Ankle Fractures

Sterile Instruments/Equipment

Tourniquet, if desired, unless contraindicated
Small self-retaining retractors (Weitlaner)
Small Hohmann retractors
Small pointed bone reduction clamps (Weber clamps)
Small serrated bone reduction clamps
Dental pick
Freer, Cobb, and/or periosteal elevators
Implants: anatomically contoured locking or nonlocking periarticular fibular plates (lateral or posterolateral), one-third tubular plates; small and mini-fragment plates/screws
Long 3.5- or 4.0-mm cortical screws for syndesmosis
Long 3.0-, 3.5-, or 4.0-mm cortical, cancellous, or cannulated screws for medial malleolus/anterior colliculus
Mini-fragment screws and mini-fragment plates for fibular lag screws and for posterior or medial malleolar comminution
K-wires and wire driver/drill

Positioning

Patient positioning is variable depending on fracture pattern and operative plan.
Supine positioning with ipsilateral hip bolster for most lateral malleolar, bimalleolar, and trimalleolar fractures
Abstaining from using a hip bolster allows more external rotation for posteromedial exposure.
Figure-of-four positioning increases ability to expose posteromedially.
Lateral or prone position may be necessary for access to the posterior malleolus.
Prone position allows open reduction internal fixation (ORIF) of medial and lateral malleolus, albeit from an unusual perspective.
Lateral position may allow fixation of medial malleolus with sufficient external rotation of the hip.

Approaches

Direct lateral and posterolateral approach

Skin incision directly over, or on the posterior aspect of, the fibula
Requires protection of superficial peroneal nerve (Figure 25-1)
Plane between posterior border of fibula and peroneal tendons

May be preferable for:

Access to the fibula for lateral or posterolateral plating
Access to the posterior malleolus in the interval between flexor hallucis longus (FHL) and peroneal tendons

Allowing a separate anterolateral approach for pilon fractures

Figure 25-1. Incision for the lateral approach to the fibula, which can be used for direct lateral and posterolateral plating. Reprinted with permission from Easley ME, Wiesel SW. Operative Techniques in Foot and Ankle Surgery. 1st ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2010. Chapter 135 Figure 7A.

Posteromedial approach
- Access the posterior portion of the medial malleolus, and the posterior malleolus can be achieved anterior to the posterior tibial (PT) tendon or posterior to the PT/flexor digitorum longus (FDL) tendons.
- The FHL is retracted posteriorly and laterally with the PT neurovascular bundle.
Anteromedial approach
- Gently curved skin incision parallel to saphenous vein and nerve
- Access to the medial malleolus and medial gutter

Reduction and Fixation Tips

Fibula Fractures—Rotational Mechanism

K-wires

K-wires are used after reduction for provisional fixation and should be driven anterior to posterior to avoid obstruction of the lateral or posterolateral plate (Figure 25-2).

Figure 25-2. Obtain provisional fixation with K-wires in the sagittal plane to avoid plate interference.

Lag Screws

In addition to plate fixation, most spiral fibular fractures benefit from lag screw fixation.

Lag screws may be placed before lateral plate placement or through a posterolateral plate after antiglide positioning and distal/proximal fixation to augment compressive fixation force at fracture (Figure 25-3).

Figure 25-3. Anteroposterior radiograph demonstrating lag screw fixation with a neutralization plate for fibular stabilization. Reprinted with permission from Easley ME, Wiesel SW. Operative Techniques in Foot and Ankle Surgery. 1st ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2010. Chapter 135 Tech Figure 7A and B.

Posterior-to-anterior placement avoids soft-tissue stripping anteriorly.
2.0-, 2.4-, or 2.7-mm screws provide adequate fixation, with small heads less likely to interfere with plate application or cause peroneal irritation.
Use of a mini-fragment lag screw allows to upsize to a slightly larger small-fragment screw if fixation is inadequate.

Plating

Posterolateral plating allows posterior-to-anterior distal screws in the lateral malleolus that may provide better distal fixation because they are longer and bicortical.
Antiglide plate position on fracture apex is biomechanically favorable.
Reduced implant prominence with posterior placement decreases removal rates.
In osteoporotic bone, consider converging distal screw tips to improve fixation by creating a thread interference fit or use a locking plate.
Unicortical cancellous screws should be utilized distally in lateral plating to avoid impingement of the incisura.