Executive Editor: Steve Krikler

Authors: Paulo Barbosa, Felix Bonnaire, Kodi Kojima

Malleoli Infrasyndesmotic, posteromedial fracture with LCL rupture

back to skeleton

Glossary

General considerations

As these injuries involves both sides of the ankle mortise, they are usually unstable, so compromise articular congruity, and therefore fixation is usually preferred.

Circular cast
Indication summary Skill Equipment
Undisplaced or reduced fractures, marked soft-tissue swelling, patient not fit for surgery, vascular disease, nonambulant patient Basic surgical experience, no specialized skills Basic equipment only

General considerations
Nonoperative treatment of ankle fractures is usually reserved for inherently stable fractures, but can be indicated for unstable fractures in the presence of local, or general, contraindications to surgery.

Indications

  • Undisplaced or reduced fractures
  • Severe soft-tissue swelling 
  • Patient not fit for surgery
  • Peripheral vascular disease
  • Poor state of soft tissues

Contraindications

  • Dislocated or unstable joint 
  • Inadequate reduction 
  • Severe soft-tissue injury

Advantages

  • Full weight bearing possible
  • Good stability

Disadvantages

  • Risks of cast complications (eg, pressure ulcer, nerve compression) 
  • Risks of immobilization
  • Risk of secondary displacement and post-traumatic arthrosis 
  • Risk of malunion 
  • Possible longer period of rehabilitation
External fixation
Indication summary Skill Equipment
Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF) Some specialized surgical experience Simple surgical and imaging resources

General considerations
In a polytrauma patient it takes too much time to reconstruct the ankle-joint anatomically.
However, joint instability increases soft-tissue insult and should be eliminated. In patients with excessive swelling, or severe soft-tissue injuries early ORIF could cause further damage to the soft tissues.
With an external fixator, the joint can be reduced and provisionally stabilized in an adequate position, while awaiting decrease of swelling. Later anatomical reconstruction by ORIF becomes possible.

The modular external fixator maintains the length and holds the foot in a neutral position without a tibiotarsal transfixation.

Further indications

  • Displaced, unstable fractures 
  • Open fractures with severe soft-tissue injury

Contraindications

  • Patient not fit for surgery
  • Low demand patient 
  • Peripheral vascular diseases or poor soft tissues

Advantages

  • Stabilization of the joint
  • Early functional recovery 

Disadvantages

  • Risk of pin-track infection
  • Risk of soft-tissue breakdown
Triangular external fixation
Indication summary Skill Equipment
Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF) Some specialized surgical experience Simple surgical and imaging resources

General considerations
In a polytrauma patient it takes too much time to reconstruct the ankle joint anatomically.
However, joint instability increases soft-tissue insult and should be eliminated. In patients with excessive swelling, or severe soft-tissue injuries early ORIF could cause further damage to the soft tissues.
With an external fixator, the joint can be reduced and provisionally stabilized in an adequate position, while awaiting decrease of swelling. Later anatomical reconstruction by ORIF becomes possible.

Further indications

  • Displaced, unstable fractures 
  • Open fractures with severe soft-tissue injury

Contraindications

  • Patient not fit for surgery
  • Low demand patient 
  • Peripheral vascular diseases or poor soft tissues

Advantages

  • Stabilization of the joint
  • Early functional recovery 

Disadvantages

  • Risk of pin-track infection
  • Risk of soft-tissue breakdown
Lag screw
Indication summary Skill Equipment
Large posteromedial fragment, good bone quality Highly experienced and skilled surgeon Simple surgical and imaging resources

Indications

  • Large posteromedial fragment
  • Good bone quality
  • Displaced, unstable fractures
  • Open fractures 
  • Severe soft-tissue injury 
  • Loss of reduction after nonoperative treatment

Contraindications

  • Poor general condition of the patient (high anesthetic risk) 
  • Severe soft-tissue swelling 
  • Severely osteoporotic bone
  • Low demand patient 
  • Peripheral vascular diseases 
  • Poor quality of soft tissues

Advantages

  • Absolute stability
  • Interfragmentary compression
  • Anatomical reduction of the joint 
  • Early functional recovery 
  • Good long-term results

Disadvantages

  • Risk of fragmentation of the malleolar fragment
  • Technically demanding
  • Risk of wound infection 
  • Risk of soft-tissue breakdown 
  • Cosmetic appearance
*Skill
Basic surgical experience, no specialized skills Basic surgical experience, no specialized skills
Some specialized surgical experience Some specialized surgical experience
Highly experienced and skilled surgeon Highly experienced and skilled surgeon
*Equipment
Basic equipment only Basic equipment only
Simple surgical and imaging resources Simple surgical and imaging resources
Full specialized surgical and imaging resources Full specialized surgical and imaging resources

v1.0 2015-12-04