
– Lauge-Hansen
– Weber
– OTA
• Additional Anatomic Evaluation
– Posterior Malleolar Fractures
– Syndesmotic Injuries
– Common Eponyms
 LAUGE-HANSEN

 Based on cadaveric study

• First word: position of foot at time of injury
• Second word: force applied to foot relative to tibia at time
of injury

Types:
Supination External Rotation
Supination Adduction
Pronation External Rotation
Pronation Abduction
LAUGE - HANSEN
CLASSIFICATION
Primary advantage :
 Characteristic fibular fracture pattern
 useful for reconstructing the mechanism of
injury
 a guide for the closed reduction
 Sequential pattern – inference of ligament
injuries

Disadvantages:
 complicated, variable inter observer
reliability
 doesn’t signify prognosis
 internal rotation injuries (Weber A3) missed
 doesn’t indicate stability
SUPINATION-EXTERNAL
ROTATION
Stage 1 Anterior
tibio- fibular
ligament
Stage 2 Fibula fx
Stage 3 Posterior
malleolus fx or
posterior tibio-
fibular ligament
4 1 Stage 4 Deltoid
ligament tear or
3 2 medial malleolus
fx
 SUPINATION ADDUCTION

• Stage 1: fibula fracture is

transverse below mortise.
• Stage 2: medial malleolus
fracture is classic vertical
2
pattern.

1
PRONATION-EXTERNAL
ROTATION � Stage 1 Deltoid
ligament tear or
medial malleolus
fx
� Stage 2 Anterior
tibio-fibular
ligament and
interosseous
membrane
� Stage 3 Spiral,
proximal fibula
fracture
1 2 � Stage 4 Posterior
malleolus fx or
4 3 posterior tibio-
fibular ligament
PER

• Must x-ray knee to ankle to assess

injury
• Syndesmosis is disrupted in most
cases
– Eponym: Maissoneuve Fracture
• Restore:
– Fibular length and rotation
– Ankle mortise
– Syndesmotic stability
PRONATION-ABDUCTION

� Stage 1 Transverse
medial malleolus fx
distal to mortise

� Stage 2 Posterior
malleolus fx or posterior
tibio-fibular ligament

� Stage 3 Fibula fracture,

typically proximal to
1 mortise, often with a
2 3 butterfly fragment
 WEBER CLASSIFICATION

Based on location of fibula

fracture relative to mortise
and appearance

 Weber A fibula distal to

mortise
 Weber B fibula at level
of mortise
 Weber C fibula proximal
to mortise

Concept - the higher the

fibula the more severe the
injury
CLASSIFICATION: LAUGE-HANSEN MEETS
DANIS-WEBER

SKELETAL TRAUMA
 OTA
� Alpha-Numeric Code

Infrasyndesmotic=44A

Transsyndesmotic=44B

Tibia =4 Malleolar segment =4

Suprasyndesmotic=44C
 OTA
� Alpha-Numeric Code

Infrasyndesmotic=44A
 OTA
� Alpha-Numeric Code

Transsyndesmotic=44B
 OTA
� Alpha-Numeric Code

Suprasyndesmotic=44C
POSTERIOR MALLEOLUS FRACTURES

Function:
Stability- prevents posterior translation of talus &
enhances syndesmotic stability

Weight bearing- increases surface area of ankle joint

POSTERIOR MALLEOLUS FRACTURES:
RADIOGRAPHIC EVALUATION

• Fracture pattern:
– Variable
– Difficult to assess on standard lateral
radiograph
• External rotation lateral view
• CT scan
POSTERIOR MALLEOLUS FRACTURE

67% 19%

Type I- posterolateral oblique type Type II- medial extension type

14%

Type III- small shell type

SYNDESMOTIC INJURY

FUNCTION:

Stability- resists external rotation,

axial, & lateral
displacement of talus

Weight bearing- allows for standard

loading

J Bone Joint Surg Am, 1989 Dec; 71 (10): 1548 -1555

 COMMON NAMES OF FRACTURE VARIANTS

• Maisonneuve Fracture
– Fracture of proximal fibula
with syndesmotic disruption
• Volkmann Fracture
– Fracture of tibial attachment
of PITFL
– Posterior malleolar fracture
type
• Tillaux-Chaput Fracture
– Fracture of tibial attachment
of AITFL
Pott Fracture Dupuytren fracture
Wagstaffe-LeFort fracture
 COMMON NAMES OF FRACTURE
VARIANTS

•Collicular Fractures INTERCOLLICULAR GROOVE

–Avulsion fracture of distal

portion of medial malleolus
–Injury may continue and
rupture the deep deltoid
ligament POSTERIOR COLLICULUS ANTERIOR COLLICULUS

•Bosworth fracture dislocation

–Fibular fracture with posterior
dislocation of proximal fibular
segment behind tibia
TREATMENT

 Non Surgical
- Nondisplaced, stable pattern fracture
- For whom surgery is contraindicated (non-
ambulatory patient, very poor soft tissue envelope,
peripheral vascular disturbance to affected limb)
 Surgical
- ORIF ankle (plate, screw, tension band)
- External fixation of ankle

Bucholz RW, Heckman JD, Court-Brown C [Ed] 2015. Rockwood and Green’s
Fracture in Adult 8th Ed. Philadelphia: Lippincott Williams&Wilkins, pp 2541-
2580
 STABLE VS UNSTABLE

Stable fractures:-
 Isolated A fractures of the distal fibula
 Isolated B type fractures with congruent
ankle mortis

Well molded POP cast, 4 to 6 weeks,

non weight bearing

Unstable Fractures:-
All displaced ankle fractures require
- accurate anatomical reduction,
- open reduction
- internal fixation.
NON OPERATIVE VS
OPERATIVE
Nonoperative

short-leg walking cast/boot

• indications
• isolated nondisplaced medial malleolus fracture or tip avulsions
• isolated lateral malleolus fracture with < 3mm displacement and no talar shift
• bimalleolar fracture if elderly or unable to undergo surgical intervention
• posterior malleolar fracture with < 25% joint involvement or < 2mm step-off
Operative

open reduction internal fixation

• indications
• any talar displacement 
• displaced isolated medial malleolar fracture
• displaced isolated lateral malleolar fracture
bimalleolar fracture and bimalleolar-equivalent fracture
• posterior malleolar fracture with > 25% or > 2mm step-off     
• Bosworth fracture-dislocations
open fractures
malleolar nonunions     
 NON OPERATIVE VS
OPERATIVE
Isolated Lateral Malleolus Fracture
•Nonoperative
• short leg walking cast vs cast boot
• indications 
• if intact mortise, no talar shift, and < 3mm displacement
• classically fractures with more than 4-5 mm of medial clear space widening on stress radiographs have
been considered unstable and need to be treated surgically
• recent studies have shown the deep deltoid may be intact with up to 8-10 mm of widening on stress
radiographs
• if the mortise is well reduced, results from operative and non-operative treatment are similar 
•Operative
• ORIF
• indications
• if talar shift or > 3 mm of displacement
• can be treated operatively if also treating an ipsilateral syndesmosis injury

Isolated Medial Malleolus Fracture

•Nonoperative
• short leg walking cast or cast boot
• indications
• nondisplaced fracture and tip avulsions
• deep deltoid inserts on posterior colliculus
• symptomatic treatment often appropriate
•Operative
• ORIF
• indications
• any displacement or talar shift
Medial and Lateral (Bimalleolar) Fracture
•Nonoperative

• total contact casting

• indications
• elderly or unable to undergo surgical intervention
•Operative
• ORIF
• indications
• any lateral talar shift

Functional Bimalleolar Fracture (deltoid ligament tear with fibular fracture)

•Operative
• ORIF of lateral malleolus
• indications
• examination has been shown to be largely unreliable in predicting medial injury
• can see significant lateral translation of the talus in this pattern

Posterior Malleolar Fracture

•Nonoperative
• short leg walking cast vs cast boot
• indications
• < 25% of articular surface involved
• evaluation of percentage should be done with CT, as plain radiology is unreliable
• < 2 mm articular stepoff
• syndesmotic stability
•Operative
• ORIF
• indications
• > 25% of articular surface involved

• > 2 mm articular stepoff

• syndesmosis injury
 Non-operative treatment
• Congruent / Nondisplaced
fractures
• Stable fractures
Isolated undisplaced
fracture of malleollii

Well molded POP cast,

4 to 6 weeks, non weight bearing
Rockwood and Green’s Fractures in Adults
9th edition
SURGERY PRINCIPLE

Anatomical reduction of the Preservation of the blood supply to

fracture fragment especially in joint the bone fragment and the soft
surface tissue by atraumatic surgery

GOAL
GOAL
Early active pain-free mobilization
Stable internal fixation
of muscle and joint

RAPID RECOVERY OF INJURED LIMB

Muller MA, Algower M. 1991. Manual of Internal Fixation 3rd Ed. Springer-Verlag. Berlin. pp 574-588
COMPLICATION
COMPLICATION
THANK YOU