Executive Editor: Steve Krikler

Authors: Paulo Barbosa, Felix Bonnaire, Kodi Kojima

Malleoli Transsyndesmotic, posterior, lateral multifragmentary, and medial fractures

back to skeleton

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
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, but can be indicated for unstable fractures in the presence of local, or general, contraindications to surgery.

Indications

  • Marked soft-tissue swelling 
  • Medical compromise
  • Vascular disease 
  • Nonambulant patient 
  • Undisplaced fractures
  • Patient not fit for surgery
  • Peripheral vascular diseases
  • Poor state of soft tissues

Contraindications

  • Dislocated or unstable joint 
  • Inadequate reduction and unstable syndesmosis
  • Shortening of the fibula
  • Joint subluxation
  • Significant articular posterior fragment
  • Open fractures with severe soft-tissue injury 

Advantages

  • Full weight bearing possible
  • Relatively 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
  • Failure to control large posterior fragment
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
  • Failure to control large posterior fragment
ORIF
Indication summary Skill Equipment
Most fractures when the patient is fit and soft tissues do not preclude surgery Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Indications

  • Displaced, unstable fractures 
  • Osteoporotic bone
  • 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
  • Poor state of soft tissues

Advantages

  • Anatomical reduction of the joint
  • Early functional recovery
  • Good long-term results

Disadvantages

  • Skin irritation through bulky implant
  • Risk of wound infection 
  • Risk of soft-tissue breakdown
  • Distal positioning of the plate on the distal fragment limited by peroneal tendons 
  • Risk of injury to peroneal tendons
*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