Ankle Fractures

Ankle Fractures

Dennis E. Kramer, MD

Sterile Instruments/Equipment (Figure 26-1)

  • Tourniquet

  • Fluoroscopy

  • Fracture reduction set

    • Fracture clamps, K-wires, and freer elevators

    • Large bone reduction clamp

  • Small fragment set 3.5 mm

    • Potentially small fragment combi plates (locking/nonlocking screws)

  • Cannulated screw set 3.5 or 4.5 mm diameter screws

    • partial versus fully threaded

Figure 26-1 ▪ Standard small fragment instruments for ankle fractures.

Figure 26-2 ▪ Supine position with ability to internally rotate at hip for lateral exposure.

Figure 26-3 ▪ Medial incision marking for exposure.

Patient Positioning (Figure 26-2)

  • Vast majority of fracture patterns call for supine positioning

  • place leg extension on bed or flip bed around (operative ankle at the head of bed) to allow for more room for fluoroscopy

  • Bolster under hip to help with exposure of fibula/Tillaux fragments

  • Prone positioning is rare and usually in skeletally mature adolescents with large posterior malleolus fracture

Surgical Approaches

  • Medial approach is direct medial vertical incision, which may need to curve in a hockey shape anteriorly (Figure 26-3)

    • Allows for assessment of anterior medial articular surface for reduction

    • Allows for assessment of metaphyseal bone reduction

    • Plan incision location based on medial malleolar fracture pattern

    • can always place medial malleolar screws through separate/percutaneous incision more distal, so do not compromise view of fracture site and articular surface with fracture exposure incision

    • beware of saphenous vein and nerve often in incision

  • Lateral approach is direct lateral incision over fibula (Figure 26-4)

    • Peroneal tendons posterior and more proximal fractures need to be aware of superficial branch of sensory nerve

    • SPN crosses fibula 8 to 10 cm proximal to lateral malleolus

      Figure 26-4 ▪ Incision for lateral exposure.

    • Other dangers include sural nerve (posterior)

      • Incision is lateral over fibula, heads from about 3 cm proximal to fracture just distal to lateral malleolus

    • Go down to bone at lateral malleolus first, and then dissect proximally

  • Posterior approach is done in prone position (Figure 26-5A-C)

    • Posterior-medial should be centered between Achilles and medial neurovascular structures

    • can dissect between PT and FDL and retract FDL posteriorly to protect neurovascular bundle

    • Posterior lateral should be centered between Achilles and peroneal tendons with avoidance of sural nerve. Deep plane between Achilles and peroneals.

  • Anterior-lateral exposure classically done centered over ankle joint in-line with fourth metatarsal. Avoid the superficial branch of peroneal nerve. Retraction is then done by pulling anterior muscles/tendons medially or if needed develop a plane between tendons down to fracture. Avoid midline as tibialis anterior vessels and deep peroneal nerve (Figure 26-6).

    • For Tillaux fractures, use fluoroscopy to center incision at fracture which may be slightly lateral or medial—choose anterolateral or anteromedial approach based on the fracture position (Figure 26-7)

Figure 26-5 ▪ A, AP radiograph of an adolescent with displaced fracture. B, Lateral CT view demonstrating a large posterior malleolus piece. C, Lateral radiograph after prone fixation of fractures.

Figure 26-6 ▪ Incision for anterolateral exposure.

Figure 26-7 ▪ Fluoro view for centering incision over Tillaux fragment.

Reduction and Fixation Techniques

Medial Malleolar Fractures

Feb 5, 2020 | Posted by in ORTHOPEDIC | Comments Off on Ankle Fractures
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