An oblique, spiral lateral malleolar fracture at the level of the joint mortise (an impaction injury) + avulsion of the deltoid ligament (± avulsion fracture of the medial malleolus) ▸ there is partial rupture of the tibiofibular complex ▸ it may require surgery From: Grainger & Allison's Diagnostic Radiology Essentials, 2013
William C. McGarvey, Michael C. Greaser, in Baxter's the Foot and Ankle in Sport (Third Edition), 2020 Isolated lateral
malleolar fractures present one of the most challenging management dilemmas in the realm of sports injuries. Associated syndesmosis widening or medial injury, bony or ligamentous, make the choice of treatment fairly simple and obvious.18,41-43 However, fibular fractures at any level without concomitant injury or significant radiographic displacement generate varied and controversial opinions as to what is considered appropriate intervention. On one hand, arguments may be made that surgery is unnecessary because, even though the lateral stability is compromised, it is not completely diminished. Intact medial structures, specifically the malleolus and deltoid ligament, provide primary resistance to lateral talar translation, thus limiting or preventing abnormal ankle mechanics. Several studies support displacement, lateral or posterior, of up to 5 mm without significant compromise in clinical
outcomes.42-46 Physiologic loading studies of the normal and compromised ankle suggest that the medial structures are, in fact, most important for stability.2,11-20,46,47 It also has been shown by CT analysis that fibular displacement occurring as a result of an external rotation force with intact medial structures (Lauge-Hansen SER2) is the result of internal rotation of the proximal fragment.19 This implies that the distal
fibula maintains its relationship with the mortise and that no functional incongruity is present (Fig. 6.5, A through D). Clinical studies have supported this notion, demonstrating good results with up to 30-year follow-up on nonoperative treatment of isolated lateral malleolar fractures.43,44,48,49 Alternatively, an argument may be made for repairing all but nondisplaced fibular fractures, the rationale being that even
small increments of displacement may lead to fibular shortening or mortise widening.4,11 Early mechanical testing suggested that the lateral talar displacement of as little as 1 mm would significantly increase contact pressures in the tibiotalar joint, thus creating a potential predisposition to early arthritic changes. 10 In addition, it was shown that the talus would routinely follow the displacement of the fibula, thus lending itself to anatomic
malpositioning and subsequent abnormal loading stresses (Fig. 6.6, A through F).11 However, these studies10,11 are some of the most often misquoted or misinterpreted in the literature. These analyses were performed in vitro and, as such, focused specifically on the relationship between the fibula and talus after eliminating all other attachments. There was no medial restraint to motion; thus,
even though the results can be viewed as reliable and truthful, they bear limited clinical applicability because the contribution of the medial osseous and ligamentous structures was ignored. Appropriate interpretation of these studies suggests that abnormal ankle mechanics may be encountered when a fibular fracture exists in the face of medial deficiency. In these cases, operative treatment should be used.18 However, these studies fail to speak to the long-term, clinical
consequences of a truly isolated lateral malleolar fracture. More practical arguments for operative fixation in the athlete are more reliable reduction in the face of unclear medial injury; anatomic bone-to-bone contact, facilitating primary bone healing, faster recovery times, and earlier return to weight bearing; stabilizing weight bearing; rehabilitation; and shorter duration of pain. All are anecdotal, and none have been demonstrated in a prospective
comparison study of operative versus nonoperative treatment specific to this injury pattern. Controversy persists surrounding the process of decision making. Despite evidence to the contrary, many surgeons perform, and athletes elect to undergo, repair of the injured lateral malleolus, presumably for fear of abnormal and untoward results of pathologic mechanics and to resume activity as quickly as possible. A large body of clinical evidence favoring this
faction is the demonstrated lack of reliability of reproducible medial tenderness on clinical examination in disclosing the presence or absence of deltoid ligament injury.50 It is unclear as to what degree of deltoid injury in the face of the fibular fracture will allow for clinical instability.11 Therefore many surgeons ascribe to the philosophy that it is better to be aggressive, especially in someone
whose livelihood may depend on the anatomic function of an ankle or lower extremity. Again, the perspective is anecdotal but reasonable. Surgical treatment often is pursued, as detailed later. Nonoperative management consists of immobilization until swelling and pain allow motion, usually about 10 to 14 days. Subsequent weight bearing ensues in a walking boot, again, when symptoms abate. In most instances, athletes are back to protected weight bearing
somewhere between 3 and 4 weeks. The walking boot is maintained until full weight bearing and nearly normal range of motion are restored. Physical therapy focuses on maintaining muscle tone, joint mobility, and proprioception during the healing phase. Return to activity is dictated by relief of pain, normal symmetric joint range, and strength equal to 80% of that in the normal, unaffected side. Sports-specific activities are resumed with protective taping or bracing as necessary. Radiographs are
monitored frequently in the first month to ensure no displacement, but after 4 weeks these typically are not helpful as long as no changes are noted, specifically no mortise widening. Should one embark on the surgical management of the isolated lateral malleolus fracture, operative principles of anatomic restoration and rigid fixation apply. The goal is to allow early mobilization and quick recovery. Debate still exists regarding the use of interfragmentary
fixation combined with lateral buttress plating versus posteriorly placed, anti-glide fixation. Lateral plating is technically easier, whereas posterior plating theoretically provides greater mechanical stability.51,52 Both seem to perform well clinically. No current consensus exists, and the method remains the preference and comfort level of the surgeon. Weber A variant lateral malleolus
fractures present another clinical dilemma. The majority of these fractures represent stable injuries, and may be treated with a short period of non-weight bearing immobilization. Early range of motion is initiated once swelling and tenderness has diminished, and weight bearing is usually possible within 10–14 days of the injury in a fracture boot. In cases with significant displacement at the fracture site or athletes requiring a more expedited return to play, surgical stabilization may be
permissible. Depending on the size of the fracture, a single 4-mm or larger intramedullary screw or a hook plate provides stable fixation. Postoperative recovery commences with a short period of non-weight-bearing immobilization. Weight bearing is allowed at 10–14 days in a fracture boot, and an ankle rehabilitation program is initiated. Return to play is allowed as early as 6–8 weeks postop if managed aggressively in the postoperative period. Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B9780323549424000063 Ankle and Midfoot Fractures and DislocationsWilliam C. McGarvey, in Baxter's the Foot and Ankle in Sport (Second Edition), 2008 Lateral fracturesIsolated lateral malleolar fractures present one of the most challenging management dilemmas in the realm of sports injuries. Associated syndesmosis widening or medial injury, bony or ligamentous, make the choice of treatment fairly simple and obvious.15,21,22,23 However, fibular fractures at any level without concomitant injury or significant radiographic displacement generate varied and controversial opinions as to what is considered appropriate intervention. On one hand, arguments may be made that surgery is unnecessary because, even though the lateral stability is compromised, it is not completely diminished. Intact medial structures, specifically the malleolus and deltoid ligament, provide primary resistance to lateral talar translation, thus limiting or preventing abnormal ankle mechanics. Several studies support displacement, lateral or posterior, of up to 5 mm without significant compromise in clinical outcomes.22–25,26 Physiologic loading studies of the normal and compromised ankle suggest that the medial structures are, in fact, most important for stability.1,10–19,26,27 It also has been shown by CT analysis that fibular displacement occurring as a result of an external rotation force with intact medial structures (Lauge-Hansen SER2) is the result of internal rotation of the proximal fragment.18 This implies that the distal fibula maintains its relationship with the mortise and that no functional incongruity is present (Fig. 5-8, A through D). Clinical studies have supported this notion, demonstrating good results with up to 30-year follow-up on nonoperative treatment of isolated lateral malleolar fractures.24,28–30 Alternatively, an argument may be made for repairing all but nondisplaced fibular fractures, the rationale being that even small increments of displacement may lead to fibular shortening or mortise widening.4,10 Early mechanical testing suggested that the lateral talar displacement of as little as 1 mm would significantly increase contact pressures in the tibiotalar joint, thus creating a potential predisposition to early arthritic changes.9 In addition, it was shown that the talus would routinely follow the displacement of the fibula, thus lending itself to anatomic malpositioning and subsequent abnormal loading stresses10 (Fig. 5-9, A through F). However, these studies9,10 are some of the most often misquoted or misinterpreted in the literature. These analyses were performed in vitro and, as such, focused specifically on the relationship between the fibula and talus after eliminating all other attachments. There was no medial restraint to motion; thus, even though the results can be viewed as reliable and truthful, they bear limited clinical applicability because the contribution of the medial osseous and ligamentous structures was ignored. Appropriate interpretation of these studies suggests that abnormal ankle mechanics may be encountered when a fibular fracture exists in the face of medial deficiency. In these cases, operative treatment should be used.15 However, these studies fail to speak to the long-term, clinical consequences of a truly isolated lateral malleolar fracture. More practical arguments for operative fixation in the athlete are more reliable reduction in the face of unclear medial injury; anatomic bone-to-bone contact, facilitating primary bone healing, faster recovery times, and earlier return to weight-bearing; and stabilizing weight bearing; rehabilitation; and shorter duration of pain. All are anecdotal, and none have been demonstrated in a prospective comparison study of operative versus nonoperative treatment specific to this injury pattern. Controversy persists surrounding the process of decision making. Despite evidence to the contrary, many surgeons perform, and athletes elect to undergo, repair of the injured lateral malleolus, presumably for fear of abnormal and untoward results of pathologic mechanics and to resume activity as quickly as possible. A large body of clinical evidence favoring this faction is the demonstrated lack of reliability of reproducible medial tenderness on clinical examination in disclosing the presence or absence of deltoid ligament injury.31 It is unclear as to what degree of deltoid injury in the face of the fibular fracture will allow for clinical instability.10 Therefore many surgeons ascribe to the philosophy that it is better to be aggressive, especially in someone whose livelihood may depend on the anatomic function of an ankle or lower extremity. Again, the perspective is anecdotal but reasonable. Surgical treatment often is pursued, as detailed later. Nonoperative management consists of immobilization until swelling and pain allow motion, usually about 10 to 14 days. Subsequent weight bearing ensues in a walking boot, again, when symptoms abate. In most instances, athletes are back to protected weight bearing somewhere between 3 and 4 weeks. The walking boot is maintained until full weight bearing and nearly normal range of motion are restored. Physical therapy focuses on maintaining muscle tone, joint mobility, and proprioception during the healing phase. Return to activity is dictated by relief of pain, normal symmetric joint range, and strength equal to 75% of that in the normal, unaffected side. Sports-specific activities are resumed with protective taping or bracing as necessary. Radiographs are monitored frequently in the first month to ensure no displacement, but after 4 weeks these typically are not helpful as long as no changes are noted, specifically no mortise widening. Should one embark on the surgical management of the isolated lateral malleolus fracture, operative principles of anatomic restoration and rigid fixation apply. The goal is to allow early mobilization and quick recovery. Debate still exists regarding the use of interfragmentary fixation combined with lateral buttress plating versus posteriorly placed, anti-glide fixation. Lateral plating is technically easier, whereas posterior plating theoretically provides greater mechanical stability.32,33 Both seem to perform well clinically. No current consensus exists, and the method remains the preference and comfort level of the surgeon. A recent resurgence of interest has been noticed in an older technique of fibular fixation—intramedullary nailing. This method of fixation has some limited application in the treatment of fibular fractures but really has no place in the operative fixation of a high-demand individual or high-performance athlete. What little advantage one can gain from biomechanical stability of an intramedullary device quickly is counteracted by the notorious inability to correct or control rotation and length. In fact, my experience suggests that the insertion of the device often will alter or displace a previously anatomic reduction because of the force required to install it, as well as the angled flange on the interlocking nails. These are not recommended when one is in need of an anatomic restoration of the joint and should be reserved for lower-demand, medically compromised patients in need of surgical stabilization. One indication for this type of fixation would be in the athlete with a displaced, low (Weber A) fibula fracture. In this instance, an intramedullary, 4.0-mm, cancellous screw would be reasonable, provided that an anatomic reduction can be achieved. Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B9780323023580100053 Ankle FracturesIn Fracture Management for Primary Care Updated Edition (Third Edition), 2018 Isolated Nondisplaced Lateral Malleolar FracturesIsolated nondisplaced lateral malleolar fractures have a low risk of complications and have good clinical results regardless of treatment.10,11 Small nondisplaced avulsion fractures of the tip of the lateral malleolus (Figure 13-4) are best treated with early mobilization similar to treatment of an ankle sprain. A functional stirrup splint that can be worn in a shoe works well during the healing process. Ankle rehabilitation exercises can be started as soon as symptoms allow. Isolated oblique lateral malleolar fractures at or below the level of the ankle joint (Figure 13-7) should be immobilized in a commercially available walking fracture boot or short-leg walking cast for 4 to 6 weeks. Care should be taken to immobilize the ankle in a neutral position (90 degrees flexion) to minimize Achilles tendon shortening. Careful patient selection is required if use of a commercial fracture boot (Figure 13-16) is considered. Compliance with immobilization is essential to ensure adequate fracture healing, and patients may be tempted to alter treatment when using a removable fracture brace. The patient should be seen in 10 to 14 days to check the condition of the cast or compliance with wearing the fracture boot and to ensure that alignment remains acceptable. At 4 weeks, if the fracture site is nontender and repeat radiographs show evidence of fracture union, the patient may begin gradual weight bearing and ankle rehabilitation. If no radiographic evidence of healing is apparent in 4 weeks, the patient should remain immobilized for an additional 2 weeks and then return for repeat radiographs. If the patient is still not clinically healed (nontender over the fracture site and with some callus evident on the radiograph) at 6 weeks, a removable fracture boot should be used and daily range of motion (ROM) exercises started to minimize the stiffness and disuse muscle atrophy that can be caused by further immobilization. Radiographs are repeated and the patient reexamined at 8 weeks. If there is no evidence of callus on the radiograph, orthopedic consultation should be considered. An acceptable alternative is to continue rehabilitation exercises to restore function, use a functional stirrup splint as needed for support, and repeat the radiographs at 12 weeks after the injury. If there is still no radiographic healing, the patient should be referred to an orthopedist. Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B9780323546553000139 Fractures and Dislocations of the AnkleKeith Heier MD, Cory A. Collinge MD, in Core Knowledge in Orthopaedics: Trauma, 2008 Medial Malleolus Fractures• Medial malleolus fractures usually occur in conjunction with lateral malleolus fractures but occasionally occur as an isolated injury in P-ER or P-AB injuries (see Figure 21-2). •Obtaining radiographs of the entire tibia and fibula is important because an “isolated” medial malleolus may be part of a more complex “Maisonneuve fracture” with a proximal fibula fracture and injury to the syndesmosis. •Medial malleolar fractures may be transverse, oblique, or nearly vertical in orientation. •Transverse or oblique fractures represent avulsion injuries and may involve the entire medial malleolus or just the anterior colliculus. This distinction is made by careful review of the lateral radiograph. Because the deep deltoid ligament attaches to the posterior colliculus, injury to the deep deltoid ligament can coexist with an anterior collicular fracture. •In this case, repair of the anterior malleolar fragment will not restore competence of the medial ligament, and the ankle may remain potentially unstable. •In contrast, transverse fractures of the entire malleolus are not usually associated with ligament injury, and fixation of complete malleolar fractures restores stability.10 •Currently, long-term studies on outcomes of isolated medial malleolus fractures do not exist. •We recommend that nondisplaced or minimally displaced fractures be treated with immobilization, but fractures displaced more than 2 mm should be treated with ORIF. •Plain radiographs provide limited accuracy for imaging the medial malleolus, and even small amounts of residual radiographic displacement of medial malleolus fractures may in reality correlate to much larger amounts of true malreduction. •One should carefully scrutinize all three radiographic views of the ankle in assessing these injuries, and if the fracture pattern is not clearly visualized, a CT scan should be performed. •It has been suggested that a sizable malreduced fracture may behave as a deltoid ligament injury and lead to dynamic ankle instability.7 •Strong consideration should also be given to open reduction for fractures in which small osseous or osteochondal fragments are in the joint because these can lead to mechanical wear or impingement. •When the fractured medial malleolus is exposed, the joint should be carefully inspected for free fragments or chondral injuries, which may indicate a more guarded prognosis for the ankle. Surgical Technique of Medial Malleolar Fixation• We use a curvilinear incision extending from above the anteromedial aspect of the ankle joint superiorly and curves distally around the tip of the medial malleolus. •The advantage of this approach is the excellent visualization of the medial ankle joint and fracture reduction proximally and allows for a lag screw to be placed distally. •Partially threaded lag screws are placed if there is a transverse or oblique fracture. •The disadvantage of this approach is that the surgeon necessarily encounters the saphenous vein and nerve, which must be carefully preserved. •Some surgeons prefer a straight longitudinal medial incision extending over the fracture and the tip of the medial malleolus or a curved incision that extends around the posterior aspect of the medial malleolus. A major limitation of these approaches is impaired visualization of the articular reduction and any articular injury. •Furthermore, making an incision of the skin directly over the bone could lead to potentially catastrophic wound problems that may require a free tissue transfer. •Reduction of the medial malleolus is typically straight forward, but we have found a few “technical tricks” that are helpful. •First, a surprisingly large flap of periosteum is often present medially, which may incarcerate in the fracture and prevent accurate reduction or make fracture visualization more difficult. •This periosteal flap may be amputated as it extends off the bone of the malleolar fragment. •Second, manipulation of the malleolar fragment may be aided by insertion of K-wires through its tip. •Once reduction is achieved, these wires may be inserted across the fracture into the distal tibial metaphysis for provisional fixation. •Maintaining two points of fixation is recommended (provisionally and definitively) to prevent rotational dis-placement. •Other potentially useful instruments for this manipulation include the dental pick and the small pointed reduction clamp (a drill hole can be made on the distal tibia's medial cortex proximally). •Assessment of reduction is accomplished by direct visualization of the extraarticular fracture line medially and anteriorly and at the anteromedial corner of the ankle joint. •Ideally then, if cannulated screws are to be used, three K-wires should be placed so that when a screw's pilot hole is drilled and that K-wire's stabilizing effect is lost, reduction will be maintained. •Most medial malleolus fractures are well fixed with two partially threaded cancellous lag screws (Figure 21-11), either cannulated (3.5 to 4.5 mm) or noncannulated (4 mm). •A technical trick for placing noncannulated screws involves using a cannulated drill and tap over a precisely placed guidewire and then removing the guidewire and placing the solid core screw in the already drilled location. •Depending on the fracture configuration, smaller fragments may be fixed with a screw and a K-wire (cut short and bent) placed for rotational stability. •Comminuted fractures may require a tension band construct or even supplemental fixation with minifragment screws. S-AD type fractures (see Figure 21-2) or other more vertically oriented fractures that extend further into the tibia should be fixed with an antiglide plate (with or without lag screws) to prevent vertical migration (Figure 21-12). Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B978032303424110021X Foot and AnkleMichael Noordsy, in Orthopaedics for Physician Assistants (Second Edition), 2022 Operative ManagementICD-10 S82.53XA Closed medial malleolus fracture S82.63XA Closed lateral malleolus fracture S82.843A Closed bimalleolar ankle fracture S82.853A Closed trimalleolar fracture S82.873A Closed tibial pilon fracture CPT 27792 ORIF lateral malleolus 27814 ORIF bimalleolar fracture 27823 ORIF trimalleolar fracture (with posterior malleolus ORIF) Indications• Instability of ankle or syndesmosis, significant fracture displacement •Open fractures require immediate surgical débridement and antibiotic therapy. Staged treatment is often used in open fractures. External fixator is initially placed to stabilize the fracture/joint followed by delayed ORIF once soft tissues allow. •Bimalleolar and trimalleolar fractures result in instability of mortise and surgical fixation necessary to stabilize ankle. •Medial malleolar fractures are often associated with injury to the deltoid ligament and most require ORIF. Informed consent and counseling• Risks include wound complications, infection, nonunion, and DVT. The rate of complication is significantly higher in diabetics, nicotine users, and patients with peripheral vascular disease.1 Posttraumatic arthritis may still occur despite proper stabilization. Major structures at risk are the superficial peroneal nerve (crosses fibula approximately 4 to 5 cm proximal to joint) and saphenous vein (for medial incisions). Anesthesia• General anesthesia with ankle or popliteal block Patient positioning• Supine with toes pointing directly toward ceiling. A small bump can be placed under the ipsilateral hip to internally rotate the leg. Place a thigh tourniquet. Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B9780323709842000089 Fractures and Dislocations of the Foot and AnkleT.R. Hockenbury MD, in Orthopaedic Physical Therapy Secrets (Third Edition), 2017 1 How are ankle fractures classified?Ankle fractures are described by the number of malleoli involved: •Single malleolar fracture is a lateral or medial malleolar fracture. Bimalleolar fracture is a fracture of both the medial malleolus and the lateral malleolus. •Trimalleolar fracture is a fracture of the lateral malleolus, medial malleolus, and posterior aspect of the distal tibial articular surface. There are two major classification systems for ankle fractures: the Weber/AO classification and the Lauge-Hansen classification (more complex). Fractures are classified to dictate treatment, simplify communication between medical personnel treating the fracture, and predict outcome. The Weber/AO classification is the simplest method to classify ankle fractures: •Weber A—below the level of the syndesmosis •Weber B—at or near the level of the syndesmosis; 50% have disruption of the syndesmosis •Weber C—above the level of the syndesmosis; > 50% have disruption of the syndesmosis The four Lauge-Hansen classes are (the first term in parentheses refers to the foot position and the second term describes the external force applied to the ankle): •Supination-Adduction (SA, 10%–20%) •Supination-External Rotation (SER, 40%–75%) •Pronation-Abduction (PA, 5%–20%) •Pronation-External Rotation (PER, 5%–20%) Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B9780323286831000771 Ankle FracturesShawn F Kane MD, in The Sports Medicine Resource Manual, 2008 Clinical featuresThe main clinical feature of this type of fracture is tenderness to palpation over both malleoli or significant tenderness of the medial ankle ligaments in the presence of a lateral malleolar fracture. The fracture pattern will help with the identification of the mechanism that caused the injury, and it will also increase the suspicion for a possible deltoid ligament injury. Inversion injuries are associated with a vertical fracture of the medial malleolus and a transverse fracture of the lateral malleolus. Eversion injuries usually have a transverse fracture of the medial malleolus and a spiral/vertical fracture of the lateral malleolus. A spiral fibular fracture that is 2 to 3 inches proximal to the mortise or a fibular fracture at the joint line should prompt a thorough evaluation of the medial structures of the ankle.1 Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B978141603197010028X Skeletal traumaNyree Griffin MD FRCR, Lee Alexander Grant BA (Oxon) FRCR, in Grainger & Allison's Diagnostic Radiology Essentials, 2013 Weber A fracture• A transverse fracture of the distal fibula below the joint mortise (an avulsion injury) + an oblique fracture of the medial malleolus (an impaction injury) ▸ there is a preserved tibiofibular complex ▸ it can be treated with closed reduction and casting •Following ankle supination Weber B fracture (the most common)• An oblique, spiral lateral malleolar fractureat the level of the joint mortise (an impaction injury) + avulsion of the deltoid ligament (± avulsion fracture of the medial malleolus) ▸ there is partial rupture of the tibiofibular complex ▸ it may require surgery •Following ankle supination with external rotation Weber C fracture• A proximal fibula fracture above the joint mortise ▸ there is avulsion of the deltoid ligament (± an avulsion fracture of the medial malleolus) ▸ there is a ruptured tibiofibular complex ▸ this usually requires surgery •Following ankle pronation with external rotation Pilon fracture• A comminuted supramalleolar distal tibial fracture extending into the tibial plafond ▸ it is caused by axial loading and impaction of the talar dome against the tibial plafond (driving the fragments apart) ▸ it is associated with distal fibular fractures Tillaux and triplanar fractures• See paediatric fracture section Trimalleolar fracture• A fractured posterior lip of the distal tibia + a fractured medial and lateral malleoli Maisonneuve fracture• An avulsion fracture of the medial malleolus – the force is dissipated superiorly causing disruption of the interosseous ligament (joining the fibula and tibia) with an associated proximal fibula fracture ▸ it usually requires surgery Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B9780702034480000372 Open Reduction and Internal Fixation of the AnkleGraham Linck, ... Richard D. Ferkel, in Rehabilitation for the Postsurgical Orthopedic Patient (Third Edition), 2013 Surgical Indications and ConsiderationsAnkle fractures can be treated conservatively if the ankle mortise remains stable. The medial clear space (space between medial malleolus and talus) or lateral clear space (space between lateral malleolus and talus) must measure less than 3 mm on a mortise radiographic view, or less than 5 mm on a stress radiographic view. It is important to ensure that the talus is well reduced beneath the tibia plafond and not subluxated forward or backward. The following specific injuries are indications for conservative treatment: isolated nondisplaced medial malleolar fracture or tip avulsion fracture, isolated lateral malleolar fracture with less than 3 mm displacement and no talar shift, and a posterior malleolar fracture with less than 25% joint involvement or less than 2-mm stepoff. Conservative management usually entails immobilization in a short-leg cast or boot, which extends to the tips of the toes with the foot in an appropriate position for the type of fracture deformity. Any fracture of the ankle with a residual talar tilt or subluxation, in which the ankle mortise is not anatomically reduced, warrants surgical fixation. In general, ORIF should be performed on all patients, regardless of age, gender, activity level, or vocation, as long as they are healthy enough to undergo the procedure. However, exceptions do exist, including paraplegics and quadriplegics, and patients who are nonambulatory and lack sensation to the lower extremities. Preoperative variables that predict a successful outcome include an otherwise healthy patient who is well motivated to recover after surgery. Systemic diseases such as osteoporosis, diabetes, peripheral vascular disease, alcoholism, and tobacco abuse can all affect the ultimate outcome of surgery. These variables affect wound healing, as well as the healing of the fracture itself. Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B9780323077477000290 Foot and Ankle FracturesJames T. Reagan MD, ... John J. Jasko MD, in Clinical Orthopaedic Rehabilitation: a Team Approach (Fourth Edition), 2018 Ankle FracturesBackgroundThe incidence and severity of ankle fractures has significantly increased since the mid-20th century to approximately 187 fractures per 100,000 people each year (Egol et al. 2010c). The highest incidence occurs in elderly females and young adult males. The mechanism of injury for an ankle fracture is classically a twisting or rotational injury, and thus most are not typically regarded as high energy fractures (Davidovitch and Egol 2010). About two thirds of ankle fractures are isolated malleolar fractures; one fourth are bimalleolar, and the remaining 5% to 10% are trimalleolar (Egol et al. 2010c). Increased BMI and cigarette smoking are both considered risk factors for sustaining an ankle fracture. Stable Versus UnstableThe ankle joint functions as a complex hinge and consists of the articulations of the distal tibia, distal fibula, and the talus. The distal tibial articular surface, termed the plafond, in concert with the medial and lateral malleoli form the ankle mortise. In addition to the bony anatomy, ligamentous structures contribute to the stability of the ankle. The deltoid ligament complex provides support to the medial aspect of the ankle. The syndesmotic ligament complex confers stability to the distal tibia-fibula articulation, and the fibular collateral ligament complex (anterior talofibular, posterior talofibular, and calcaneofibular ligaments) add lateral stability to the joint. In general, anatomic reduction and stability of the ankle mortise are the primary determinants upon which treatment decisions regarding ankle fractures are made (Davidovitch and Egol 2010). Ankle fractures can generally be divided into avulsion fractures, isolated malleolus fractures, bimalleolar fractures, trimalleolar fractures, and those with syndesmosis disruption. Isolated avulsion fractures represent injuries where ligaments have avulsed a small piece of bone from either the medial or lateral malleoli. Thus, they often can be treated nonoperatively in a manner similar to ligamentous sprains. Isolated malleolus fractures can be treated either nonoperatively or operatively depending on the stability of the mortise and amount of displacement of the fracture. Most isolated lateral malleolus fractures at or distal to the plafond are stable injuries in which the mortise remains reduced due to the intact syndesmosis and thus may be treated nonoperatively (Davidovitch and Egol 2010). However, with lateral malleolus fractures that occur proximal to the plafond there is a higher rate of mortise instability or syndesmosis disruption, and these fracture patterns deserve further investigation with a stress radiograph to determine stability. If a stress exam demonstrates significant lateral talar tilt or displacement or significant widening of the syndesmosis, then the fracture is unstable and thus would be appropriately treated surgically to restore the anatomy and stability of the mortise (Davidovitch and Egol 2010). Some recent literature suggests that nonoperative treatment of unstable fractures is possible if one is able to hold the mortise anatomically reduced with immobilization, but this is not the gold standard at this time. One must also consider the deleterious effects of prolonged cast immobilization that is required for nonoperative treatment of unstable fractures. Initial treatment of displaced or unstable ankle fractures should include closed reduction and immobilization in the emergency department. Most experts would agree that bimalleolar and trimalleolar fractures are inherently unstable and therefore need to be treated with surgery (Egol et al. 2010c, Rudloff 2013). Likewise, disruption of the syndesmosis should be treated operatively to restore mortise stability (Davidovitch and Egol 2010, Rudloff 2013). Fig. 38.1, A is a radiograph of a trimalloelar ankle fracture with obvious syndesmosis disruption, and Fig. 38.1, B shows the same ankle after open reduction internal fixation (ORIF). RehabilitationStability also plays a critical role in the rehabilitation protocols used for these injuries. In the case of stable isolated malleolus fractures, including avulsion fractures, the patient can be treated with bracing and may weight bear as tolerated (WBAT) (Egol et al. 2010c). Physical therapy should initially focus on managing swelling and edema and returning ankle range of motion (ROM) to preinjury levels. Gradually, after a period of about 4 to 6 weeks, the patient may progressively wean from bracing to full weight bearing (FWB) (Davidovitch and Egol 2010). At this point, therapy should focus on strengthening of the foot and ankle musculature, in particular the lateral everters, and move on to proprioceptive training analogous to the therapy regimen used for severe ankle sprains (Chinn and Hertel 2010, Davidovitch and Egol 2010). The final category includes unstable ankle fractures treated in an operative manner. These patients may require a period of time preoperatively to allow the swelling to decrease and provide a soft tissue envelope conducive for surgical intervention. Postoperatively, these fractures are typically held immobilized in a splint or cast for 10 to 14 days to allow wound healing. In a patient with good bone quality and stable anatomic fixation, a removable fracture boot is applied once the wound has healed so that gentle ankle active and passive ROM exercises within pain tolerance may begin (Davidovitch and Egol 2010, Egol 2011, Rudloff 2013). Studies have shown that early motion is associated with improved early functional outcomes in these fractures (Davidovitch and Egol 2010). In situations of tenuous fixation or poor bone quality and medical comorbidities, the surgeon may extend the immobilization period. Patients are typically NWB for a period of 4 to 6 weeks postoperatively until there is radiographic evidence of healing. Exceptions to this include the neuropathic patient, which will be discussed later, and fractures requiring syndesmosis fixation, which will require about 8 weeks of NWB (Davidovitch and Egol 2010). After 6 weeks, patients may progressively WBAT and begin to work toward restoration of full ROM and strength. When FWB has been achieved, rehab progresses in a similar fashion as after an ankle sprain with functional and proprioceptive training. Studies have shown that patients return to baseline breaking function while driving about 9 weeks status post right ankle surgery (Davidovitch and Egol 2010, Egol 2011). Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B978032339370600038X Can you walk with a fractured lateral malleolus?Similar to a nondisplaced medial malleolus fracture, a nondisplaced lateral malleolus fracture can often be treated with a short leg cast or walking boot. Most isolated lateral malleolus fractures are stable enough to allow you to put weight on the ankle.
Is a lateral malleolus fracture serious?Ankle fractures tend to be stable (less serious) or unstable (more serious). Lateral malleolus fractures are stable ankle fractures, and you usually don't need surgery. They can happen when you take an awkward step and roll your ankle. To treat these ankle fractures, aim to reduce pain and swelling.
Do I need a cast for a lateral malleolus fracture?OVERVIEW: Lateral malleolar fractures are fractures that occur in the distal aspect of the fibula. They can be distal, at or proximal to the joint line of the ankle. CONSERVATIVE CARE: If non-displaced and stable, these fractures can be treated non-operatively with cast immobilization.
Can lateral malleolus fracture heal without surgery?Isolated lateral malleolar fractures can be treated with or without surgery, depending on their location and placement. Stable fractures treated without surgery can often be safe for immediate protected (in a boot) weight bearing.
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How long does a lateral malleolus fracture take to heal
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