Ankle Fractures
Dennis E. Kramer, MD
Indications
Displaced unstable ankle fractures
Fibular fracture with ankle instability (mortise widening, medial malleolar fracture)
mortise widening is defined as the medial clear space >5 mm or medial clear space > superior clear space
Distal tibial articular fractures to include Tillaux fragments and medial malleolus
surgery for displacement >2 mm at weight-bearing joint surface
Ages: Any
Soft tissue envelope in operable state
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
Standard medial incision with cleaning of fracture fragments to allow for visualization of cortices as well as anterior-medial joint line (Figure 26-8)
curette/dental pick to clear joint
irrigate joint and look for osteochondral injury
reduce fragment
Reduction obtained by weber clamps or dental pick taking care to avoid further physeal damage
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