Figure 20.1
Shows anteroposterior and lateral views of ankle joint. (a). Anteroposterior view. (b). Lateral view
Using the Weber classification, this would be Type C indicating syndesmotic injury with the fracture of the fibula proximal to the syndesmosis.
Operative Treatment and Timing of Surgery
These injuries are generally associated with gross swelling and blisters may develop indicating more severe soft tissue damage. In case of gross swelling it is safe practice to wait till the appearance of wrinkle sign; meanwhile the joint can be stabilized with joint spanning external fixator if needed for stability.
However in this, the patient was seen immediately after injury and reduced, with minimal swelling observed.
As this was an unstable ankle fracture with joint subluxation, we decided to treat this fracture with open reduction and internal fixation with fibular plate, tension band wiring for medial malleolus, and screw fixation for syndesmotic injury [1].
Initial Surgery
Lateral malleolus is fixed with 1/3rd tubular plate and medial malleolus with tension band wiring.
For the syndesmotic injury, syndesmotic screw was placed from anterior to posterior direction.
There is anterolateral bony fragment which was not fixed.
Postoperative anteroposterior radiological report (Fig. 20.2) showed syndesmotic injury that was not reduced which can be determined by tibiofibular clear space >5 mm, tibiofibular overlap < 10 mm, and widened medial clear space. Therefore surgery was revised.
Figure 20.2
Shows avulsion of anterior tibiofibular ligament as evidenced by tibiofibular clear space >5 mm, tibiofibular overlap < 10 mm, and widened medial clear space
We believe that this was secondary to surgical error in not recognizing and reducing the syndesmosis. The bony fragment represents avulsion of the anterior tibiofibular ligament (ATFL) and should be recognized and reduced with fixation using a screw if the fragment is large enough.
Also, in this case the syndesmosis screw is directed posteriorly likely exaggerating the mal-reduction by pushing the fibula posteriorly.
Postoperative Radiographs After First Surgery
After discussion with the patient, a repeat surgery was planned for reduction and fixation of the syndesmosis [2].
Surgical Technique
Position: Supine with sand bag under ipsilateral hip (Fig. 20.3).
Figure 20.3
Shows supine position with pillow underneath the gluteal region to keep the limb in internal rotation for lateral approach of fibula
Approach: Lateral approach over right ankle, using the distal end of the prior incision [4].
Related posts:
Trimalleolar Ankle Fracture: Screws Only for Posterior Malleolus
Trimalleolar Ankle Fracture: Posterior Plate for Posterior Malleolus Fractures
Bimalleolar Ankle Fracture: Medial Plate
Nail Plate Combination (NPC) Treatment for Infected, Charcot Ankle Fracture Malunion
Calcaneus Malunion with Subtalar Fusion (Bone Block Arthrodesis)
Cuboid and Nutcracker Fractures
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