ANKLE FRACTURES

John W Cory MD
OrthoArizona
The Foot & Ankle Center
ADULT ANKLE FRACTURES
AO/WEBER
CLASSIFICATION
Based on level of
fibular fracture
Medial malleolar
fracture
Posterior racture


AO/WEBER
A~(sup/add)
A1isolated fibular
fracture below
syndesmosis
A2 A1+ medial
malleolus fracture
A3A1 or A2+
posterior medial
fracture
ADULT ANKLE FRACTURES
AO/WEBER A
ADULT ANKLE FRACTURES
AO/WEBER B~(SER)
B1isolated fibula
fracture @ syndesmosis
B2B1 + medial
lesion(frx or lig)
B3B2 + posterior
lateral fracture
Volkmanns fragment

AO/WEBER C~(PER)
C1isolated simple
diaphyseal fracture of
fibula
C2complex diaphyseal
fracture of fibula
C3proximal fibula
fracture,w/medial &/or
syndesmosis injury
ADULT ANKLE FRACTURES
AO/WEBER B AO/WEBER C
ADULT ANKLE FRACTURES
ADULT ANKLE FRACTURES
LAUGE-HANSEN CLASSIFICATION
Position of foot
Force applied
Better descriptor of injury
Helps catalog injury pattern
Allows for understanding of injured
structures & guide treatment
ADULT ANKLE FRACTURES
LAUGE-HANSEN-SA
Supination of foot
Inward rotation at
ankle
Adduction of the
hindfoot
Inversion of the
forefoot



LAUGE-HANSEN-SA
~Weber A
SA I
Transverse or short
oblique fibula fracture
SA II
Vertical fracture of
medial malleolus

ADULT ANKLE FRACTURES
LAUGE-HANSEN SA
ADULT ANKLE FRACTURES
LAUGE-HANSEN SA
ADULT ANKLE FRACTURES
LAUGE-HANSEN-SER
Oblique frx at the level of
sydesmosis
Supination of foot w/
internal rotation of ankle
Supinated foot externally
rotates
SER I-IV
~Weber B

LAUGE-HANSEN-SER
SER I
AITFL rupture or Wagstaff
tub. frx
SER II
Spiral oblique fibular
fracture @ syndesmosis
SER III
Posterior injury
SER IV
Medial injury
ADULT ANKLE FRACTURES
LAUGE-HANSEN SER
ADULT ANKLE FRACTURES
LAUGE-HANSEN SER

ADULT ANKLE FRACTURES
LAUGE-HANSEN-PER
Pronated forefoot w/ ER
of ankle
Abduction of hindfoot
Eversion of forefoot
Avulsion frx of medial
malleolus
Syndesmosis rupture
Transverse(butterfly)
fibula frx





LAUGE-HANSEN-PER
PER I
deltoid rupture or medial
malleolus avulsion frx
PER II
Sydysmosis rupture
PER III
Transverse fibula fracture
@ syndesmosis w/ butterfly
Unstable
Maisonneuve Fracture
ADULT ANKLE FRACTURES
LAUGE-HANSEN PA
ADULT ANKLE FRACTURES
LAUGE-HANSEN PA
ADULT ANKLE FRACTURES
LAUGE-HANSEN-PER
Eversion injury
Medial side injury is first
~Weber C

LAUGE-HANSEN-PER
PER 1
Deltoid rupture or
transverse frx of medial
malleolus
PER 2
ATFL or Wagstaff tub. frx
PER 3
Short oblique fibula frx
above syndesmosis
PER 4
PITFL or post malleolus frx

ADULT ANKLE FRACTURES
LAUGE-HANSEN PER
ADULT ANKLE FRACTURES
LAUGE-HANSEN PER

ADULT ANKLE FRACTURES
PILON FRACTURES
Hammer
Compression injury
Axial loading
Low & High energy
injuries
Posterior injury-ankle
plantar flexion
Anterior injury-ankle
dorsiflexion
Cleavage-neutral
ADULT ANKLE FRACTURES
ADULT ANKLE FRACTURES
PILON FRACTURES
High association of secondary injury
Fibula fractured in 75-85%
If fibula intact-massive medial plafond injury,
ankle varus
30% ipsilateral LE injury
15% contralateral LE injury
ADULT ANKLE FRACTURES
PILON FRACTURES
L1 compression fractures
High rate of compartment syndrome
Hip fracture
Knee injury
Tibial shaft fracture
Calcaneus fracture


ADULT ANKLE FRACTURES
PILON FRACTURES
RUEDI-ALLGOWER
I: cleavage w/o severe
joint surface injury
II: cleavage w/ joint
injury, not
comminuted
III: comminution &
impaction
ADULT ANKLE FRACTURES
PILON FRACTURES
AO CLASSIFICATION
A1-3
extraarticular (w/
increasing injury)
B1-3
Partial articular
C1-3
articular +
metaphyseal
ADULT ANKLE FRACTURES
PILON FRACTURE TREATMENT GOALS
Restoration of length
Reconstruct metaphyseal shell
Bone grafting
Reattachment of metaphysis to diaphysis
*Restoration of articular surface
*Early mobilization


ADULT ANKLE FRACTURES
PILON TREATMENT OPTIONS
Splinting/ Casting
External Fixation
ORIF
External fixation + limited ORIF
Compartment syndrome
Associated injuries
ADULT ANKLE FRACTURES
CASTING
Rarely treatment
choice
Only with most
univolved
Ruedi-Allgower I
AO A1
EXTERNAL FIXATION
Indirect reduction
Skeletal traction
Temporizing
Maintain length &
alignment
Preserves biology

ADULT ANKLE FRACTURES
ORIF
Timing is key
6 hours/ 6 days-swelling peaks b/w 24hr-3
days
Usually delayed 7-10 days w/ severe swelling
>21 days-granulation, hematoma
organization, bone resorption, cartilage
malnutrition
29% fracture blisters w/ pilon fracture

ADULT ANKLE FRACTURES
ORIF
Soft tissue handling is KEY
Full thickness flaps
Avoid compromised skin
Surgical approach
2 incision technique is workhorse
Posterior lateral incision for fibula
Extended anterior arthrotomy

ADULT ANKLE FRACTURES
ORIF
Restoration of length
Reconstruct
metaphyseal shell
Bone grafting
Reattachment of
metaphysis to
diaphysis

ORIF
2X rate of delayed
wound healing
High complication
rate
Reports of excellent
results skewed
Best results with low
energy injuries
ADULT ANKLE FRACTURES
EXTERNAL FIXATION
+ ORIF
Massive soft tissue injury
Severe comminution
Utilizes inderect reduction
Restore/maintain length
Maintain aligment

EXTERNAL FIXATION
+ ORIF
Limited ORIF
Fibular plate
Interfrag screws
Increased rate of:
Delayed/nonunion
malunion
Decrease rate of:
Skin slough
Infection
Secondary closure


ADULT ANKLE FRACTURES
EXTERNAL
FIXATION + ORIF
Half-pin fixator
Skinny wire fixator
Hybrid frame
EXTERNAL
FIXATION + ORIF
Half-pin fixator
Tibiotalar
Tibiocalcaneal
Triangular frame

*No early mobilization



ADULT ANKLE FRACTURES
EXTERNAL
FIXATION + ORIF
Skinny wire fixator
Does not span ankle
Excellent for C1 & C2
Diaphyseal
comminution
Highly comminuted
EXTERNAL
FIXATION + ORIF
Hybrid fixator
Does not span ankle
half pins diaphyseal
Skinny wire ring
metaphyseal

ADULT ANKLE FRACTURES
PILON FRACTURES OUTCOMES
Initial injury
Soft tissue envelope
Treatment
Delayed wound healing w/ traditional ORIF &
soft tissue injury
Malunion/Nonunion w/ fixators