Executive Editor: Steve Krikler

Authors: Paulo Barbosa, Felix Bonnaire, Kodi Kojima

Malleoli Transsyndesmotic, lateral isolated multifragmentary fracture

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Glossary

General considerations

As both sides of the ankle mortise have failed, the ankle is inherently unstable, and these injuries are usually treated operatively.

Fractures involving a large posterior malleolar fragment cause significant disruption to the articular surface and in these cases the posterior fragment should also be fixed.

Circular cast
Indication summary Skill Equipment
Undisplaced or reduced fractures, marked soft-tissue swelling, medical compromise, 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, which is typical of isolated lateral fractures but may be indicated for unstable fractures in the presence of local, or general, contraindications to surgery.

Indications

  • Undisplaced or reduced fractures
  • Severe soft-tissue swelling 
  • Poor general condition of the patient (high anesthetic risk)
  • Peripheral vascular disease
  • Poor state of soft tissues

Contraindications

  • Dislocated or unstable joint 
  • Inadequate reduction 
  • Shortening, malrotation and axis deviation of the fibula
  • Open fractures with 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
Bridging plate
Indication summary Skill Equipment
Significant comminution Highly experienced and skilled surgeon Simple surgical and imaging resources

Indications

  • Significant comminution
  • Displaced, unstable fractures
  • Open fractures with severe soft-tissue injury 
  • Loss of reduction after nonoperative treatment

Contraindications

  • Poor general condition of the patient (high anesthetic risk)
  • Low demand patient 
  • Peripheral vascular diseases

Advantages

  • Restoration of fibular length
  • Early functional recovery 
  • Good long-term functional results

Disadvantages

  • Risk of wound infection 
  • Risk of soft-tissue breakdown
Antiglide plate
Indication summary Skill Equipment
Displaced fractures, osteoporotic bone, small distal fibular fragment, Le Fort fibular avulsion (fixed independently) Highly experienced and skilled surgeon Simple surgical and imaging resources

Indications

  • Oblique fracture of the fibula, transsyndesmotic, with the tip of the proximal fragment additionally fractured "Le Fort fragment"
  • Osteoporotic bone
  • Displaced, unstable fractures
  • Open fractures with severe soft-tissue injury 
  • Loss of reduction after nonoperative treatment

Contraindications

  • Truly multifragmentary fibular fracture
  • Patient not fit for surgery
  • Low demand patient 
  • Peripheral vascular diseases 
  • Poor state of soft tissues

Advantages

  • Buttressing effect against displacement of the distal fragment
  • Less implant prominence because of posterolateral plate position
  • Earlier weight bearing
  • Reconstruction of the joint 
  • Early functional recovery 
  • Good long-term functional results

Disadvantages

  • Distal positioning of the plate on the distal fragment limited by peroneal tendons 
  • Risk of injury to peroneal tendons 
  • Risk of inadequate reduction
  • Risk of wound infection 
  • Risk of soft-tissue breakdown
*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