import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Location**: Emerges between peroneus tertius and EDL approximately 10cm proximal to lateral malleolus tip, pierces crural fascia and runs subcutaneously to dorsum of foot providing sensory innervation to dorsal foot. **Protection**: Stay posterior to posterolateral fibular border during lateral approach. Identify and protect if encountered in subcutaneous tissues. Injury causes dorsal foot numbness and painful neuroma. **Location**: Runs posterolateral along lateral border of Achilles tendon, crosses laterally approximately 10cm proximal to lateral malleolar tip to reach lateral foot. Supplies sensation to lateral foot and 5th toe. **Protection**: Incision 1cm posterior to posterolateral fibular border keeps anterior to nerve. Visualize and protect during posterolateral dissection. Injury causes lateral foot numbness and painful neuroma formation. **Location**: Runs anterior to medial malleolus at subcutaneous level tracking 1-2cm anterior to medial malleolar tip. Provides sensation to medial foot and ankle. **Protection**: Medial incision 1cm posterior to medial malleolar tip protects structures. Identify early in superficial dissection. Saphenous nerve injury (5-10%) causes medial foot dysesthesias and problematic for patients. **Location**: Runs posterior to medial malleolus within tarsal tunnel, located between posterior tibial tendon (anterior) and flexor hallucis longus (posterior). Continues to divide into medial and lateral plantar nerves beneath flexor retinaculum. **Protection**: Stay anterior to posterior tibial tendon during medial malleolar exposure. Avoid aggressive retraction posterior to malleolus. Essential for plantar foot sensation and intrinsic muscle function. **Location**: Run anterior to ankle joint between tibialis anterior and extensor hallucis longus tendons, approximately 1-2cm lateral to tibial crest at ankle level. Continue onto dorsum of foot. **Protection**: Critical when placing anterior-to-posterior screws for posterior malleolus - insert screw 3-4cm proximal to joint and 1-2cm medial to tibial crest, aim posterolaterally. Palpate anterior tibial pulse to identify neurovascular bundle location. ## Weber Classification **Based on fibular fracture level relative to syndesmosis:** ## Lauge-Hansen Classification **Based on mechanism - position of foot then direction of deforming force:** **Clinical Relevance**: Lauge-Hansen predicts injury pattern and guides assessment of associated ligamentous injuries. SER most common mechanism in low-energy ankle fractures. ## Medial Malleolar Fracture Classification ## Posterior Malleolar Classification (Haraguchi) **Fixation Threshold**: >25% plafond involvement on lateral view OR >2mm articular step-off ## Ankle Mortise Anatomy **Tibiotalar Joint**: Highly congruent modified hinge joint - **Tibial plafond**: Concave articular surface with medial malleolus and anterior/posterior tibial lips - **Fibular mortise**: Lateral wall formed by distal fibula articulating with lateral talar dome - **Talus**: Trapezoidal dome - wider anteriorly (10-15% wider than posterior) creating mortise stability in dorsiflexion **Critical Measurements on Radiographs:** - **Medial clear space**: Distance from medial talar dome to medial malleolus tip - normal <4mm, should equal superior clear space within 1mm - **Tibiofibular clear space**: Distance between medial fibular border and posterior tibial incisura - normal <6mm on AP view - **Tibiofibular overlap**: Overlap of fibula and tibia should be >6mm on AP view (or >42% of fibular width) - **Talocrural angle**: 83±4° on mortise view - decreased with varus tilt, increased with valgus ## Syndesmotic Complex **Four Ligamentous Components:** 1. **Anterior Inferior Tibiofibular Ligament (AITFL)** - Strongest - resists external rotation and lateral fibular translation - Origin: Anterior tubercle of tibia (Chaput tubercle) - Insertion: Anterior fibular tubercle (Wagstaffe tubercle) 2. **Posterior Inferior Tibiofibular Ligament (PITFL)** - Deep and superficial components (Volkmann fragment when avulsed) - Resists posterior fibular translation and external rotation - Stronger than AITFL 3. **Interosseous Tibiofibular Ligament** - Distal extension of interosseous membrane - Provides stability throughout syndesmosis 4. **Interosseous Membrane** - Runs entire length of leg - High injuries (Maisonneuve) disrupt membrane extensively **Biomechanics**: Syndesmosis widens 1-2mm during dorsiflexion (talus wider anteriorly). Disruption increases external rotation and lateral translation of talus, accelerating arthritis. ## Deltoid Ligament Complex **Superficial Layer** (tibiospring, tibionavicular, tibiocalcaneal, superficial tibiotalar): - Resists valgus tilting - Broader fan-shaped origin from anterior colliculus of medial malleolus **Deep Layer** (deep posterior tibiotalar): - Resists external rotation and lateral talar shift - Most critical for mortise stability - Origin: Posterior colliculus and intercollicular groove **Clinical Significance**: Deep deltoid rupture allows lateral talar shift even with intact superficial layer. Bimalleolar equivalent = lateral fracture with deltoid rupture (medial clear space >4mm). ## Fibular Biomechanics **Functions:** 1. Lateral buttress preventing lateral talar shift 2. Maintains syndesmotic width 3. Load transmission - fibula bears 10-15% of axial load through syndesmosis **Critical Principles:** - **Length restoration paramount**: 2mm shortening increases tibiotalar contact stress 42% and shifts load medially - **Rotation**: Lateral malleolus must point anteriorly toward 1st toe - external rotation malreduction common error - **Alignment**: Sagittal plane bow must be restored ## Blood Supply **Fibula**: Peroneal artery (nutrient vessel at middle third) - preserve periosteal sleeve **Medial malleolus**: Branches from posterior tibial and anterior tibial arteries **Talus**: Vulnerable - supplied by branches from posterior tibial, peroneal, and dorsalis pedis - AVN risk with severe talar body displacement or fractures ## Fibular Fixation Options ## Syndesmotic Fixation Options ## Medial Malleolar Fixation Variations ## Posterior Malleolar Fixation Approaches ## Landmark Studies **Fibular Length and Outcomes:** - **Ramsey & Hamilton (1976)**: Classic cadaveric study demonstrating 1mm lateral talar shift decreases tibiotalar contact area 42% - **Leeds & Ehrlich (1984)**: 2mm fibular shortening increases contact stress and correlates with arthritis development - **Clinical Correlation**: Multiple series show residual talar shift >1mm predicts poor outcome and arthritis **Syndesmotic Fixation:** - **Andersen et al (2019)**: RCT comparing suture button vs screw - equivalent outcomes, lower removal rate with suture button - **Laflamme et al (2006)**: Tricortical vs quadricortical screws - similar stability, lower malreduction and removal with tricortical - **Wikerøy et al (2010)**: Syndesmotic malreduction (>2mm) occurred in 52% of cases and correlated with poor outcomes - **Consensus**: Anatomic syndesmotic reduction more important than fixation method **Posterior Malleolus:** - **Bartoníček et al (2015)**: Large retrospective series - fragments >25% plafond or >2mm step benefit from fixation - **Verhages et al (2017)**: Fixation of posterior malleolus improves syndesmotic stability and may reduce screw fixation need - **Gardner et al (2006)**: Direct fixation provides better reduction than indirect techniques for large fragments **Weber B Stability:** - **Michelson et al (2007)**: Isolated Weber B with intact medial structures can be treated conservatively with good outcomes - **Stress radiographs under anesthesia help determine true stability in borderline Weber B fractures** ## Australian Context - AOANJRR Data While AOANJRR focuses on arthroplasty, trauma registry data relevant to ankle fractures: - **Post-traumatic ankle arthritis**: 15-30% at 10-20 years even with anatomic reduction (Victorian Orthopaedic Trauma Outcomes Registry) - **Conversion to ankle arthroplasty**: Increasing in Australia for post-traumatic arthritis; AOANJRR shows ankle replacement revision rate 9.4% at 10 years - **PBS implications**: No specific PBS considerations for ORIF; post-traumatic arthritis may qualify for subsidized arthroplasty ## eTG Antibiotic Guidelines (Australia) **Prophylaxis for Closed Fracture ORIF:** - **Cefazolin 2g IV** at induction (3g if >120kg) - **Additional doses** q4h intraoperatively if prolonged - **Penicillin allergy**: Vancomycin 25-30mg/kg IV or clindamycin 600mg IV **Open Fracture (Gustilo I-IIIB):** - **Cefazolin 2g IV q8h** PLUS **gentamicin 4-7mg/kg IV daily** for 24-72 hours - Consider **benzylpenicillin 1.8g IV q4h** if soil/agricultural contamination (Clostridium coverage) ## Outcome Data **Functional Outcomes (Meta-analyses):** - **Good-excellent outcomes**: 75-85% with anatomic reduction - **Return to sport**: 4-6 months for impact activities; 6-12 months for elite athletes - **Residual symptoms**: 20-30% report chronic ankle pain or stiffness at 2 years - **Arthritis development**: 15-30% radiographic arthritis at 10+ years **Predictors of Poor Outcome:** - Residual talar shift >1mm (strongest predictor) - Syndesmotic malreduction - Posterior malleolar step-off >2mm - Patient factors: age >50, diabetes, smoking, workers' compensation **Patient Position**: Supine with radiolucent table. Small bump under ipsilateral hip to internally rotate leg 15-20° (brings fibula anterior for exposure). Knee flexed 30-45° over triangle or end of table - allows gravity to assist fibular reduction and provides access to posterior structures if needed. **Surgical Approach**: Lateral approach for fibula (posterolateral border), medial approach for medial malleolus (anterior to posterior tibial tendon). May need posterolateral approach for posterior malleolus if >25% tibial plafond involved or significantly displaced. **Incision Planning**: - **Lateral**: 8-12cm incision centered 1cm posterior to posterolateral border of fibula extending from mid-shaft to tip - **Medial**: 6-8cm curvilinear incision 1cm posterior to medial malleolar tip extending proximally along posterior border of tibia - **Posterior (if needed)**: Between peroneal tendons and Achilles tendon or posteromedial between FHL and neurovascular bundle **Tourniquet**: Thigh tourniquet optional - improves visualization but increases risk if prolonged. Consider tourniquet-free technique if soft tissue concerns. **Imaging Setup**: C-arm positioned on contralateral side for AP, mortise (15-20° internal rotation), and lateral views of ankle. Ensure all views obtainable before draping. Have contralateral ankle X-rays available for comparison. ### Step 1: Patient Positioning and Pre-operative Planning Patient Positioning and Pre-operative Planning: Position patient supine with bump under ipsilateral hip achieving 15-20° internal rotation. Knee flexed 30-45° over triangle or end of table. Thigh tourniquet applied but consider tourniquet-free if soft tissue concerns. Prep and drape circumferentially from mid-calf to toes. C-arm positioned on contralateral side. Systematic pre-operative imaging review: (1) Weber classification (A/B/C based on fracture level relative to syndesmosis), (2) Medial injury pattern (malleolar fracture vs deltoid rupture - medial clear space >4mm suggests deltoid), (3) Syndesmotic injury indicators (tibiofibular clear space >6mm, decreased overlap <6mm, medial clear space widening), (4) Posterior malleolar involvement (measure % on lateral view - fix if >25% or >2mm step-off). CT scan invaluable for surgical planning especially if posterior malleolus involved - assess fragment size, rotation, comminution. **Technical Tip**: EXAM KEY: 'Pre-operative CT scan essential for complex fractures - provides accurate assessment of posterior malleolar size and displacement, fibular fracture pattern and comminution, syndesmotic injury, and surgical planning. I systematically assess Weber type, medial injury (fracture vs deltoid), syndesmotic integrity, and posterior malleolus. Positioning critical - bump internally rotates leg bringing posterolateral fibula anterior for direct exposure.' - Inadequate pre-operative imaging missing syndesmotic or posterior malleolar injury requiring different surgical plan - Poor positioning making fibular exposure and reduction difficult - Operating through compromised soft tissue envelope - delay for wrinkle sign if severe swelling or fracture blisters ### Step 2: Lateral Fibular Approach and Exposure Lateral Fibular Approach and Exposure: Longitudinal 8-12cm incision centered 1cm posterior to posterolateral border of fibula from mid-shaft to lateral malleolar tip. Incise skin and subcutaneous tissues. Identify and protect superficial peroneal nerve if visible (emerges ~10cm proximal, runs subcutaneously) and sural nerve (runs along lateral Achilles border). Deepen to fibular periosteum. Elevate periosteum anteriorly and posteriorly as continuous sleeve using periosteal elevator - preserve periosteal blood supply to fracture fragments. Expose fracture site and adequate length proximal (4-6cm) and distal (2-3cm) for plate application. Protect peroneal tendons posteriorly. Place Hohmann retractors anterior and posterior. Clean fracture site of hematoma and debris using pulsatile lavage and curette. Assess fracture pattern - simple oblique (most Weber B SER), comminuted (Weber C or high-energy Weber B). **Technical Tip**: EXAM KEY: 'Lateral approach to fibula - incision 1cm posterior to posterolateral border protects superficial peroneal nerve anteriorly and sural nerve posterolaterally. I elevate soft tissue as single continuous periosteal sleeve to preserve fracture biology. Expose adequate length for plate - typically 6-8 hole one-third tubular plate for Weber B, longer for Weber C. Assess fracture pattern to determine fixation strategy - simple oblique allows lag screw compression, comminuted requires bridge plating.' - Sural nerve injury causing lateral foot and 5th toe numbness plus painful neuroma - Superficial peroneal nerve injury causing dorsal foot numbness - Excessive soft tissue stripping causing AVN of fracture fragments - Inadequate proximal and distal exposure preventing optimal plate application ### Step 3: Fibular Fracture Reduction and Provisional Fixation Fibular Fracture Reduction and Provisional Fixation: Anatomic fibular reduction is paramount - determines entire mortise alignment. Three-dimensional reduction required: (1) **LENGTH**: Use intact contralateral fibula as template - measure from lateral malleolar tip to joint line (typically ~1cm) and compare both sides. Even 2mm shortening unacceptable. Use Weber clamp or distraction if shortened. (2) **ROTATION**: Lateral malleolus must point anteriorly toward 1st toe - external rotation malreduction common error. Assess rotational profile of distal fragment. (3) **SAGITTAL ALIGNMENT**: Restore normal anteroposterior bow of fibula. Reduce fracture using pointed reduction clamps or Weber clamp applying longitudinal traction if shortened. Provisional hold with small pointed reduction clamp across fracture or 2.0mm K-wire. Check reduction with fluoroscopy: AP view (fibular length, alignment), mortise view (medial clear space should be <4mm if medial structures intact), lateral view (sagittal alignment). If medial clear space >4mm despite anatomic fibular reduction, indicates syndesmotic or deltoid injury requiring additional fixation. **Technical Tip**: EXAM KEY: 'FIBULAR REDUCTION IS KEY TO ENTIRE ANKLE FRACTURE FIXATION. I confirm anatomic reduction: (1) Length - compare to contralateral ankle, measure from tip to joint line both sides, use calipers; (2) Rotation - lateral malleolus points to 1st toe, not externally rotated; (3) Mortise view shows medial clear space <4mm and symmetric tibiotalar joint space. Even 2mm fibular shortening increases tibiotalar contact stress 42% and predisposes to arthritis. Perfect reduction achievable and required.' - Fibular shortening >2mm - most common error causing talar shift and arthritis (check contralateral radiograph) - Malrotation with external rotation of distal fragment - alters mortise biomechanics - Accepting fracture comminution with bone loss - may need bone graft to restore length - Provisional fixation loosening during plate application - maintain reduction clamp until plate applied ### Step 4: Fibular Plate Application and Fixation Fibular Plate Application and Fixation: One-third tubular plate (3.5mm system) applied to posterolateral fibula (preferred) or lateral fibula. Posterolateral position biomechanically optimal - resists external rotation forces and avoids peroneal tendons. Plate length: 6-8 holes for simple Weber B, longer (8-10 holes) for Weber C or comminuted fractures. Contour plate to match fibular anatomy using bending irons. For **simple oblique fracture** (SER mechanism): Place lag screw perpendicular to fracture line through plate - drill 3.5mm glide hole in near cortex, 2.5mm thread hole in far cortex, measure depth, insert 3.5mm cortical lag screw achieving interfragmentary compression. Then apply plate screws as neutralization - minimum 3 bicortical screws (6 cortices) proximal and 2 bicortical screws (4 cortices) distal to fracture. For **comminuted fracture**: Bridge plate technique - do not compress comminuted zone. Use unicortical or locking screws in comminuted area, bicortical screws in intact bone proximal and distal. Maintain fibular length with plate acting as buttress. Confirm final reduction on fluoroscopy: AP (fibular length, alignment), mortise (medial clear space <4mm, symmetric joint), lateral (sagittal alignment). **Technical Tip**: EXAM KEY: 'I use one-third tubular plate on posterolateral fibula - biomechanically superior and avoids peroneal tendons. Simple oblique Weber B: LAG SCREW perpendicular to fracture through plate for interfragmentary compression, then neutralization plate. Weber C or comminuted: bridge plate maintaining length without lag screw - plate acts as buttress. Final mortise view must show medial clear space <4mm - if widened despite anatomic fibular fixation indicates deltoid incompetence or syndesmotic injury requiring additional fixation.' - Inadequate screw purchase - must achieve bicortical fixation; unicortical insufficient except in comminuted zone with locking plate - Accepting malreduction - check fluoroscopy before final screw tightening - Plate too short - inadequate working length causing fixation failure especially in osteoporotic bone - Over-tightening lag screw causing fracture propagation in osteoporotic bone ### Step 5: Syndesmotic Stability Assessment Syndesmotic Stability Assessment: CRITICAL STEP after anatomic fibular fixation. Systematic stress testing under fluoroscopy to assess syndesmotic competence. **Cotton test** (external rotation stress): Externally rotate foot while watching mortise view - observe medial clear space and tibiofibular clear space. STABLE: no widening. UNSTABLE: medial clear space widens >4mm or tibiofibular clear space widens >6mm. **Hook test** (lateral stress): Use bone hook or clamp to laterally stress fibula - observe tibiofibular relationship. If >2mm lateral translation or increased tibiofibular clear space, syndesmosis incompetent. **Indications for syndesmotic fixation**: (1) Weber C fracture - syndesmosis typically disrupted; (2) Weber B with positive stress test; (3) Medial clear space remains >4mm after anatomic fibular fixation despite intact medial malleolus; (4) Fracture >4.5cm proximal to plafond; (5) Posterior malleolus fracture with PITFL avulsion. When in doubt, fix - consequences of missed syndesmotic instability (chronic pain, instability, arthritis) worse than over-treatment. **Technical Tip**: EXAM KEY: 'I systematically assess syndesmosis after fibular fixation using Cotton test (external rotation stress) and Hook test (lateral fibular stress) under fluoroscopy with mortise view. Normal: medial clear space <4mm, tibiofibular clear space <6mm, tibiofibular overlap >6mm. Weber C fractures almost always need syndesmotic fixation. Weber B may need it if fracture proximal (>4.5cm from plafond) or positive stress test. Literature shows 50% of surgeons miss syndesmotic instability - must stress test systematically.' - Missing syndesmotic injury - leads to chronic instability, pain, and accelerated arthritis (most common major complication) - Inadequate stress testing - must be systematic with fluoroscopic visualization - Assuming Weber B fractures stable - many have syndesmotic injury requiring fixation - Not recognizing importance of posterior malleolar fracture indicating PITFL injury ### Step 6: Syndesmotic Reduction and Fixation (if unstable) Syndesmotic Reduction and Fixation (if unstable): Anatomic syndesmotic reduction paramount - malreduction worse than no fixation. Reduction technique: (1) Ensure fibula reduced anatomically in fibular incisura of tibia; (2) Apply pointed reduction clamp from medial tibia to lateral fibula 2-3cm proximal to joint line - clamp should be parallel to joint, slightly anterior to posterior (if clamp too posterior will externally rotate fibula); (3) Dorsiflex ankle to neutral position - locks wider anterior talus in mortise and reduces syndesmosis; (4) Confirm reduction on AP and mortise fluoroscopy - tibiofibular clear space <6mm, tibiofibular overlap >6mm (or >42% fibular width). **Fixation options**: (1) **Screw fixation** - two 3.5mm cortical screws 2-3cm and 3.5cm proximal to plafond, inserted 25-30° from lateral to posteromedial (parallel to joint line), engage tricortical (preferred - allows micro-motion, may not need removal) or quadricortical (traditional but requires removal 10-12 weeks to prevent breakage); (2) **Suture button device (TightRope)** - flexible construct allowing physiologic motion, no routine removal needed, equivalent outcomes to screws in RCTs. Remove clamp after screw or button placement. Confirm mortise restoration and syndesmotic reduction on fluoroscopy all views. **Technical Tip**: EXAM KEY: 'For syndesmotic fixation I reduce with pointed clamp from medial tibia to lateral fibula 2-3cm proximal to joint, ankle in neutral dorsiflexion to lock talus. Critical: clamp placement parallel to joint and slightly anterior prevents external rotation malreduction of fibula. Traditional fixation: two 3.5mm cortical screws 25-30° anteroposterior. I prefer TRICORTICAL (stops in medial tibial cortex) - allows physiologic motion, lower breakage, may not need removal. Alternative: suture button increasingly popular - allows motion, no removal, similar outcomes. Confirm tibiofibular overlap >6mm and symmetric mortise on AP and mortise views.' - Syndesmotic malreduction with external rotation of fibula in incisura - most common syndesmotic error, check CT post-op if concern - Reduction clamp placed too posterior causing external rotation malreduction - Over-compression causing restricted dorsiflexion and pain - Screw breakage with quadricortical fixation if not removed before weight-bearing (5-20% incidence) - Injury to deep peroneal nerve or anterior tibial vessels during screw insertion ### Step 7: Medial Malleolar Approach and Exposure Medial Malleolar Approach and Exposure: Medial curvilinear incision 6-8cm long starting 1cm posterior to medial malleolar tip extending proximally along posterior border of tibia. Incise skin and subcutaneous tissues. Identify and protect greater saphenous vein (large superficial vein) and saphenous nerve (runs with vein) anteriorly - visualize and retract gently. Deepen to periosteum over medial malleolus and medial tibial metaphysis. Stay anterior to posterior tibial tendon - tendon marks posterior extent of safe dissection. Expose medial malleolar fracture site. Use periosteal elevator to expose fracture and proximal tibia for screw placement. Clean fracture hematoma and debris. Assess fracture pattern: transverse/oblique (most common - avulsion from deltoid tension), vertical shear (SA mechanism - unstable pattern), or comminuted. If vertical shear pattern identified, plan for anti-glide plate fixation as screws alone insufficient. **Technical Tip**: EXAM KEY: 'Medial approach - incision 1cm posterior to medial malleolar tip protects saphenous vein and nerve anteriorly. I identify saphenous structures early and protect throughout. Stay anterior to posterior tibial tendon - this marks posterior extent of dissection and protects posterior tibial neurovascular bundle. Assess fracture pattern - vertical shear requires plate fixation, transverse/oblique can use screws alone. Medial malleolus is articular - reduction must be perfect (zero tolerance for step-off).' - Saphenous nerve injury causing medial foot numbness and painful neuroma (5-10% incidence) - careful identification critical - Saphenous vein injury causing hematoma and wound complications - Injury to posterior tibial neurovascular bundle if dissection extends posterior to PT tendon - Inadequate fracture visualization preventing anatomic reduction ### Step 8: Medial Malleolar Reduction and Fixation Medial Malleolar Reduction and Fixation: Medial malleolus is articular surface - anatomic reduction mandatory with zero tolerance for articular step-off. Reduce fracture using pointed clamps - usually reduces easily with direct pressure. Hold reduction provisionally with 1.6-2.0mm K-wire. Confirm reduction on AP, mortise, and lateral fluoroscopy - articular surface must be flush. **Fixation technique for transverse/oblique fracture** (most common): Two 3.5mm or 4.0mm partially threaded cancellous screws. Insert from distal (malleolar tip) to proximal (tibial metaphysis). If oblique fracture, aim screws perpendicular to fracture line for maximum compression. If vertical fracture, slightly divergent trajectory. Critical: screws must be parallel to tibial plafond to avoid penetrating ankle joint. Technique: Drill 2.5mm guidewire from tip aimed at proximal tibial metaphysis staying parallel to plafond. Measure depth. Drill over wire with 3.5mm drill bit. Insert 3.5mm partially threaded cancellous screw engaging both cortices. Place second screw parallel to first. **Vertical shear pattern**: Requires medial anti-glide plate (one-third tubular) on medial tibial surface acting as buttress - screws alone will fail. Confirm final reduction and hardware position on all fluoroscopic views - ensure mortise restored with medial clear space <4mm and congruent joint space 360°. **Technical Tip**: EXAM KEY: 'Medial malleolus fixed with two 3.5mm or 4.0mm partially threaded cancellous screws from tip to proximal metaphysis. If oblique fracture I aim perpendicular to fracture for compression. Critical: screws must be parallel to tibial plafond, not angled into joint - common error on exam questions. Use lateral fluoroscopy to confirm screws parallel to plafond. Vertical shear fracture pattern (SA mechanism): screws alone insufficient - use medial anti-glide buttress plate. Confirm mortise restored with medial clear space <4mm and congruent joint space.' - Screws angled into ankle joint - must be parallel to plafond (check lateral fluoroscopy) - Malreduction with articular step-off - causes arthritis; reduction must be perfect - Inadequate screw purchase in osteoporotic bone - may need longer screws or consider plate - Using screws alone for vertical shear pattern - will fail; requires anti-glide plate ### Step 9: Posterior Malleolar Assessment and Fixation (if indicated) Posterior Malleolar Assessment and Fixation (if indicated): Assess posterior malleolus on lateral fluoroscopy. Measure fragment size as percentage of tibial plafond - draw lines from anterior and posterior tibial lips to center of talar dome, measure fragment size. **Fixation indications**: (1) Fragment >25% of tibial plafond on lateral view; (2) Articular step-off >2mm; (3) Syndesmotic instability (PITFL attached to fragment). Small fragments (<25%, <2mm step) often reduce indirectly with anatomic fibular fixation and syndesmosis - verify on lateral fluoroscopy after fibular and syndesmotic fixation. **Fixation options**: (1) **Percutaneous anterior-to-posterior lag screws** if minimally displaced - patient remains supine. Insert 2.7mm or 3.5mm screws from anterior tibia 3-4cm proximal to joint, 1-2cm medial to tibial crest, aim posterolaterally into posterior malleolar fragment. Palpate anterior tibial pulse to avoid neurovascular bundle. One or two screws. (2) **Posterolateral approach with direct reduction and plate fixation** if large displaced fragment - approach between peroneal tendons and Achilles, buttress plate on posterior tibia. (3) **Posteromedial approach** if medial extension (Haraguchi Type II). Goal: restore posterior plafond articular congruity, improve syndesmotic stability, prevent posterior talar subluxation. **Technical Tip**: EXAM KEY: 'Posterior malleolus fixation indicated if >25% plafond OR >2mm articular step-off. Small fragments often reduce indirectly with fibular and syndesmotic fixation - verify on lateral view. Large fragments: I use percutaneous A-P screws if minimally displaced - 2.7 or 3.5mm partially threaded screws from anterior tibia 3-4cm proximal, 1-2cm medial to crest, aim posterolaterally. Stay medial to avoid anterior neurovascular bundle - palpate anterior tibial pulse. Large displaced fragments require posterolateral approach and buttress plate. Fixation improves syndesmotic stability and outcomes.' - Deep peroneal nerve and anterior tibial vessel injury with A-P screws - stay medial (1-2cm from tibial crest) and proximal (3-4cm from joint) - Under-treatment of large posterior fragments causing persistent syndesmotic instability and posterior talar subluxation - Intra-articular screw penetration into ankle joint - check fluoroscopy carefully - Malreduction of posterior fragment accepting articular step-off ### Step 10: Final Reduction Confirmation and Stability Testing Final Reduction Confirmation and Stability Testing: Systematic final fluoroscopic assessment of ankle mortise restoration. **AP view**: (1) Tibiotalar joint space symmetric; (2) Tibiofibular overlap >6mm and <10mm (or >42% fibular width); (3) Tibiofibular clear space <6mm; (4) Medial clear space <4mm and should equal superior clear space within 1mm. **Mortise view (15-20° IR)**: (1) Symmetric medial and lateral clear space (both <4mm); (2) Congruent tibiotalar joint space 360° around talar dome; (3) No talar shift - medial clear space critical measurement. **Lateral view**: (1) Posterior malleolar reduction if fixed (step-off <2mm); (2) No anterior or posterior talar subluxation; (3) Hardware position - screws parallel to plafond. If any asymmetry identified: reassess fibular length and rotation, syndesmotic reduction, medial malleolar reduction. Perform stress views if concern about residual instability. Range of motion testing: Gently dorsiflex and plantarflex ankle - should have smooth motion without crepitus or mechanical block. Ensure no hardware impingement. Remove all provisional K-wires. Irrigate all wounds thoroughly with 3L pulsatile lavage. **Technical Tip**: EXAM KEY: 'Final imaging must confirm ANATOMIC MORTISE RESTORATION - perfect reduction is achievable and required. Mortise view most critical: I assess symmetric medial and lateral clear space (both <4mm), tibiofibular overlap >6mm, congruent tibiotalar joint 360° around talar dome. Even 1mm of talar shift (medial clear space >4mm) doubles tibiotalar contact stress and predisposes to arthritis. If any asymmetry: reassess fibular length (compare contralateral), rotation (lateral malleolus points to 1st toe), syndesmotic reduction (stress test), and medial fixation. Don't accept malreduction.' - Accepting residual talar shift (medial clear space >4mm) - most important predictor of poor outcome - Missing syndesmotic malreduction - external rotation of fibula in incisura (CT post-op if concern) - Intra-articular hardware - screws penetrating ankle joint - Forgetting to remove provisional K-wires before closure ### Step 11: Deltoid Ligament Assessment and Management Deltoid Ligament Assessment and Management: After medial malleolar fixation complete (or if no malleolar fracture but suspected deltoid rupture - "bimalleolar equivalent" injury), assess deltoid integrity. On mortise fluoroscopy with anatomic fibular and syndesmotic fixation, medial clear space should be <4mm and equal to superior clear space. If medial clear space remains >4mm despite anatomic fibular and syndesmotic fixation, indicates deep deltoid ligament incompetence. Options: (1) **Direct repair** if deltoid tear identified on exploration - use non-absorbable sutures to repair torn deltoid to medial malleolus or tibial attachment; (2) **Suture anchor repair** - place suture anchors in medial malleolar footprint and repair deep deltoid; (3) **Accept widening** if mortise otherwise stable - some literature suggests anatomic fibular fixation alone sufficient with good outcomes. Current consensus: if medial clear space persistently >4mm, repair deltoid to ensure mortise stability and prevent chronic talar shift. Technique: If exploring deltoid, incise between superficial and deep layers, identify tear (usually at tibial or malleolar insertion), repair with suture anchors or transosseous sutures. **Technical Tip**: EXAM KEY: 'Bimalleolar equivalent injury = lateral malleolar fracture with deltoid rupture (no medial malleolar fracture). Diagnosis: medial clear space >4mm despite anatomic fibular fixation. I address deltoid if persistent widening - suture anchor repair to medial malleolar footprint or direct repair if tear identified. Deep deltoid most critical for preventing lateral talar shift. Some literature suggests fibular fixation alone adequate, but I prefer repair if medial clear space remains >4mm to ensure stability and prevent chronic instability and arthritis.' - Missed deltoid injury causing chronic medial-sided instability and recurrent talar shift - Assuming intact medial malleolus means intact deltoid - can have both fracture and deltoid tear - Over-aggressive repair causing stiffness and medial pain - Failure to stress test mortise after fibular fixation to identify deltoid incompetence ### Step 12: Soft Tissue Assessment and Surgical Timing Considerations Soft Tissue Assessment and Surgical Timing Considerations: Critical in ankle fracture management - soft tissue envelope dictates surgical timing and outcomes. Pre-operative assessment: Examine for severe swelling, fracture blisters (serous vs hemorrhagic), skin compromise, compartment syndrome. **If compromised soft tissues**: DELAY surgery until soft tissues recover - typically 7-14 days until "wrinkle sign" appears (skin wrinkles indicate edema resolved). Immediate management: (1) Closed reduction and well-padded posterior splint in reduced position; (2) Strict elevation above heart level; (3) Ice therapy; (4) Monitor compartments if high-energy mechanism; (5) Serial examinations every 2-3 days assessing swinkle sign. **Exceptions requiring urgent surgery**: (1) Open fracture (immediate irrigation and debridement, temporary stabilization, delayed definitive fixation); (2) Compartment syndrome (urgent fasciotomy); (3) Skin tenting/compromise (urgent reduction and temporary fixation); (4) Vascular injury. Operating through compromised soft tissues dramatically increases wound complications (dehiscence, infection, skin necrosis) especially medial malleolus in diabetics/PVD patients. Lower leg has four compartments: anterior (deep peroneal nerve), lateral (superficial peroneal nerve), deep posterior (tibial nerve and posterior tibial vessels), superficial posterior (sural nerve). **Technical Tip**: EXAM KEY: 'SOFT TISSUE ENVELOPE CRITICAL IN ANKLE FRACTURES - timing of surgery as important as technique. If severe swelling or fracture blisters, I delay surgery until wrinkle sign appears indicating edema resolution (typically 7-14 days). Temporary closed reduction and splinting with strict elevation. Operating through compromised soft tissues increases wound complications dramatically (10-30% wound dehiscence/necrosis). Exception: open fracture, compartment syndrome, or vascular injury require urgent intervention. Ankle compartment syndrome rare but check if high-energy mechanism - fasciotomy if pressure >30mmHg absolute or delta <30mmHg.' - Operating through compromised soft tissue envelope causing wound dehiscence, skin necrosis, and deep infection - Missing compartment syndrome - rare in ankle fractures but devastating if missed - Inadequate temporary reduction causing skin tenting and necrosis during waiting period - Failing to educate patient about importance of strict elevation during waiting period ### Step 13: Wound Irrigation and Hemostasis Wound Irrigation and Hemostasis: Thorough irrigation all surgical wounds critical for infection prevention. Use minimum 3 liters pulsatile lavage normal saline per wound (fibular, medial malleolar, posterior if applicable). Irrigate deep and superficial layers. Remove all debris, bone fragments without soft tissue attachments, and clot. Release tourniquet if used and achieve meticulous hemostasis - identify bleeding vessels and cauterize with bipolar electrocautery. Avoid monopolar cautery near nerves (saphenous, sural). Pack wounds temporarily with lap sponges while achieving hemostasis. Ensure hemostasis complete - hematoma formation increases infection risk and wound complications. Reassess hardware position ensuring no prominent edges or corners causing soft tissue irritation. Bury all screw heads where possible. Ensure adequate soft tissue coverage over all hardware - if questionable coverage consider hardware position adjustment. **Technical Tip**: EXAM KEY: 'Copious irrigation reduces infection risk - I use minimum 3 liters pulsatile lavage per wound. Release tourniquet and achieve meticulous hemostasis with bipolar cautery to prevent hematoma formation. Hematoma increases infection risk 3-fold and causes wound tension predisposing to dehiscence. Ensure all hardware adequately covered by soft tissue - prominent hardware causes skin irritation, breakdown, and wound complications especially medially where soft tissue coverage minimal.' - Inadequate irrigation increasing deep infection risk - Hematoma formation from inadequate hemostasis causing wound tension and breakdown - Thermal injury to nerves from electrocautery - use bipolar near neurovascular structures - Prominent hardware not identified causing skin irritation and breakdown post-operatively ### Step 14: Layered Wound Closure and Dressing Application Layered Wound Closure and Dressing Application: Close wounds in layers ensuring tension-free closure. If deep fascia opened, close with interrupted 2-0 absorbable suture (vicryl) - avoid tight closure causing compartment syndrome. Subcutaneous layer closed with 3-0 absorbable suture in interrupted or running fashion to eliminate dead space and reduce skin tension. Skin closure options: (1) **Non-absorbable sutures** 3-0 or 4-0 nylon with interrupted vertical mattress or simple interrupted - provides excellent wound edge eversion and strength, remove at 14 days; (2) **Skin staples** - faster closure, equivalent outcomes, remove at 14 days; (3) **Absorbable subcuticular** - 4-0 monocryl running subcuticular if excellent soft tissue quality and low tension, no suture removal needed. I prefer non-absorbable interrupted sutures for ankle fractures given soft tissue concerns. Apply sterile absorbent dressing (telfa, 4x4 gauze). Apply well-padded below-knee posterior splint: multiple layers cast padding, plaster or fiberglass slab from toes to fibular head, secure with elastic bandage (not circumferential cast). Ankle in neutral dorsiflexion (90° to leg) - avoid equinus which causes Achilles contracture. Elevate limb on pillows with foot above heart level. Strict elevation instructions and written post-operative orders. **Technical Tip**: EXAM KEY: 'Layered tension-free closure essential. I use interrupted non-absorbable sutures (3-0 or 4-0 nylon) for skin allowing excellent wound edge eversion and strength. Remove at 14 days. Posterior splint (NOT circumferential cast initially) in neutral dorsiflexion well-padded to allow swelling. Circumferential cast before swelling resolved risks compartment syndrome or cast-induced pressure injury. Strict elevation above heart level critical first 48-72 hours to minimize swelling and optimize wound healing.' - Wound closure under tension predisposing to dehiscence and necrosis - Circumferential cast application before swelling resolved causing compartment syndrome or pressure injury - Inadequate padding in splint causing pressure ulcers over malleoli or heel - Ankle positioned in equinus causing Achilles contracture - Inadequate elevation instructions leading to persistent swelling and wound complications ### Step 15: Post-operative Protocol and Follow-up Plan Post-operative Protocol and Follow-up Plan: **Immediate post-op (0-2 weeks)**: Strict non-weight-bearing (NWB), strict elevation above heart level, posterior splint, ice therapy. DVT prophylaxis per institutional protocol - consider LMWH or aspirin 100mg daily for high-risk patients (age >60, obesity, prior VTE, cancer, prolonged immobilization). Early ankle pumping exercises within splint to reduce DVT risk. Pain management with multimodal approach. **2 weeks**: First follow-up, wound check, suture/staple removal if healing well. X-rays (AP, mortise, lateral) assess fracture position and hardware. If wounds healed, transition to removable CAM boot or well-padded short leg cast. Continue NWB. Begin ankle ROM exercises out of boot. **6 weeks**: X-rays assess healing. If early callus formation and clinical healing, begin weight-bearing as tolerated (WBAT) in CAM boot with progressive weight-bearing protocol guided by symptoms. Continue physiotherapy. **10-12 weeks**: Remove quadricortical syndesmotic screws if used (prevent breakage). Tricortical screws and suture buttons do not need routine removal. Progress to full weight-bearing in supportive shoe. Wean from boot based on comfort. **3-4 months**: Full weight-bearing, return to normal shoes, continue strengthening and proprioception exercises. **4-6 months**: Return to impact activities and sport if strength and ROM adequate. **Long-term**: Annual X-rays first 2-3 years monitoring for arthritis development. Hardware removal 10-20% if symptomatic prominence (typically 12-24 months after fracture union). **Technical Tip**: EXAM KEY: 'Strict NWB for 6 weeks allows ligamentous healing (deltoid, syndesmosis) and fracture healing. I use CAM boot at 6 weeks and progress weight-bearing based on radiographic healing and symptoms. Quadricortical syndesmotic screws I remove at 10-12 weeks before full weight-bearing to prevent breakage (5-20% if not removed). Tricortical screws and suture buttons can stay. Expected outcomes: 75-85% good-excellent if anatomic reduction achieved. Residual pain/stiffness 20-30%. Post-traumatic arthritis 15-30% at 10-20 years despite anatomic reduction.' - Early weight-bearing before 6 weeks causing fixation failure or loss of reduction - Inadequate elevation causing persistent swelling, wound complications, and CRPS - Forgetting to remove quadricortical syndesmotic screws causing screw breakage with full activity - Inadequate physiotherapy causing chronic stiffness and poor functional outcome - Failure to provide DVT prophylaxis in high-risk patients ## References 1. Ramsey PL, Hamilton W. Changes in tibiotalar area of contact caused by lateral talar shift. J Bone Joint Surg Am. 1976;58(3):356-357. - Classic cadaveric study demonstrating 1mm lateral talar shift decreases tibiotalar contact area 42% 2. Stufkens SA, van den Bekerom MP, Kerkhoffs GM, Hintermann B, van Dijk CN. Long-term outcome after 1822 operatively treated ankle fractures: a systematic review of the literature. Injury. 2011;42(2):119-127. - Systematic review showing 75-85% good-excellent outcomes with anatomic reduction, 15-30% post-traumatic arthritis at 10-20 years 3. Wikerøy AK, Høiness PR, Andreassen GS, Hellund JC, Madsen JE. No difference in functional and radiographic results 8.4 years after quadricortical compared with tricortical syndesmosis fixation in ankle fractures. J Orthop Trauma. 2010;24(1):17-23. - RCT demonstrating tricortical syndesmotic screws equivalent outcomes to quadricortical with lower hardware complications 4. Andersen MR, Frihagen F, Madsen JE, Figved W, Haugan K, Ugland S. High complication rate after syndesmotic screw removal. Injury. 2015;46(11):2283-2287. - Large series showing 5-20% syndesmotic screw breakage if quadricortical screws not removed, supporting tricortical or suture button 5. Laflamme M, Belzile EL, Bédard L, van den Bekerom MP, Glazebrook M, Pelet S. A prospective randomized multicenter trial comparing clinical outcomes of patients treated surgically with a static or dynamic implant for acute ankle syndesmosis rupture. J Orthop Trauma. 2015;29(5):216-223. - RCT comparing suture button (TightRope) to screw fixation - equivalent outcomes with lower removal rate 6. Bartoníček J, Rammelt S, Kostlivý K, Vaněček V, Klika D, Trešl I. Anatomy and classification of the posterior tibial fragment in ankle fractures. Arch Orthop Trauma Surg. 2015;135(4):505-516. - Comprehensive classification of posterior malleolar fractures (Haraguchi classification) with fixation guidelines 7. Gardner MJ, Brodsky A, Briggs SM, Nielson JH, Lorich DG. Fixation of posterior malleolar fractures provides greater syndesmotic stability. Clin Orthop Relat Res. 2006;447:165-171. - Biomechanical study demonstrating posterior malleolar fixation improves syndesmotic stability 8. Franke J, von Recum J, Suda AJ, Grützner PA, Wendl K. Intraoperative three-dimensional imaging in the treatment of acute unstable syndesmotic injuries. J Bone Joint Surg Am. 2012;94(15):1386-1390. - Study showing 50% of surgeons fail to achieve anatomic syndesmotic reduction using fluoroscopy alone, highlighting importance of systematic technique 9. Michelson JD, Ahn U, Magid D, Morrison W. Defining the role of ankle arthrodesis in the treatment of complex ankle and hindfoot disorders. Tech Foot Ankle Surg. 2007;6(3):133-147. - Discussion of post-traumatic ankle arthritis management including conversion to arthrodesis or arthroplasty 10. Therapeutic Guidelines: Antibiotic. Version 16. Melbourne: Therapeutic Guidelines Limited; 2019. - Australian eTG guidelines for perioperative antibiotic prophylaxis: cefazolin 2g IV for closed fracture ORIF, cefazolin + gentamicin for open fractures

Ankle Fracture ORIF - Weber B/C Fibula with Medial Malleolus

Ankle Fracture ORIF - Weber B/C Fibula with Medial Malleolus