import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Location**: Emerges from anterior compartment 10-12cm proximal to lateral malleolus tip. May cross operative field in distal fibula exposure. **Protection**: Incision POSTERIOR to fibula, careful retraction if visualized. **Location**: Anterior and superior to medial malleolus, running with great saphenous vein. **Protection**: Incision posterior to subcutaneous tibial border, identify and protect anteriorly. **Location**: Posterior to lateral malleolus, 1.5-2cm posterior to fibula at joint level, runs with lesser saphenous vein. **Protection**: Avoid posterior dissection, minimize posterolateral retraction. **Location**: Posterior to medial malleolus, deep to flexor retinaculum (Tom, Dick, And Nervous Harry). **Protection**: Stay anterior with medial approach, avoid posterior dissection. **Location**: Directly posterior to fibula in retromalleolar groove. **Protection**: Subperiosteal dissection, avoid posterior stripping, protect with retractors during plating. ### Absolute Indications - **Weber B with instability**: Talar shift greater than 1mm, medial clear space greater than 4mm, positive stress test - **Weber C fractures**: All require ORIF plus syndesmotic fixation (syndesmosis always injured) - **Bimalleolar fractures**: Unstable by definition - requires fixation of both malleoli - **Trimalleolar fractures**: Fix lateral, medial, and posterior malleolus if greater than 25-33% or subluxation - **Open fractures**: Urgent irrigation, debridement, and fixation - **Irreducible dislocations**: Closed reduction failed, interposed periosteum/tendon - **Neurovascular compromise**: Urgent reduction required ### Relative Indications - **Weber A with displacement**: Usually stable but fix if significant displacement or rotation - **Isolated medial malleolus**: Fix if greater than 2mm displacement - **Young active patients**: Lower threshold for operative management - **Failed non-operative treatment**: Displacement in cast, loss of reduction ### Contraindications - **Absolute**: Active infection, severe peripheral vascular disease with non-healing potential - **Relative**: Significant medical comorbidities, non-ambulatory patients, severe neuropathy with Charcot risk, poor soft tissue envelope (delay surgery) **Stability Assessment Key**: Weber B is the "grey zone" - 50% have syndesmotic injury. Must stress test! Weber B with medial tenderness, medial clear space greater than 4mm, or positive stress test = unstable = surgery. **Wrinkle Test Must Be Positive**: If skin wrinkles with ankle dorsiflexion = adequate soft tissue recovery. If not, delay surgery 5-14 days. Operating through swollen tissues leads to 20-30% wound complication rate versus 2-5% with adequate soft tissue envelope. ### Weber Classification (Anatomical) | Type | Fibula Fracture Level | Syndesmosis | Stability | Treatment | |------|----------------------|-------------|-----------|-----------| | **A** | Below syndesmosis | Intact | Stable | Usually non-operative | | **B** | At syndesmosis level | Variable (50% injured) | Variable | ORIF if displaced/unstable | | **C** | Above syndesmosis | Always injured | Unstable | ORIF + syndesmotic fixation | **Weber Key**: Tells you anatomical level and predicted syndesmotic status. Weber B is the "grey zone" - must stress test! Weber C = always fix syndesmosis. ### Lauge-Hansen Classification (Mechanism-Based) | Type | Frequency | Foot Position | Force | Injury Pattern | |------|-----------|---------------|-------|----------------| | **SER** | 60% | Supinated | External Rotation | Stage I: AITFL → Stage II: Spiral fibula → Stage III: PITFL/post mal → Stage IV: Medial mal/deltoid | | **SA** | 20% | Supinated | Adduction | Stage I: Transverse lateral mal → Stage II: Vertical medial mal | | **PER** | 10% | Pronated | External Rotation | Stage I: Medial mal/deltoid → Stage II: AITFL → Stage III: Spiral fibula above syndesmosis → Stage IV: PITFL | | **PA** | 5% | Pronated | Abduction | Stage I: Medial mal/deltoid → Stage II: AITFL/syndesmosis → Stage III: Comminuted fibula | **Lauge-Hansen Key**: Tells you mechanism and predicts associated injuries. SER Stage IV = Weber B with all ligaments injured. Understanding mechanism helps predict what other structures may be damaged. **Know BOTH systems for exam**: Weber tells WHERE (anatomical), Lauge-Hansen tells HOW (mechanism). Examiners expect you to correlate: "This is a Weber B, or SER Stage II, injury..." ### Osseous Anatomy - **Mortise**: Tibial plafond, medial malleolus, lateral malleolus, posterior malleolus - **Talus**: Wider anteriorly by 2-4mm (critical for syndesmotic reduction) - **Incisura fibularis**: Tibial groove for fibula - syndesmosis sits here - **Fibula**: 1cm more distal than medial malleolus, rotated 15-25° externally ### Ligamentous Structures - **Syndesmosis**: AITFL (anterior inferior tibiofibular ligament), PITFL (posterior), IOL (interosseous ligament), IT (inferior transverse ligament) - **Lateral complex**: ATFL, CFL, PTFL - **Deltoid**: Superficial (tibionavicular, tibiocalcaneal, tibiotalar) and deep (deep tibiotalar) ### Neurovascular Structures - **Superficial peroneal nerve**: Exits anterior compartment 10-12cm proximal to lateral malleolus tip, runs anterolaterally - **Sural nerve**: 1.5-2cm posterior to fibula at joint level, runs with lesser saphenous vein - **Saphenous vein/nerve**: Anterior to medial malleolus, with great saphenous vein - **Posterior tibial NV bundle**: Posterior to medial malleolus in tarsal tunnel (Tom, Dick, And Nervous Harry) - **Peroneal tendons**: Directly posterior to fibula in retromalleolar groove **Critical Anatomy for Exam**: "The talus is wider anteriorly by 2-4mm. This is why we MUST reduce the syndesmosis with the ankle in DORSIFLEXION - the wider anterior talus forces the fibula into anatomic position. Plantarflexed reduction leads to overtightening." **Lateral Incision**: POSTERIOR to fibula protects superficial peroneal nerve anteriorly. **Medial Incision**: POSTERIOR to subcutaneous tibial border protects saphenous structures anteriorly. **Posterior Approach**: Risk to sural nerve - keep 1.5-2cm from fibula. ### Intraoperative Syndesmotic Stress Testing **When to Test**: After ALL bony fixation complete (cannot assess with unstable malleoli) **External Rotation Stress Test**: - Ankle in dorsiflexion (talus widest anteriorly) - Neutral rotation - Apply external rotation force to foot - Observe under fluoroscopy for widening **Cotton Test (Hook Test)**: - Lateral force applied to talus and fibula with bone hook - Should not displace laterally more than 2mm **Abnormal Parameters**: | Measurement | Normal | Abnormal | |-------------|--------|----------| | Tibiofibular clear space | Less than 6mm | Greater than 6mm | | Tibiofibular overlap (AP) | Greater than 6mm | Less than 6mm | | Tibiofibular overlap (Mortise) | Greater than 1mm | Less than 1mm | | Medial clear space | Less than 4mm | Greater than 4mm | **Syndesmotic Malreduction**: Number ONE cause of poor outcomes after ankle fracture ORIF. Up to 50% malreduced in some series. Must assess AFTER bony fixation with stress testing under fluoroscopy. Compare to contralateral if in doubt. **For syndesmotic fixation**: Ankle DORSIFLEXED (wider anterior talus), NEUTRAL rotation (internal rotation malreduces), clamp 2-3cm proximal to joint in AP direction. Confirm reduction on fluoroscopy BEFORE fixing. ### Posterior Malleolus Management **Indications for Fixation**: - Greater than 25-33% of articular surface (controversial threshold) - **ANY posterior talar subluxation** (absolute indication - more important than size!) - Syndesmotic instability (large fragments contribute to stability) - Step-off greater than 2mm **Fixation Options**: | Technique | Approach | Advantages | Disadvantages | |-----------|----------|------------|---------------| | **Indirect (A-P screws)** | Via lateral approach | Less dissection, faster | No direct visualization | | **Direct buttress plate** | Posterolateral | Direct visualization, better reduction | More dissection, prone position | **CT Assessment**: Essential for accurate sizing - plain films underestimate by 30% **Critical Point**: Size matters LESS than subluxation - a 20% fragment with posterior talar shift NEEDS fixation! The posterior malleolus contributes to syndesmotic stability and talar containment. PITFL attaches to posterior malleolus. **CT Scan**: Obtain preoperatively for all trimalleolar fractures. Plain films underestimate posterior malleolus size by 30%. CT shows fragment size, comminution, and posterior subluxation. ### Expected Outcomes - **Union rate**: Greater than 95% with adequate fixation - **Return to activity**: 3-6 months for most activities - **Long-term function**: 80-90% good to excellent outcomes with anatomic reduction - **Post-traumatic arthritis**: 15-40% at 10 years (higher with residual incongruity) ### Risks to Discuss **Common (greater than 5%)**: - Symptomatic hardware requiring removal (10-30%) - Stiffness (10-20%) - Swelling (permanent in 20-30%) - Wound healing problems if soft tissues compromised **Less Common (1-5%)**: - Infection (2-5% closed fractures, higher for open) - Nerve injury (superficial peroneal, saphenous - usually temporary) - DVT/PE (1-2% with prophylaxis) - Syndesmotic malreduction (up to 50% in some series) **Rare but Serious (less than 1%)**: - Non-union (less than 5%) - Compartment syndrome (rare but devastating) - Complex regional pain syndrome ### Alternative Treatments - **Non-operative**: Weber A, truly stable Weber B (no talar shift), elderly non-ambulatory - **External fixation**: Severe soft tissue injury, open fractures, bridging until soft tissue recovery **Australian Context (Medicare MBS)**: Ankle ORIF typically MBS item 47528 (malleolar fracture ORIF). Syndesmotic screw removal may require separate procedure. Document instability and syndesmotic injury status for appropriate coding. **Key Evidence Points**: - 2mm fibular shortening causes 42% decrease in tibiotalar contact area (Thordarson 1997) - Syndesmotic malreduction in up to 50% of cases (Gardner 2006) - Suture-button vs screws: Both effective, suture-button allows micromotion, no removal needed (Kortekangas 2015) - Posterior malleolus: Subluxation more predictive of outcomes than fragment size (Miller 2010) **Patient Position**: Supine with bump under ipsilateral hip for 15-30° internal rotation (brings lateral malleolus up). Radiolucent table essential. **Surgical Approach**: Lateral approach posterior to fibula. Medial approach posterior to subcutaneous tibial border. Posterolateral for direct posterior malleolus fixation. **Incision**: - Lateral: 8-10cm posterior to fibular shaft, from 8-10cm proximal to tip distally to joint line - Medial: 5-7cm just posterior to subcutaneous tibial border, centered on medial malleolus **Pre-operative Considerations**: - Wrinkle test must be positive (adequate soft tissue) - If significant swelling: delay 5-14 days - CT for posterior malleolus assessment - Document baseline neurovascular status ### Step 1: Pre-operative Assessment and Classification Examine patient for soft tissue envelope - wrinkle sign indicates safe to proceed. Document neurovascular status: dorsalis pedis, posterior tibial pulses, and sensation in all nerve distributions. Review imaging with both Weber AND Lauge-Hansen classifications. CT scan for posterior malleolus sizing. Plan fixation sequence. **Examiner Question**: "How do you assess the soft tissue envelope for surgery timing?" **Model Answer**: "I assess for the 'wrinkle sign' - the ability to wrinkle the skin over the ankle with passive dorsiflexion indicates adequate soft tissue recovery and it's safe to proceed. If the skin is tense without wrinkles, I delay surgery 5-14 days with elevation and ice. Operating through swollen tissues leads to 20-30% wound complication rates versus 2-5% with recovered soft tissues." - Confirm neurovascular status documented pre-operatively (baseline for comparison) - Review CT for posterior malleolus sizing (plain films underestimate by 30%) - Know both Weber AND Lauge-Hansen classification before entering OR - Plan fixation sequence: FMSP (Fibula, Medial, Syndesmosis, Posterior) ### Step 2: Patient Positioning and Setup Supine on radiolucent table with bump under ipsilateral hip (15-30° internal rotation). Contralateral leg positioned to allow C-arm mortise views. Thigh tourniquet (250-300mmHg). Test ALL fluoroscopic views before prepping: AP, mortise (15-20° internal rotation), lateral. C-arm from contralateral side. **Critical Setup Point**: The bump under the hip (15-30° internal rotation) brings the lateral malleolus UP - this provides optimal access to the fibula. Testing fluoroscopy BEFORE prepping is essential - a true mortise view (15-20° internal rotation of the leg) must be achievable. - Thigh tourniquet 250-300mmHg (not calf - peroneal nerve risk) - Pad all pressure points - fibular head, malleoli, heel - Test ALL fluoroscopy views BEFORE prepping - repositioning sterile patient is problematic - Ensure contralateral leg positioned to allow C-arm access for mortise view ### Step 3: Lateral Approach - Fibula Exposure Mark incision POSTERIOR to fibular shaft (protects superficial peroneal nerve anteriorly). Incise 8-10cm from proximal to tip. Careful dissection through subcutaneous tissue - identify and protect any nerve branches. Incise periosteum longitudinally. Subperiosteal dissection anteriorly and posteriorly (protects peroneal tendons). **Examiner Question**: "Where do you place your lateral incision for fibula ORIF?" **Model Answer**: "I place my incision POSTERIOR to the fibular shaft, not directly lateral. This protects the superficial peroneal nerve which emerges from the anterior compartment 10-12cm proximal to the lateral malleolus tip and runs anterolaterally. By staying posterior, I avoid this nerve. I make an 8-10cm incision centered on the fracture site, and perform subperiosteal dissection to protect the peroneal tendons posteriorly." - **Superficial peroneal nerve**: 10-12cm proximal to tip, runs anteriorly - incision POSTERIOR to fibula - **Sural nerve**: 1.5-2cm posterior to fibula at joint level - avoid excessive posterior dissection - **Peroneal tendons**: Directly posterior in retromalleolar groove - subperiosteal dissection protects them - If nerve visualized, protect with vessel loop - do NOT divide ### Step 4: Fibula Reduction and Fixation Clear fracture site of interposed tissue. Assess pattern: spiral, oblique, or comminuted. **Reduction Goals**: - Restore length (compare to contralateral - 2mm shortening is unacceptable) - Correct rotation (posterior malleolar fragment provides best guide) - Anatomic fracture reduction **Fixation Options by Pattern**: - **Spiral/Long oblique**: Lag screw perpendicular to fracture + lateral neutralization plate - **Short oblique**: Antiglide plate posterolaterally (buttress principle) - **Comminuted**: Bridge plating **Examiner Question**: "How do you achieve lag screw fixation for a spiral fibula fracture?" **Model Answer**: "Lag screw technique requires a glide hole (3.5mm) in the near cortex and a thread hole (2.5mm) in the far cortex. The screw must be perpendicular to the FRACTURE LINE, not the bone axis - this provides compression across the fracture. I then add a neutralization plate to protect the lag screw from rotational and bending forces. For spiral fractures greater than 2x fibula diameter, I place the lag screw outside the plate. For shorter spirals, the lag screw can go through the plate." - **Length**: 2mm shortening causes 42% decrease in tibiotalar contact area - compare to contralateral! - **Rotation**: Use posterior malleolar fragment as guide for correct fibular rotation - **Comminution**: Do NOT strip periosteum excessively - maintain blood supply - **Antiglide plate**: Position posterolaterally for short oblique fractures - biomechanically superior to lateral plating ### Step 5: Confirm Fibular Reduction Fluoroscopically Obtain mortise and lateral views. Check: - Tibiofibular clear space less than 6mm - Tibiofibular overlap greater than 6mm on AP - Fibular rotation on lateral - Length compared to contralateral If medial clear space remains greater than 4mm after anatomic fibular fixation → either deltoid torn or syndesmosis injured. **Examiner Question**: "What parameters do you assess on intraoperative fluoroscopy after fibular fixation?" **Model Answer**: "I assess the MORTISE parameters: Medial clear space should be less than 4mm and equal to the superior joint space. Tibiofibular clear space should be less than 6mm. Tibiofibular overlap should be greater than 6mm on AP and greater than 1mm on mortise. I also confirm fibular length and rotation on lateral view. If the medial clear space remains greater than 4mm despite anatomic fibular reduction, this indicates either deltoid ligament rupture or syndesmotic injury requiring further intervention." - Must obtain TRUE mortise view (15-20° internal rotation) - false readings with poor technique - Compare to contralateral ankle if available - anatomic variation exists - If tibiofibular clear space greater than 6mm despite fibular fixation, reassess fibular length and rotation - Persistent medial clear space widening = additional pathology (deltoid or syndesmosis) ### Step 6: Medial Approach - Medial Malleolus Incision 5-7cm just POSTERIOR to subcutaneous tibial border (protects saphenous vein/nerve anteriorly). Identify and protect saphenous structures. Incise periosteum. Clear any interposed deltoid from fracture site (common cause of non-reduction). **Examiner Question**: "What prevents anatomic reduction of a medial malleolus fracture?" **Model Answer**: "The most common cause of inability to reduce a medial malleolus fracture is interposed deltoid ligament in the fracture site. The ligament can get pulled into the fracture gap during injury and physically blocks reduction. I always carefully inspect the fracture site and remove any interposed soft tissue before attempting reduction. Additionally, periosteal interposition can occur. Direct visualization and clearing of the fracture site is essential before reduction." - **Saphenous vein/nerve**: Anterior to medial malleolus - incision POSTERIOR to tibial border - **Posterior tibial NV bundle**: Deep and posterior - avoid excessive posterior dissection - **Interposed deltoid**: Remove from fracture site or reduction will fail - Protect skin edges - medial soft tissues are thin and prone to wound complications ### Step 7: Medial Malleolar Fixation Reduce with pointed reduction clamp. Verify articular reduction (less than 1mm step acceptable). **Fixation Options**: - **Standard**: Two parallel 4.0mm partially-threaded cancellous screws - **Alternative**: Tension band wire for transverse fractures - **Comminuted/Osteoporotic**: Buttress plate Screws directed from tip toward metaphysis, slightly posterolateral. Parallel orientation (convergent spreads fracture, divergent reduces purchase). **Examiner Question**: "Describe your screw configuration for medial malleolus fixation." **Model Answer**: "I use two parallel 4.0mm partially-threaded cancellous screws. Partially-threaded screws provide compression by having threads only in the far fragment while gliding through the near fragment. The entry point is at the tip of the malleolus, directed toward the posterolateral metaphyseal bone where the bone density is best for purchase. I keep the screws parallel - convergent screws can spread the fracture apart, and divergent screws reduce purchase. For vertical fractures (SA pattern), I may use an antiglide plate or buttress plate. For comminuted or osteoporotic bone, buttress plating provides superior fixation." - **Partially-threaded screws**: Threads only in far fragment for compression (fully-threaded = no compression) - **Parallel screws**: Convergent spreads fracture, divergent reduces purchase - **Posterolateral trajectory**: Best bone quality in metaphysis - **Articular step greater than 1mm**: Associated with post-traumatic arthritis - accept only if unable to improve - **Vertical fractures (SA)**: May need buttress plate, screws alone may fail ### Step 8: Syndesmotic Assessment **CRITICAL STEP** - Only performed AFTER all bony fixation complete. External rotation stress test under fluoroscopy: - Ankle in dorsiflexion (talus widest) - Neutral rotation - Apply external rotation force - Observe for tibiofibular widening greater than 6mm or medial clear space greater than 4mm Weber C fractures = ALWAYS assess (syndesmosis injured by definition) Weber B fractures = ASSESS if any doubt **Examiner Question**: "How do you assess syndesmotic stability intraoperatively?" **Model Answer**: "I perform syndesmotic stress testing ONLY after all bony fixation is complete - you cannot accurately assess the syndesmosis with unstable malleoli. I perform the external rotation stress test with the ankle in dorsiflexion (talus is widest anteriorly), neutral rotation, and apply external rotation force to the foot while observing under fluoroscopy. Abnormal findings include tibiofibular clear space greater than 6mm, loss of tibiofibular overlap, or medial clear space widening greater than 4mm. I also perform the Cotton test (hook test) - applying lateral force to the talus and fibula should not cause greater than 2mm lateral displacement. Weber C fractures ALWAYS have syndesmotic injury and require fixation. Weber B fractures have 50% syndesmotic injury rate, so I stress test all Weber B fractures." - Testing BEFORE bony fixation is complete = inaccurate (unstable malleoli give false positive) - Not dorsiflexing ankle during stress test = may miss instability (talus narrower posteriorly) - Accepting tibiofibular clear space greater than 6mm = syndesmotic malreduction, poor outcomes - Skipping stress test in Weber B = miss 50% of syndesmotic injuries ### Step 9: Syndesmotic Fixation (If Unstable) Apply large pointed reduction clamp from fibula to tibia, 2-3cm proximal to joint. **Critical**: ankle in full dorsiflexion, neutral rotation, clamp in AP direction. **Fixation Options**: | Device | Technique | Advantages | Removal | |--------|-----------|------------|---------| | 3.5mm cortical screws (x2) | 3-4 cortices, 2-3cm proximal to joint | Rigid fixation | Remove at 12 weeks (controversial) | | Suture-button | Per manufacturer protocol | Allows micromotion, physiologic healing | No removal needed | **Examiner Question**: "Why must the ankle be dorsiflexed during syndesmotic reduction?" **Model Answer**: "The talus is 2-4mm wider anteriorly than posteriorly. When I dorsiflex the ankle, I bring the wider anterior portion of the talus into the mortise, which forces the fibula into its anatomic position within the incisura. If I reduce the syndesmosis with the ankle in plantarflexion, the narrower posterior talus allows the fibula to sit too close to the tibia - this causes syndesmotic malreduction and the patient loses dorsiflexion post-operatively. I apply the reduction clamp with the ankle dorsiflexed, in neutral rotation (internal rotation causes malreduction), 2-3cm proximal to the joint, in an AP direction. I confirm reduction on fluoroscopy before fixing with either two 3.5mm cortical screws or suture-button device." - **Plantarflexed reduction**: Narrower posterior talus allows overtightening - loss of dorsiflexion - **Internal rotation**: Malreduces fibula posteriorly in incisura - **Clamp too close to joint**: Risks articular damage, does not recreate physiology - **Clamp medial-lateral**: Overtightens syndesmosis - must be AP direction - Confirm reduction on fluoroscopy BEFORE definitive fixation ### Step 10: Posterior Malleolus (If Indicated) **Indications**: Greater than 25-33% articular surface OR posterior talar subluxation **Indirect Technique**: - A-P lag screws from lateral approach - 3.5mm or 4.0mm screws capturing fragment - Fluoroscopy confirms no joint penetration **Direct Technique**: - Posterolateral approach - Direct visualization and buttress plate fixation - Better reduction but more dissection **Examiner Question**: "When do you fix the posterior malleolus and how?" **Model Answer**: "I fix the posterior malleolus when it involves greater than 25-33% of the articular surface OR if there is any posterior talar subluxation - subluxation is the more important indication regardless of fragment size. A 20% fragment with posterior subluxation needs fixation. I have two techniques: Indirect fixation using A-P lag screws through the lateral approach is faster with less dissection, but provides no direct visualization. Direct fixation via a posterolateral approach allows direct visualization and buttress plating, achieving better reduction but requiring more dissection and often prone positioning. The posterior malleolus is important because the PITFL attaches to it, so its fixation can contribute to syndesmotic stability." - **Subluxation more important than size**: A 20% fragment with posterior shift NEEDS fixation - **CT is essential**: Plain films underestimate fragment size by 30% - **Indirect screws**: Must confirm no joint penetration on lateral fluoroscopy - **Posterolateral approach**: Risk to sural nerve (1.5-2cm posterior to fibula) - **PITFL attachment**: Large posterior fragments contribute to syndesmotic stability ### Step 11: Final Fluoroscopic Assessment Quality control checklist: - [ ] Medial clear space less than 4mm and symmetric - [ ] Tibiofibular clear space less than 6mm - [ ] Tibiofibular overlap greater than 6mm AP, greater than 1mm mortise - [ ] No talar subluxation (anterior or posterior) - [ ] Articular congruence on mortise - [ ] All screws out of joint - [ ] Posterior malleolar reduction (if fixed) Compare to contralateral if available. Document images. **Examiner Question**: "What are the key radiographic parameters you assess at the end of ankle fracture ORIF?" **Model Answer**: "I use the MORTISE parameters for quality control. Medial clear space should be less than 4mm and equal to the superior joint space. Tibiofibular clear space should be less than 6mm. Tibiofibular overlap should be greater than 6mm on AP and greater than 1mm on mortise view. I confirm there is no talar subluxation and the articular surface is congruent with no step greater than 1mm. All screws must be out of the joint - I obtain lateral and mortise views to confirm. If I fixed the posterior malleolus, I confirm its reduction. If any parameter is outside acceptable range, I DO NOT leave the operating theatre - I revise immediately. Delayed revision for malreduction has worse outcomes." - **Do NOT accept malreduction**: Revise immediately - delayed revision has worse outcomes - **True mortise view**: Must be 15-20° internal rotation for accurate measurements - **Compare to contralateral**: If any doubt about what is "normal" for this patient - **Document all images**: Medicolegal protection and for post-operative comparison - **Syndesmotic malreduction in up to 50%**: Be vigilant - most common cause of poor outcomes ### Step 12: Closure and Post-operative Care **Closure**: Copious irrigation (3L minimum). Meticulous hemostasis. Close periosteum if possible. Layered skin closure - avoid tension. **Immediate Post-op**: - Well-padded posterior slab or bulky Jones dressing - Leg elevation above heart level - DVT prophylaxis per risk **Rehabilitation Protocol**: | Phase | Time | Activity | |-------|------|----------| | Protection | 0-2 weeks | Splint, NWB, elevation | | Early ROM | 2-6 weeks | Removable boot, NWB, begin ROM | | Progressive WB | 6-12 weeks | Progress to FWB | | Strengthening | 12+ weeks | Physiotherapy, return to activities | Syndesmotic screws: Some remove at 12 weeks (controversial). Suture-buttons don't require removal. **Examiner Question**: "What is your post-operative protocol after ankle fracture ORIF?" **Model Answer**: "Immediate post-operatively, I apply a well-padded posterior splint or bulky Jones dressing to protect the reduction and control swelling. The leg is elevated above heart level. I initiate DVT prophylaxis - typically LMWH or aspirin depending on risk factors. For weeks 0-2, the patient is non-weight bearing in a splint. At 2 weeks, I reassess the wound and convert to a removable boot. The patient remains non-weight bearing until 6 weeks, but begins gentle active ROM exercises out of the boot. From 6-12 weeks, I progressively increase weight bearing to full weight bearing as tolerated. Strengthening and proprioception work begins at 12 weeks with formal physiotherapy. For syndesmotic fixation, if I used screws, some surgeons remove them at 12 weeks - this is controversial. If I used suture-buttons, no removal is needed." - **Elevation critical**: Reduces swelling, promotes wound healing, prevents compartment syndrome - **DVT prophylaxis**: Risk stratified - LMWH for high-risk, aspirin for low-risk (AOANJRR data supports aspirin in low-risk patients) - **Wound monitoring**: Ankle skin is thin - monitor closely for dehiscence, especially medial - **Early ROM**: Begin at 2 weeks to prevent stiffness (ankle most prone to stiffness after fracture) - **Syndesmotic screw removal**: Controversial - evidence shows similar outcomes with or without removal 1. Court-Brown CM, McBirnie J, Wilson G. Adult ankle fractures—an increasing problem? Acta Orthop Scand. 1998;69(1):43-47. 2. Michelson JD. Fractures about the ankle. J Bone Joint Surg Am. 1995;77(1):142-152. 3. Gardner MJ, Demetrakopoulos D, Briggs SM, et al. Malreduction of the tibiofibular syndesmosis in ankle fractures. Foot Ankle Int. 2006;27(10):788-792. 4. Miller AN, Carroll EA, Parker RJ, et al. Posterior malleolar stabilization of syndesmotic injuries is equivalent to screw fixation. Clin Orthop Relat Res. 2010;468(4):1129-1135. 5. Sagi HC, Shah AR, Sanders RW. The functional consequence of syndesmotic joint malreduction at a minimum 2-year follow-up. J Orthop Trauma. 2012;26(7):439-443. 6. Egol KA, Pahk B, Walsh M, et al. Outcome after unstable ankle fracture: effect of syndesmotic stabilization. J Orthop Trauma. 2010;24(1):7-11. 7. Thordarson DB, Motamed S, Hedman T, et al. The effect of fibular malreduction on contact pressures in an ankle fracture malunion model. J Bone Joint Surg Am. 1997;79(12):1809-1815. 8. Donken CC, Al-Khateeb H, Verhofstad MH, et al. Surgical versus conservative interventions for treating ankle fractures in adults. Cochrane Database Syst Rev. 2012;(8):CD008470. 9. van den Bekerom MP, Haverkamp D, Kloen P. Biomechanical and clinical evaluation of posterior malleolar fractures. A systematic review of the literature. J Trauma. 2009;66(1):279-284. 10. Kortekangas T, Savola O, Flinkkilä T, et al. A prospective randomised study comparing TightRope and syndesmotic screw fixation for accuracy and maintenance of syndesmotic reduction assessed with bilateral computed tomography. Injury. 2015;46(6):1119-1126.

Open Reduction and Internal Fixation of Ankle Fracture

Open Reduction and Internal Fixation of Ankle Fracture