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Internal Fixation of Ankle Fractures

Internal Fixation of Ankle Fractures. 6-10. Objectives. Review ankle anatomy Identify the indications & treatment goals for ORIF of ankle fractures Summarize the implant options. Anatomy Ankle Bones. Formed by medial malleolus of tibia, and lateral malleolus (fibula)

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Internal Fixation of Ankle Fractures

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  1. Internal Fixation of Ankle Fractures 6-10

  2. Objectives • Review ankle anatomy • Identify the indications & treatment goals for ORIF of ankle fractures • Summarize the implant options

  3. AnatomyAnkle Bones • Formed by medial malleolus of tibia, and lateral malleolus (fibula) • Talus sits in “mortise” (as in “mortise & tenon”) Fibula Tibia Talus

  4. AnatomyAnkle Soft Tissues • Ligaments connect ankle on medial & lateral sides • Important for stability

  5. AnatomyAnkle Soft Tissues • Fibula connected to tibia by fibrous band of tissue called syndesmosis • Also important for stability

  6. Ankle Fractures

  7. Ankle 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

  8. Ankle 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

  9. Ankle FracturesClassification Weber / AO Classification based on level of fibula fracture A – Below syndesmosis B – At syndesmosis C – Above syndesmosis

  10. Simple Classification: Stable & Unstable • Stable fractures • Most commonly involve medial or lateral side only • Talus remains anatomic relative to tibia

  11. Simple Classification:Stable & Unstable • Unstable fractures • Disruption of 2 or more aspects of the mortise -- bone and/or ligament • Talus may sublux or be dislocated from tibia

  12. Stable Examples

  13. Unstable Examples

  14. Indications for SurgeryAnkle Fractures Inability to obtain or maintain an anatomic mortise (unstable fracture pattern) Open fractures

  15. Basic 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

  16. General 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)

  17. General Considerations • Limited soft tissue coverage

  18. InstrumentationAnkle Fractures • Small fragment set • Cannulated screws • K-wires • Cerclage wire • Power • Have mini-frag available

  19. 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 >20 - 25% articular surface involved Ankle FractureSurgical Tx

  20. Implant ConsiderationsLateral Malleolus • One-third tubular plate & 3.5 mm cortex screws • Lateral • Posterior • 3.5mm compression plate for unstable fractures

  21. Implant ConsiderationsLateral Malleolus • Locking plates -- lateral or posterolateral • Osteoporotic bone • Unstable fractures • Distal fractures

  22. Implant ConsiderationsLateral Malleolus • Hook Plate • Used to obtain purchase in very distal fibula fractures

  23. Posterior to anterior Anterior to posterior Implant ConsiderationsPosterior Malleolus

  24. Implant ConsiderationsMedial Malleolus • Two partially threaded 4.0 mm cancellous screws • K-wires • Cerclage wire for tension band technique

  25. Syndesmosis FixationIndications • Syndesmotic instability after fixation of malleolus • Consider if fibula fracture > 4 cm above joint line & Maisonneuve’s fracture • Have bone hook on back table to check stability • Have large frag screws & instruments available

  26. Implant 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

  27. Implant 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

  28. Case #1 Age: 81 Gender: Female Cause of Injury: Fall Fixation: 3.5mm LCP Lateral Distal Fibula Plate

  29. Age: 64 Gender: Female Cause of Injury: Fall Fixation: 3.5mm LCP Lateral Distal Fibula Plate Case #2

  30. Summary • Reviewed ankle anatomy • Identified the indications & treatment goals for ORIF of ankle fractures • Summarized the implant options

  31. ThankYou

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