Title: Internal Fixation of Ankle Fractures
1Internal Fixation of Ankle Fractures
6-10
2Objectives
- Review ankle anatomy
- Identify the indications treatment goals for
ORIF of ankle fractures - Summarize the implant options
3AnatomyAnkle Bones
- Formed by medial malleolus of tibia, and lateral
malleolus (fibula) - Talus sits in mortise (as in
mortise tenon)
Fibula
Tibia
Talus
4AnatomyAnkle Soft Tissues
- Ligaments connect ankle on medial lateral sides
- Important for stability
5AnatomyAnkle Soft Tissues
- Fibula connected to tibia by fibrous band of
tissue called syndesmosis - Also important for stability
6Ankle Fractures
7Ankle Fractures
- History
- Twisting injury
- Immediate pain lateral and/or medial
- Difficulty weight-bearing
- Physical examination
- Malleolar pain (posterior anterior)
- Difficulty weight-bearing
- Swelling
- Neurovascular involvement
8Ankle FracturesRadiographs
- Ankle Series AP, mortise, lateral
- Rule out other injuries
- Osteochondral injuries
- Lateral process fracture
- Anterior calcaneus fracture
- Base of 5th MT fracture
AP
Mortise
Lateral
9Ankle FracturesClassification
- Weber / AO Classification based on level of
fibula fracture - A Below syndesmosis
- B At syndesmosis
- C Above syndesmosis
10Simple Classification Stable
Unstable
- Stable fractures
- Most commonly involve medial or lateral side
only - Talus remains anatomic relative to tibia
11Simple ClassificationStable Unstable
- Unstable fractures
- Disruption of 2 or more aspects of the mortise --
bone and/or ligament - Talus may sublux or be dislocated from tibia
12Stable Examples
13Unstable Examples
14Indications for SurgeryAnkle Fractures
- Inability to obtain or maintain an anatomic
mortise (unstable fracture pattern) - Open fractures
15Basic Set-UpAnkle 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
16General 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)
17General Considerations
- Limited soft tissue coverage
18InstrumentationAnkle Fractures
- Small fragment set
- Cannulated screws
- K-wires
- Cerclage wire
- Power
- Have mini-frag available
19Ankle Fracture Surgical Tx
- Type
- One malleolus
- Bimalleolar
- Tri-malleolar
- Treatment
- Fix fibula with screw / TB wire / plate
- Plate fibula, lag screw tibia (medial malleolus)
- Plate fibula, lag screw tibia, fix posterior if
gt20 - 25 articular surface involved
20Implant ConsiderationsLateral Malleolus
- One-third tubular plate 3.5 mm cortex screws
- Lateral
- Posterior
- 3.5mm compression plate for unstable fractures
-
21Implant ConsiderationsLateral Malleolus
- Locking plates -- lateral or posterolateral
- Osteoporotic bone
- Unstable fractures
- Distal fractures
22Implant ConsiderationsLateral Malleolus
- Hook Plate
- Used to obtain purchase in very
distal fibula fractures
23Implant Considerations Posterior Malleolus
- Posterior to anterior Anterior to
posterior
24Implant ConsiderationsMedial Malleolus
- Two partially threaded 4.0 mm cancellous screws
- K-wires
- Cerclage wire for tension band technique
25Syndesmosis FixationIndications
- Syndesmotic instability after fixation of
malleolus - Consider if fibula fracture gt 4 cm above
joint line Maisonneuves fracture - Have bone hook on back table to check stability
- Have large frag screws instruments available
26Implant ConsiderationsSyndesmosis
- 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
27Implant ConsiderationsSyndesmosis
- 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
28Case 1
Age 81 Gender Female Cause of Injury
Fall Fixation 3.5mm LCP Lateral Distal
Fibula Plate
29Case 2
Age 64 Gender Female Cause of Injury
Fall Fixation 3.5mm LCP Lateral Distal
Fibula Plate
30Summary
- Reviewed ankle anatomy
- Identified the indications treatment goals for
ORIF of ankle fractures - Summarized the implant options
31Thank You