Open Reduction and Internal Fixation of a Trimalleolar Ankle Fracture
Table of Contents
- Case Overview
- Statement of Consent
Ankle fractures are the second most common lower limb fractures after those involving the hip, accounting for 10% of all fractures, with an incidence that has been increasing.1,2 The goal of management is to restore a stable and congruent joint. Operative management is recommended for most displaced fractures, fractures with dislocations, and open fractures.
In this video, Dr. Weaver walks us through the surgical management of a 23-year-old male who sustained a trimalleolar ankle fracture with concomitant dislocation and syndesmotic injury following a motor vehicle collision. Dr. Weaver discusses the surgical landmarks and approaches to the ankle, the methods of fixing the malleoli and the syndesmosis, and common concerns that arise during the surgical management of ankle fractures.
Ankle fractures are among the most commonly encountered fractures in orthopedics; nevertheless, their frequency should not undermine their seriousness. Disregarding the precise details of these fractures can lead to disappointing outcomes. Because the joints in the lower limb act in concert during the gait cycle, any deviation from the normal function of one joint can have significant implications on the function of the other joints.
Low-energy trauma accounts for the majority of ankle fractures. Elderly women are especially susceptible to these injuries, reporting the highest incidence of ankle fractures, particularly bimalleolar and trimalleolar patterns.1,2 High-energy trauma can also result in ankle fractures, commonly with suprasyndesmotic patterns.3 Men are more likely to sustain ankle fractures at younger ages than are women.4
There are several risk factors for ankle fractures, including obesity, multiple falls, and alcohol consumption.4,5,6 The relationship between ankle fractures and osteoporosis is less clear; while some studies identified ankle fractures as osteoporotic, others failed to identify any significant relationship between bone mineral density measurements and such injuries.7,8,9,10
A previously healthy 23-year-old male presented to the emergency department (ED) complaining of severe right ankle pain, swelling, and deformity after being a restrained driver in a head-on motor vehicle collision. On arrival at the ED, he was conscious and alert with a Glasgow coma scale of 15. Apart from his ankle, the patient had no complaints. His vital signs were all within normal limits.
Initial evaluation followed the advanced trauma life support protocol. His airway and cervical spine, breathing, circulation, and neurologic status were all sequentially evaluated and cleared. The secondary survey was significant for a grossly deformed right ankle with medial skin tenting and bruising; however, no open wounds were identified. The right foot was pink with rapid capillary refill; however, the right pedal pulses were not palpable. Intact sensation was reported in both lower limbs; however muscle strength could not be assessed on the injured side because of pain. The patient received adequate analgesia, and ankle x-rays were obtained. He was found to have a trimalleolar ankle fracture with associated lateral dislocation. A reduction was successfully performed in the ED under conscious sedation and was stabilized temporarily using a well-padded posterior splint. Postreduction physical exam was notable for the return of the right pedal pulses.
The standard ankle trauma series is anteroposterior (AP), lateral, and mortise ankle views, although some authorities believe that obtaining only mortise and lateral views without an AP view is equally reliable.11,12,13 Ottawa ankle rules are a helpful decision-making guide to determine whether radiographs are needed.14 Nevertheless, these rules may not be reliable in patients with diabetes.15 Radiographs should be obtained whenever there is doubt as to the diagnosis. Foot or full-length leg radiographs are required if there is a clinical suspicion of associated foot or proximal leg fractures, such as the Maisonneuve fracture.
Plain radiographs not only provide information regarding bony injuries but also give valuable clues about concomitant ligamentous injuries and potential fracture instability. Many radiographic parameters are used to assess reductions and the presence of ligamentous disruptions, namely deltoid ligament and syndesmotic injuries. Nevertheless, these parameters should be interpreted with caution as their reliability differs according to various studies.
The tibiofibular clear space is the most reliable measurement to detect widening of the syndesmosis, because the other parameters may vary with ankle position or rotation.16 This space is defined as the horizontal distance between the lateral margin of the anterior tibia and the medial fibular cortex measured 1 cm above the tibial plafond. A width of less than 6 mm on both AP and mortise views signifies a normal syndesmosis. The tibiofibular overlap is the maximum horizontal distance between the medial cortex of the fibula and the lateral edge of the posterior tibial cortex. Normal measurements are more than 6 mm and 1 mm of overlap on AP and mortise views, respectively.17
Fibular fractures have varying propensities for associated syndesmotic injury. Although syndesmotic disruption has been classically associated with high pronation-type fibular fractures, the mechanism of injury and the fibular fracture level have proven to be inaccurate predictors.18,19 Furthermore, a medial clear space (measured from the lateral border of the medial malleolus to the medial border of the talus at the level of the talar dome) of more than 4 mm on mortise view correlates with deltoid and syndesmotic ligament injury.20,21 Overall, it should be emphasized that static images may not predict dynamic ankle instability and that “normal” measurements do not necessarily rule out ligamentous injuries.20 Therefore, stress radiographs such as gravity or manual external rotation x-rays may help uncover occult ligamentous injuries.
CT and MRI are not routinely needed in ankle fracture management. Nevertheless, CT scan is an indispensable tool in the preoperative planning of complex fracture patterns, in assessing the size of posterior malleolus fractures and syndesmotic reductions postoperatively.22 Ligamentous injuries and osteochondral lesions are best seen on MRI.
The ankle joint is a complex hinge joint. It links the foot to the rest of the body during gait and transmits the weight of the whole body through a small surface area. It is more efficient in load transmission per surface area than the hip or knee joints while at the same time being less commonly affected by degeneration and arthrosis. The optimal function of the ankle depends on its exact anatomic congruency, and any deviation from its normal anatomy, even as small as 1 mm, can significantly affect its function, leading to chronic pain, instability, and arthrosis.23
Ankle fractures are managed either conservatively or operatively, depending on the fracture pattern and associated soft tissue injuries. Non-operative management is indicated for stable ankle injuries, which include minimal displacement, i.e. 2–3 mm displacement, isolated medial or lateral malleolus fractures and isolated ligamentous injuries.24,25 Below-knee walking casts, air casts and ankle braces all give comparable results.26,27 The management of isolated ligamentous disruptions follows that of ankle sprains.
Ankle-spanning external fixation is mainly used to obtain preliminary fracture reduction and fixation in cases complicated by excessive skin swelling, blistering, or infection that prohibits early internal fixation. Rarely, external fixation is employed as a definitive treatment method.
Unstable fibular fractures are often fixed by plating. Both lateral neutralization plates and posterior antiglide constructs have been used with similar clinical outcomes, despite being biomechanically different.28,29 While posterior plating mitigates the soft tissue complications of lateral plating, it causes more peroneal tendon irritation.30 Bridging plates are recommended in cases of fracture comminution, a common occurrence in pronation-type injuries and osteoporotic fractures. Depending on the fibular fracture pattern, lag screws alone, tension band wiring, or intramedullary devices can also be used.
Based on the fracture morphology, unstable or displaced medial malleolus fractures can be fixed using lag screws, tension band wiring, or buttress plating, each with its unique advantages and drawbacks. Similarly, lag screws and posterior buttress plating are the principal methods for posterior malleolus fixation.
There are a variety of surgical treatment options for syndesmotic disruptions. Screws of various types, numbers, and function, sutures, and staples have been used to stabilize the syndesmosis.31 Infrequently, primary ankle arthrodesis may be required in patients with low functional demands or unsalvageable bone loss.32
Ankle fracture management aims to obtain a congruent ankle mortise that remains stable throughout the healing process and allows early mobilization. Any treatment strategy, operative or non-operative, that fulfills these requirements, will ensure a favorable outcome. On the other hand, because of its small surface area, the tibiotalar joint can tolerate incongruity exceptionally poorly.
The ankle is composed of a ring with the talus placed in its center. The talus is secured in the mortise by a ring of osteoligamentous structures and the tendons crossing the joint. The static joint stabilizers are the medial and lateral osteoligamentous complexes and the syndesmosis. A break in the ring, either bony or ligamentous, at one site will not affect talar stability. The fact that several studies have shown good outcomes after nonoperative management of isolated medial or lateral malleolus fractures supports this notion.25,33
Injury of more than one static stabilizer, as in bimalleolar or trimalleolar fractures, can lead to abnormal talar motion, instability, and loss of congruency. In such cases, the talus remains faithfully attached to the fibula, adopting its external rotation and posterior and lateral displacements.34 Concerns surrounding the posterior malleolus arise from the controversial role it plays in resisting posterior talar translation and maintaining the joint contact area and pressure.
Ankle fractures in elderly and osteoporotic patients need special consideration, especially when deciding if and how to operate. If a decision for surgical fixation was made, the poor bone quality should be taken into account preoperatively. Locking plates, intramedullary devices, tension band constructs, or tibiofibular trans-fixation are all measures the can partially circumvent this issue.
Another subpopulation of patients that require special consideration is the diabetics. Besides the poor bone quality, these patients also suffer from numerous soft tissue complications and generally need more restricted postoperative rehabilitation schemes.
In the early post-fracture period, the skin should be assessed, because it is the principal factor in determining the timing of surgery. If only mild swelling is present, open reduction and internal fixation (ORIF) can be carried out safely, as most of the swelling in this period is due to fracture hematoma, not tissue edema. Because abrasions often become colonized within 12–24 hours of injury, ankles with abrasions, no matter how insignificant, may benefit from early ORIF. Otherwise, open surgery should be delayed until the abrasion has healed. Similarly, open fractures should undergo debridement, fixation, and soft tissue coverage as soon as possible, unless there is extensive soft tissue damage. In such cases, it is better to apply external fixation until the soft tissue problems have resolved. Delayed ORIF is advisable when safe surgical exposures cannot be performed because of excessive swelling and blisters. An anatomic reduction is possible within two weeks of injury; however, it becomes increasingly difficult subsequently.35 Some studies found that early ORIF has at least equivalent outcomes as delayed fixation and recommended fixation within 24 hours of injury, 36,37 while others considered delaying ORIF more than seven days to be a poor prognostic factor.38,39
The decision of where to start is, first and foremost, a matter of surgeon preference. Most surgeons start by reducing and fixing the fibula. This restores the general shape of the ankle mortise, aids in subsequent reductions of the posterior and medial malleoli, and achieves the task of syndesmotic reduction. Nonetheless, this is not the case every time. Occasionally, failure to obtain an acceptable fibular reduction signifies soft tissue interposition in the medial malleolus fracture. As a result, reducing the medial fracture first may facilitate fibular reduction. Furthermore, many prefer to deal with the medial malleolus first in cases complicated by medial joint impaction, a characteristic finding in supination-adduction injuries. Fibular comminution is also one of the indications to proceed with medial malleolus fixation initially.
Controversy does not end at the posterior malleolus. While some believe that fibular fixation assists in reducing the posterior malleolus fracture, others suggest that the radiographic assessment of the posterior malleolus reduction is significantly impaired by medial or lateral hardware, and prefer to address the posterior injury first. Furthermore, reducing the posterior malleolus early during surgery helps to reconstruct the incisura fibularis that in turn facilitates subsequent syndesmotic reductions.
The operation is performed in the supine position on a radiolucent table. A bump is placed under the ipsilateral hip to prevent gravity-induced external rotation of the limb. The C-arm comes from the side of the normal leg. Placing the leg on a raised platform facilitates lateral imaging. A tourniquet is often used.
The skin is incised longitudinally following the posterior border of the fibula. Extending the incision for 1–2 cm distally and slightly anteriorly to the fibular tip allows easier retraction of the skin flaps and better visualization of the syndesmosis and lateral joint space. If an anteromedial approach is going to be used to address the medial malleolus fracture, the lateral incision should be taken more posteriorly.
The incision is carried sharply through the subcutaneous fat until reaching the deep fascia of the leg. Care should be taken in the proximal part of the incision as the superficial peroneal nerve traverses the deep fascia about 7–10 cm from the tip of the fibula.40 The deep fascia is opened sharply to expose the fracture site. Soft tissue dissection around the fibula should be limited to the extent necessary to expose the fracture and place the plate. The periosteum is retracted 1–2 mm from the fracture edges to allow reduction, and the fracture site is debrided to remove clots and small bone fragments.
The reduction can be achieved and held by manipulating the fracture fragments using a pointer forceps or a lobster-claw reduction clamp. If unsuccessful, a second pointer forceps can be used to apply traction on the distal fibular metaphysis. Care should be taken not to fracture the distal fibula, especially in osteoporotic fractures.
The reduction is then confirmed, both visually and under fluoroscopy, to ensure that acceptable length and rotation have been restored. Four radiographic findings are used to judge the fibular reduction. First, the talocrural angle, on the mortise view, is between a line connecting the tips of both malleoli and a line perpendicular to the tibial plafond. Angles of 83 ± 4 degrees are considered acceptable. Second, the “dime sign” describes a continuous curve that connects the groove on the distal tip of the fibula and the lateral process of the talus. A broken curve indicates a shortened and malreduced fibula. Third, the sclerotic line representing the subchondral bone of the fibula should be confluent and continuous with the sclerotic line representing the subchondral bone of the tibia on a mortise view. It resembles the Shenton line of the hip. A break in this line is due to a malreduced fibula or syndesmosis. Fourth, lateral talar tilt or shift leading to loss of parallelism of the talus within the ankle mortise occurs when the fibula is malreduced, because the talus follows the fibula wherever it goes. Finally, It should be borne in mind that fibular malreduction means syndesmotic malreduction.
If an anatomic reduction is achieved, one or two lag screws are placed 1 cm apart and as perpendicular as possible to the fracture line, depending on the fracture configuration. Usually, a 3.5-mm cortical screw is needed. The near cortex is overdrilled using a 3.5-mm drill bit. This is followed by drilling the far cortex using a 2.5-mm drill bit and a centering guide. Countersinking, measuring length, tapping, and screw placement follow, in that order.
If bone loss prevents anatomic reduction, plating alone will suffice. A 3.5-mm one-third tubular plate is often used. Infrequently, dynamic compression plates are utilized. A plate of a length that allows placing three screws proximal to the fracture and 2–3 screws distally is suitable. The plate is then applied to the bone after minimal contouring. If the plate has a locking option, the guiding towers are better being locked in place during contouring to prevent distortion of the screw holes. The plate is fixed initially using K-wires, and its position is checked under fluoroscopy.
Because conventional screws press and contour the plate to the bone, they are always placed before the locking screws. The proximal screws are inserted through both cortices whereas some distal screws are inserted through the near cortex only to prevent intra-articular placement. Making a triangular configuration with the unicortical distal screws ensures better purchase if conventional screws are used. Meanwhile, unicortical locking screws can be placed distally without any modification.
The integrity of the syndesmosis is checked using the Cotton or hook test in which a bone hook is used to pull the fixed fibula laterally.41 Widening of the tibiofibular and medial clear spaces are positive findings. Reduction of the syndesmosis can be achieved either percutaneously or using an open technique. A large articular reduction clamp does the percutaneous reduction. However, the vector of the clamp should be judged carefully, because an erroneous placement is one of the causes of malreduction.42 Placing the clamp in the anatomic axis of the ankle at the level of the syndesmosis with the medial clamp tine on the anterior third of the medial tibia can reduce the risk of malreduction.43
Nevertheless, many surgeons prefer an open reduction, because it permits confirmation of syndesmotic alignment. The syndesmosis is exposed through the same approach that was used to address the fibula. Compression of the syndesmosis is accomplished manually or using a reduction clamp and initially stabilization using K-wires. The traditional orthopedic teaching described the syndesmotic screw as a fully-threaded positional screw placed 2–3 cm above and parallel to the joint line. It starts on the fibula and is directed 30° anteromedially towards the tibia. The number, type, size, and length of the screw(s), and the position of the foot during insertion are all controversial and rely on the surgeon’s preference. Finally, the alignment of the syndesmosis is checked clinically and radiographically. Because the fibula is mostly unstable in the AP direction, a lateral x-ray should be included to confirm that the distal third of the tibia completely overlaps the fibula.44
An anteromedial approach exposes the medial malleolus. After debriding the clots and periosteum from the fracture, the talar dome is inspected through either the fracture gap or using a medial arthrotomy to rule out osteochondral damage. The fracture is then reduced using a reduction clamp and is fixed using two cancellous lag screws placed perpendicular to the fracture line. Partially threaded unicortical screws provide adequate fixation in patients with good bone quality. Nevertheless, placing fully threaded lag screws with purchase in the lateral tibia cortex is biomechanically superior to partially threaded lag screws.45 The reduction and screw position are confirmed radiographically with more emphasis placed on the AP view findings rather than the mortise view.46
The authors have no financial interests or conflict of interest to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
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Cite this article
Weaver MJ. Open reduction and internal fixation of a trimalleolar ankle fracture. J Med Insight. 2023;2023(22). doi:10.24296/jomi/22.
Table of Contents
After the operative leg has been marked, anesthesia is induced, and the patient is brought to the operating room.
- Leg Positioning
- Patient positioned supine with arms out or tucked
- Trochanter roll placed under patient
- Prep/Sterilization of Surgical Site
- Shave surgical site
- Wash and sterilize entire leg
- Cover Site with Ioban Adhesive Sterile Sheet
- Seal calf and toes
- Make Skin Markings
- Apply Tourniquet
- Exsanguinate the extremity up to the thigh
- Apply pressure
- Surgical Time Out
- Identify patient, problem, correct side, procedure to be performed, medications given prior to procedure, expected time to completion
- Make a Lateral Skin Incision
- Along subcutaneous border of fibula
- Angle slightly anteriorly distally
- Incision into Fascia
- Superficial peroneal nerve branches at subcutaneous or fascial level
- Once on bone, make space for plate
- Expose fracture site with a 2-mm periosteotomy on each side
- Clean out fracture site with small curette
- Perform Fibular Reduction with Pointed Reduction Forceps
- Grab distal fibula and pull traction to achieve length
- Fit and Contour Fibular Plate
- Contour six-hole ⅓ tubular plate using locking towers for grip to match distal fibula
- Position and use K-wires to fix provisionally
- Proximal Non-locking Screw
- Drill through both fibular cortices with a 2.5-mm drill
- Use depth gauge to determine length
- 4.0-mm non-locking screws should be used initially to contour plate to the bone
- Note: Using slightly longer screws allows for better purchase in the medial cortex
- Distal Non-locking Screw
- Repeat above steps
- Fill Remaining Gaps with Locking Screws
- It is important to use locking screws, especially distally at the level of the lateral malleolus, to prevent skin irritation due to prominence
- Once complete, use clamps to pull on fibula (Cotton test) and assess status of syndesmosis
- Exposure of Syndesmosis
- Provisional K-Wire Fixation
- Fix the Tillaux fragment to the tibia
- Use a second K-wire to fix the fibula to the tibia
- First 3.5-mm Syndesmotic Tricortical Screw
- Drill through three cortices with 3.2-mm drill
- Drill to, but not through, the medial cortex of the tibia
- Measure with depth gauge
- Use a 4.5-mm cortical screw
- Lag Screw Fixation of Tillaux Fracture
- Drill through fragment into tibia with 3.2-mm drill
- Use 4.0-mm partially threaded cancellous screw to lag by design
- Second 3.5-mm Syndesmotic Tricortical Screw
- Repeat steps for first syndesmotic screw
- Prep Medial Side
- Mark approach - in this case, a curved approach anterior to the medial malleolus
- Make Medial Incision
- Be cautious of the posterior tibial tendon and saphenous nerve
- Reduce Fragment with Pointed Reduction Clamps
- Provisional K-Wire Fixation
- Use two K-Wires to keep fragment from rotating
- First Tibia Lag Screw
- Drill though fragment into tibia with 3.2-mm drill
- Use 4.0-mm partially threaded cancellous screw
- Second Tibia Lag Screw
- Repeat above steps
- Take AP and Lateral x-ray Images to confirm reduction and construct placement
My name is Michael Weaver, I am a trauma surgeon here at the Brigham and Women's Hospital in Boston, and today we have a 23-year-old gentleman with a trimalleolar ankle fracture. He was involved in a high-speed motor vehicle collision last night and presented with a dislocated ankle and a pulseless foot. So he was reduced in the emergency room and placed in a splint, and now we're going to be taking care of his ankle fracture definitively. One of the important things to recognize on the AP radiograph is the direction of dislocation. In this case, he has a lateral dislocation. And that's going to be important because that's going to be directing your fixation to try to prevent failure and redisplacement in the future. And then also, it's important to recognize the syndesmotic injury here. Here his talus is dislocated into the space of the syndesmosis, and it's obviously wide so that's something that we're going to have to address surgically. I typically like to perform an open reduction of the syndesmosis. I think it's really important to really see the reduction. There are a lot of studies that show that it's difficult to get that perfect especially if you were relying on radiographs alone. And a lot of CT data postoperatively show there's some residual subluxation of the syndesmosis, so I like to really see that. And then in his case, he does have some threatened skin on the medial side, and so we may not be able to fix the medial malleolus today. That’s just going to depend on how things look. But he has some swelling on the lateral side, but he's got a good wrinkle sign and the skin looks appropriate to proceed. So we're going to start on the lateral side and go from there.
So when I'm doing ankle fracture surgery, I like to have a platform built up so I can get orthogonal views without changing the position of the legs. So I like to build it up on a platform - and then also a pretty good bump under the hip so the - the foot's pointing straight up. That gives you good access to the lateral and medial side.
Especially in trauma patients, it’s important to do a pre-prep, so you can use Hibiclens or alcohol or something, but you want to get that skin really clean before - before you do your final prep. Nice and supple. One of the important things, particularly when you're doing surgery around a high-energy ankle injury, is the quality of the skin. You know, this patient is a young patient with good skin. He's got a fair amount of swelling, but the important thing is the skin is still dull. It's not shiny. If you have shiny skin, that's a sign that it's not going to take an incision very well. And he still develops nice wrinkles. The other thing that I find that’s really important is that it's supple - you know, you can move that skin around. If things get kind of woody and tight, then that's a really bad sign, and you're going to have trouble closing it. But I think this looks like it's going to be okay. Actually would you mind helping for a second? We just need to get that clip prepped so we can get it wrapped, you know? You just like lift below or something. There we go. All right. All right, so this is my standard setup for an ankle fracture. We got our platform. I like to use these kind of disposable drapes that let you get lateral views and keep yourself sterile, and then I'm pretty fanatical about it, but I like Ioban covering everything. All right, there we go, and then just a small little towel under the leg.
Incision is going to be just a little bit posterolateral. So one trick is you can feel the fibular head here. So if you feel the fibular head to the tip of that, that's going to be a straight line between the two, and you want to be slightly behind it. So I think you're really - I think - yeah, I think it's good, yeah. You don't want to be too far in the back especially at the tip because you're going to see your syndesmosis over the front. All right, I think that’s good. All right.
Tourniquet at 275 please. Up in a few seconds. Tourniquet up, please. All right.
He's got a broken right ankle. We're going to do surgery to fix it. He's in the supine position. Right side is marked and draped. We have a small fragment locking set in the room. So we use Ancef and vancomycin for all cases that involve metal because there's a higher incidence of MRSA infection in the community now. Squeezing the other leg for DVT prophylaxis. This case is going to take about an hour to slightly longer than that. We're not anticipating any blood loss or critical steps.
Incision. Thank you. So the thing to watch out for here obviously is the superficial branch of the peroneal nerve. That's going to be proximally. And the thing with that nerve is it lies right on the fascia, so you can be in the fat and you're okay. You know, and some people say - you know, you've got 7 to 10 centimeters from the tip of the malleolus, but I find the course is pretty variable, so I don't like to cut down to bone anywhere. All right, good. You can go a little deeper because well - like I said - you’re in the fat, you’re okay. Good - a couple wheaties, please. I don't like to spread too much because you want to dissect sharply. Pro-tip - are you ready? There you go. Good. So I want you to cut. There you go. There it is. It's broken. Good. Safe, and then go. That's what I mean by sharply. You don't want to rip it apart. You want to cut it. All right. There you go. I thought you meant to find my nerve. Yeah, I do - if you find it, but if you don’t find it, it doesn't matter, all right so those are the peroneal tendons right there, right? There you go, all right. So now you’re good with the knife. So there's the ball, right? Yeah. So you’re just going to open it up right like this. So the nerve’s going to be up front here. In fact, that’s probably it right there, but we don’t need to go up there, so we know we’re safe. Yeah, come right here? Yeah. All right, so just rip, rip. Yep - just open the fascia - just the fascia. Yep, now zip right through that. That’s good, cut it. Good, and then just keep going up and above me. Yep, all the way. Yep. So you just go to - I want you to actually release that, so like that. Good. So we just open up the fascia over the peroneals, and then we’re going to be a little bit posterior here. Perfect. You don't want to strip any of the periosteum off the bone beyond that needed to see your reduction. So there's the fracture, and there's that. All right, so you want to make sure you leave that soft tissue on there. Yep. You don’t want to cut on the bone, you want to cut down to bone. Yep, right here. Just release that. Good, good. Real gently because you want to leave that periosteum on there. Good. A little more. Good, that’s plenty. Now let’s just release the front here a little bit. So like, yeah, you don't want to - you don’t want to worry about that nerve though, so cut that way. There. So now we’ve got our fibula. We got that. We'll get that. A little bit of comminution, but pretty clean fracture line.
So when you're cleaning the fracture site, the curette just moves things around - use your Fraser tip. You see that? All right. You just suck the pressure right out. Especially in a fresh fracture like this, you do that to remove the blood and the clot. When they’re real fresh like this, it doesn't take much. There's not as much in there. The thing to look for is enfolded periosteum. That’s going to be what blocks your reduction, and that's usually going to show on the medial side because that fails in tension.
So you always want to try to use pointed reduction forceps because that is less traumatic. You get more power with the tips of these points than with that. Oh yeah, he’s stable. Almost. Oh, there it is, there it is. Okay. Okay, come on in for a shot. Come south for me, please. X-ray. And that shows that our fibula is almost out to length. And our syndesmosis is not reduced, but that's okay because we're gonna start with the fibula and then work on the syndesmosis. All right, good. Well, I don't think we're going to be able to do a lag screw because there's a lot of anterior comminution. So - and we're reduced in the back anatomically there. It looks like we're pretty close. Agree. So, you know, unfortunately, you know, it's nice to get a lag screw, but this one we're not going to be able to. You see it was a pretty high-energy injury. We didn't do any of this dissection. There's a lot of periosteum stripped around the fractures. All right, so 1/3 tubular plate.
So for most ankle fractures, you're gonna use a 1/3 tubular plate. I like the locking plate, not because I think you ever need the strength of the locking screws especially in a young person, but because distally, I like to use locking screws because they're less prominent than proximally. Some of the other sets you don't need that, but with this particular set, that kind of helps. And then also, one of things I really like to do is use the locking towers to help place the plate because we're going to use K-wires to hold it, and then once we're happy with our plate position, These plates are pretty flimsy, so they'll kind of contour themselves. But I'm just going to give it a little bit of a bend - a little bit of bend to better contour it, and the key thing is, if you're going to do that, you want to keep those locking towers in because that's going to preserve the lockings. So I like to just set the plate in place clinically. And then I'm gonna take a couple pictures, and if we're happy with that, then we will use that. So you can put your K-wire distally, pull on it, get your length, and then put another K-wire that holds it. It's a really nice way of doing that, but then it still lets you adjust your reduction a little bit in terms of flexion, extension. One cortex only. All right, x-ray there. That’s a little bit more than one cortex. X-ray. All right, so we have enough holes above and below the fracture there. So now we're out to length it looks like, and we got that by reading the posterior aspect of the fibula back here and then also radiographically. And now let’s go to a lateral view and see where our plate is. So this drape’s nice because it lets you do that, and then you just put it back - you're not wasting sheets. That looks good - worth a shot there. X-ray there. Hold on. X-ray there. Save that. So that's a true lateral of the ankle, and we can tell that by looking at the talus and also the plafond. And our plate’s sitting - the plate’s sitting square on the fibula proximally and then coming a little bit posteriorly distal, which is what we’re looking for. And that looks nice. All right, good. So give us a shot. Go live for a second. Stop there. So when we're looking at fibular length, there are three things. The first thing is talar-tibial tilt, so if the talus is tilted, then it's way off. So that's a really bad sign if the talus is tilted with respect to the tibia. So that's the first thing. And you can see our joint’s parallel, so that's good. The second thing is the parallelism between the tibia - or sorry, the talus and the fibula. See how it kind of comes together and there are some parallel lines that go down there? So that's a sign you’re out to length. And then Shenton's line - so you want to follow it up, and if you look real carefully, the fibula kind of curves and hooks at the top, and that lines up with the bottom. So those are kind of the three things I look at to say "All right, I got length."
So you always want to start with non-locking screws. If you start with locking screws, you're not going to contour the plate to the bone, and it's not going to suck it down, right? Distally, I want to use locking screws for prominence. So let's just start right there. What you're feeling for is two cortices. That's a sign that you're in the middle of the fibula, see that's one, two, good. So that’s just a check, right? So that’s a backup check. Now you know your plate's centered on the fibula. Because you found the medulla canal. A lot of people do the depth gauge wrong. So you hook it like that. So it's one hand. You feel that hook, and then you go down, and you push it pretty hard. You feel that? So I'm getting... I'm getting 12. So when it's down, 12, but I want you to put in a 14 anyway. I think a lot of people leave their screws short. You know, you want the screw to be out of the other side of the bone. You definitely want all the way through the second cortex? It’s got to be. It’s got to be. The only time you don’t want that is if there’s something really important on the other side that you don't want to irritate like a tendon like when you’re doing a distal radius fracture. X-ray. Save that. All right, so you can see our screws are starting to reduce it, and that's the ideal screw length, all right? So the tendency is to want to leave it flush with the bone - you need it to stick out because the tap of the screw has no purchase. You got to have it out like that.
16, non-lock. So again, non-locking screw, what’s going to let this 1/3 tubular plate contour to the bone. We get it close, and then the screws do the work. If you do a big beefy plate, like a LC-DCP plate, then you’re going to have to contour it yourself, but this plate will do itself. It’s high technology, self-contouring technology. Maybe not killer on this one, all right? X-ray. X-ray. X-ray. Just a little bit of comminution. Do you have a Freer? Got a little piece there, see it? That’s what we’re seeing in the x-ray, isn’t it? Again, let's get the sucker and look back there. Grab this down here. Good, so you can see we have an anatomic reduction on the posterior cortex there, and then on the front here, there's just a lot of - little pieces. And so that’s why our x-ray - you can see there's a little bit of flaking there, but posteriorly, we’re perfect. So we know we have length from looking at it, but then we have the radiographic confirmation too. All right, so… X-ray there. X-ray there. Let’s go to a lateral. X-ray there. So that looks pretty nice. We got a good straight, and now if I externally rotate - x-ray there. We’re gonna bring the fibula into view. You see some comminution, but you follow that anterior cortical line, and it looks good. And we're not getting there yet, but we're going to reduce the syndesmosis, and it's sitting on the posterior third of the tibia, which is where it's supposed to live. So, it's starting to look good that way too. All right, good. Back up to an AP.
So happy with our plate placement, we’re happy with our reduction. So now what we do is we pull it back. So we got to leave room for our syndesmosis. We're probably - that screw you put in already is probably going to become a syndesmotic screw. So why don't we - this is contoured nicely, so we'll put a locker in here, Or actually, if you wanted, you could fill it up top too. That would be other thing you could do. Let’s stay with 2-5. I’ll take an Army-Navy. What's the length of that screw? Call it out. 14. 14 please. Can we get 14 ready? 14, you got it. 14. Remeasure anyways, just for good measure. And notice we’re not taking any x-rays. We don't need any. Right? Because we had it set. We have our reduction. We have our plate in the right place. 14, please. So you can see, I like the plate a little on the posterior side. So the top of the fibulas’ up here. This is posterior, but it's not all the way posterior. That's because of the peroneals here. So you can see there’s the peroneus brevis. And so you want this plate up here so that it’s not going to interfere with those peroneals. They're not going to get tendonitis, but being out of the way here, it's going to be a little less prominent and a little stronger because you're a little bit further in the back. Good, all right. No go all the way to the far cortex but not through. So this is where I like to use a couple locking screws, and it's just purely for hardware prominence. There's no other reason. You know, good bone like this doesn't need it for strength. It seems a little bit long for a 16. 16 is fine. What’s our T time? It's about... 14? 31 minutes. 2-8 back. Another 16. You don't want them to be out the other side here because it'll bother him. Yep. Distally, it’s in the joint, and then even up there - you know, if it's too long, it'll irritate the syndesmosis. Yep, x-ray there. Okay, so now we’ve finished our fibular fixation. Could you have a clamp? So now you can do a cotton test. We know it's unstable from our pre-op, right? And even just clinically, like it seems to move around, but I grab that fibula, and I pull on it. X-ray. You can see it’s gapping - not quite as bad you would think, right? But still gapping. So we got to fix that.
All right, so put your clamp down this way. Can I see a pickup and a knife? All right, so we have the fibula fixed, and now we got to reduce the syndesmosis. And this is something I like to actually see. All right, so we're going to open up this - and we know the syndesmosis is disrupted, so I don't have to worry too much about cutting the ligaments here in the front. We’re just going to come right over the front here, and this is the area of the syndesmosis, right here. Right here. Okay. Despite all of that spraining, and the x-ray disruption, there's some - some of that capsule is left intact there, right? But it's clearly incompetent because it’s letting us move more than it should. So that must have been torn off, and now it's kind of reduced in there. So this is interesting here. So, you know, I was dissecting over the front - and this is the syndesmosis right here, and it looks intact, and I was surprised because the talus is so subluxed, but if you look up in the front here, there's actually a fracture line on the tibia. And so what's happened is there's a small Tillaux fragment. So instead of the syndesmosis failing through the ligament, it just pulled off a little flake of bone here, and you can actually kind of see that on that x-ray there.
So what we are going to do is just reduce that and pin it. So, I've got it. I can see the front of it there. That's reduced nicely. So I'm just going to hold that, and then you're gonna pin it. And straight across? Just above my thing. Yep, and aiming north a tiny bit so you don't get in the joint. Good. All right, I don’t need that anymore. Come north. X-ray there. There you go, and so now we’ve restored that relationship. So I'm just gonna reduce the syndesmosis manually by compressing it a little bit, and then I want you to put another pin - this time through the fibula into the tibia. Yep. Okay. Yep. X-ray. X-ray. X-ray. Sorry, x-ray. X-ray. Go live for a second. Stop there. So I’d like to get that view. So that's a mortise view where you’ve got a nice dark line on the talus and a nice dark line on the fibula, and that means you're looking down a corridor of bone. So the rotation of the fibula has to be correct with respect to the talus, which is kind of our goal after all. This one we're pretty sure we got a good reduction of the fibula because we're looking at it and it's anatomic on the back side, so we're good there. All right, that looks good. All right.
So now we got to take out our previous cortical screw and replace that one with a syndesmotic screw. All right, 2-5 Drill. Come on it. So I like to put these on under C-arm just to get them parallel to the joint. There is a debate about how many cortices and how many screws and what size, so I don't think there's really a right answer. You can use a tightrope if you like or some other kind of suture device, but I use two tricortical 3.5-mm screws. Parallel to the joint, right? Remember, you’re a little bit posterior, So you want to just drop it down a little bit. So shooting anterior. Yep. Not a lot, just a little bit. Ease your x-rays. Come south for me a little bit. X-ray. X-ray. Good. Let me feel. So I can feel I'm in bone there - x-ray. Now that feels like bone. X-ray. Depth gauge. On power? Yep. 45. With a gentleman like this young guy, I tend to take my syndesmotic screws out at 3 months. You don't want to take them out before that though. So you have to make - there's two holes - you have to make it go in the right one. You don't want to kill this, it should just be snug. X-ray. Good. Good. All right, so I'm pretty happy there.
We're going to put independent screw fixation actually to fix this piece, but I want - you know, I want the extra - you know, this is a pretty small flake of bone, so I don't want to rely on one screw up here to protect our syndesmosis. So I have syndesmotic screws, but we’re going to put another screw right here. And go parallel to our finger? Parallel to the joint. Parallel to the joint, not the - you got it. We’re actually way over here. X-ray. That looks pretty good. That's it. That's only through one. Yep. All right. Yep. 2-5 next. Stop here. X-ray. Okay. X-ray. I just want to make sure you're parallel, so, all right. Depth gauge. X-ray. Self-fracture. Is it really? You're good. What screw do you want? X-ray there. 40 4-0 partially threaded cancellous screw, please. Want your driver back in a sec. Wire driver. 2-5. Do you want me to get a new battery? We'll try it, it just sounded like it was… We're okay. X-ray. Excellent.
Remember that angle, right? Way down there. X-ray. X-ray. So see, that's nice. Save that. So you know you're on the tibia now. Yeah, I can feel it. For the syndesmotic screws, you’ve got to make sure you’re aiming from down to up. 3-5 cortical screw. It’s going to be a 40. If you hit the far side, it will destroy the fibula, all right? Gotcha. Because you don’t have a hole there. That was pretty bold. Next time by hand, okay? At the end, you don’t ever want to put anything down on power. Like I said, you don’t want to kill this - it’s just down. It's pretty tight. But you don't want that. Because you can over-reduce the syndesmosis. Over-reduced syndesmosis. X-ray. X-ray. X-ray. Save that. X-ray there. X-ray. Let’s come to a lateral. So the rotation of the fibula looks good. The syndesmosis looks reduced, and we look like we have it out to length, so far we're getting enough. Now we just need to decide if we're gonna do the medial side. How come you did three syndesmotic screws? So there's only two syndesmotic screws. The distal screw’s in a Tillaux piece, so it's actually in the tibia - not great bone there. It’s a pretty small flake, so I didn’t want to rely on just that, so the syndesmotic screws are doing the work, but that little screw there is kinda gonna help hold it. X-ray there. So here we can see again a perfect lateral of the ankle, and we can tell that by the plafond as well as the talus. Our fibula is sitting posteriorly with respect to the tibia. It’s - you know, the - it’s kind of centered at the junction between the middle and distal thirds of the tibia. So that’s approximately where you’re expecting to see his syndesmosis. Here we know we’re good, because we actually have that read in the front, reducing the Tillaux fragment. Normally, you'd have a read right here actually looking at the syndesmosis. And you can see that’s right where it belongs, so that looks good. And then our joint looks good, so everything looks nicely there. And it’s just a matter of the medial side. All right.
So that C-arm goes under and contaminates that side, so… So he has a little pressure ulcer on the medial side. The skin looks good, but there's a little black eschar. So we're gonna have to be a little careful about that. You know, and this is one that you can't do percutaneously because, you can see, it's all flipped around and caddywhompus.
What are you worried about? Could see the saphenous coming down here. Wheaties. I believe in a real generous incision on the medial side. You want to really see it and reduce it. If you look carefully, there's always enfolded periosteum. You want to get a good… More cutting, less spreading. Yep. like I said, there’s nothing you're worried about over here, right? You want to protect the skin by keeping full-thickness flaps. A lot of people do a curved incision like that kind of as a routine. I typically try to make straight incisions, so I don't like to do that. In him there's a little ulcer. The advantage of it is you really want to see the anterior portion of the reduction of the medial mal. That's going to be your reduction read. And then - but your screws are going to be coming in from a little bit further down, and so it kind of helps that way if you make a smaller incision. I kinda tend to think I like extensile, so... Right. Try to make it straight if you're in trouble. For him, I think this is the right move. All right, so if you look right in here - this is real common. So this is - thing failed in tension, all right? So this is the fracture. You can see - you can actually see the posterior tibial tendon is right back there. The kinda key thing here is this is the medial mal, and if you look in here, this is periosteum - and it's folded in so the - because it falls in tension, it’s going to suck the periosteum in and kind of buckle. So often it will be draped over here, kinda like this portion of periosteum in the back. But then in here, you can see this whole big piece of periosteum - you see that? That's gotta - that’s what’s stopping it from getting reduced. You can imagine you’re trying to do that percutaneously. Yeah, you can’t do it. It’s not going to happen. You got to get that out of there. So I would actually cut this band of periosteum. Then you’re going to flip this out of the way. And pull the periosteum back just a little bit, and now you can really get a good read, so. So some of this kind of stretched in from the periosteum - it's redundant. I’m just going to take that right after…
I try not to just robotically put two screws up the medial mal. I want to look at the obliquity the fracture - you know, try to put them in perpendicular to the fracture. And that’s going to lift up like that. Yep. Pretty good read there. And you can see all the way up into the front here, and then like I said, this anterior crux is really important. Let me see see if that’s reduced or not. Kind of in comminution. And overall reduction. So why don’t we check that with the x-ray? X-ray. There we go, and so there’s your AP, and that’s an anatomic reduction, so save that.
X-ray. All right, so I'm happy with the reduction on the medial side. We got it provisionally held with a K-wire. I don't use cannulated screws to the medial side. I just like to use regular screws.
So we took a 2-5 drill, and we’re going to use partially threaded cancellous screws. All right, so here - where's the fracture line? Here. Yeah, so the obliquity of the fracture line is not very transverse like a normal ankle fracture; it’s a little oblique. Yep. So we're actually going to be up here. Firing down. Firing this way. So we’re gonna do two screws. This K-wire’s gonna be where one of the screws is, and you can see that we like that. It's a nice spot. So you can use that as a reference for your other screw. Right. Yep, right posterior to. Depth gauge, please. Yeah, 40’s safe. Yep. 40? Yep. Get a wire driver. X-ray there. So that looks really nice. That’s great. Nice, good placement there. The idea is to have that kind of around the corner. Yeah. You got to be safe to the joint, but if you're really around that medial side, it’s going to bother people. So I like to kind of tuck that in there like that. That looks really good. All right, back out for a second.
Do you have a screwdriver? I am going to show you the angle. Is this one all right? Yep, and then a 3-0. So this is the angle of that last screw. Good, come out. I’ll often leave the drill in because that just holds your angle. You're not going to use the depth gauge here because you know the length already. You really have to have secure fixation when you're putting these in because the bone is pretty dense, and those are cancellous screws, screws. So when they go through the medial mal, it’ll really put a torque on it. So here we have a monster bite on the other one that's really compressing it, so it's going to hold it. Otherwise, you really should have two points of fixation like a clamp and a screw or a clamp and a K-wire or something. You can see it’s interdigitating, which is nice. That's a nice bite. That's a monster bite, and that looks unbelievable. Okay.
All right, so let’s come in for our final pictures and make sure we're happy with everything. And as you can see, it’s hard to see through the Ioban, but there’s a little bit of a black mark there, and that’s the pressure from the having his ankle dislocated. X-ray. X-ray there. Save that. X-ray there. Go live for a second. Stop there. Save that. And now let’s come to a lateral. So you can see the position of those screws are a little bit different than normal. The anterior one is more proximal, and that's because of the obliquity of the fracture; we wanted to start a little bit further up the malleolus to make sure it was perpendicular. X-ray. X-ray. X-ray. X-ray. X-ray. X-ray there. X-ray there. Go live for a second. Stop there. X-ray there. X-ray there. Save that. So there’s our lateral, again, you can actually see the fibula behind that plate. We’ve got our anatomic reduction there, so we know we got our length. And then the obliquity of those screws is very different than normal, but that’s because - once again, it’s an oblique fracture on the malleolus, and we want to stay perpendicular. That looks good. All right.
So on the skin, I try to use a no-touch technique with my pickups. You know, I use - I don't ever pinch the skin. I'm using it as a hook to pull and push, but I don’t pinch. Particularly high-energy ankle injuries - calcaneus, talus, pylon fractures - high energy ankle fractures - it’s worth doing that. So this is that little bit of eschar here, and you know, we made our incision well clear of it. And the skin edges all look very healthy, so, you know, I'm hopeful. You know, we didn't have too much of a choice. If it was minimally displaced, I probably would have left it even if it - you know, was displaced to begin with - if it reduces nicely, but it was flipped around really badly, so. You know, the soft tissue’s only going to get worse. I tend not to do horizontals. You know there are some - some plastic surgery stuff to show that - that vertical and simples are a little bit better for the blood supply. You know, I think it's really important - you know, I think a lot of people put their stitches too close together. You know, you got to give space to let it breathe. And you don't want to put them in too tight. You know, they’re only going to get tighter as the soft tissue swelling increases. Right. I think a nice closure can really help prevent a lot of wound problems. He's going to need a Hollywood splint. Okay. So what that means is I leave me splints on until follow-up. You do? And, someone like this, they’re going to complain of pain. So someone’s going to release the splint, so I want you to put a sterile dressing underneath it they are not to remove.
So there are a number of outcomes for ankle fractures. Radiographically, you know, we're going to follow this patient to make sure that the fractures unite. Clinically, the early worry is infection, and so we need to follow him very closely to make sure he doesn't have an infection. The infection rate of ankle fractures is actually fairly high; it probably ranges somewhere between 3 and 5 percent. And, you know, this guy's definitely at increased risk because of the high-energy nature of his injury and the medial ulcer that he had. And then as far as clinical outcome measures, there's been a lot of development regarding that, and here we do something a little bit differently than a lot of centers; we use computer adaptive testing and do - we use an outcome measure called "The Promise" measures, and these were developed with the NIH. And they are a good way of getting a very specific outcome on your patients, and there's some software that you can use online actually to do that. So he’ll be followed clinically but also with outcome measures. Infection is a big problem with these injuries, and I think it happens a lot more than we think. And being very careful with the soft tissues, waiting if there's a lot of swelling, and saying ,you know, this is - we just have to wait this out, and waiting two weeks for the swelling to come down I think is completely appropriate a lot of the time. And then from a surgical standpoint, once you're in the operating room, I think, you know, respecting the soft tissues, respecting the blood supply to the bone, not stripping the fracture fragments beyond what you need to see the reduction is really important to get the things to heal. And then really focusing on getting that fibular length. If you can get an anatomic reduction, it's easy, but a lot of times - if it's comminuted, you’re not going to be able to do that. And then restoring the fibular length is one of the most important things as far as restoring ankle stability and patient outcomes, so I think making sure you get it out to length is important. And we discussed in the case a little bit about how to do that with the x-rays if you can't get an anatomic read. And then beyond that, regardless of what you do at the end of the case, the talus is squarely under the tibia, and it's secure. You know, checking that syndesmosis, and making sure it's okay, and making sure everything's reduced is really important.