dj3427 internal fixation of ankle fractures 6-10

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Internal Fixation Internal Fixation

of of

Ankle FracturesAnkle Fractures

6-10

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ObjectivesObjectives

Review Review ankle anatomyankle anatomy

Identify the indications & treatment Identify the indications & treatment goals for ORIF of ankle fracturesgoals for ORIF of ankle fractures

Summarize the implant optionsSummarize the implant options

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AnatomyAnatomyAnkle BonesAnkle Bones

Formed by medial malleolus of Formed by medial malleolus of tibia, and lateral malleolus (fibula)tibia, and lateral malleolus (fibula)

Talus sits in “mortise” Talus sits in “mortise” (as in “mortise & tenon”)(as in “mortise & tenon”)

Talus

Tibia

Fibula

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AnatomyAnatomyAnkle Soft TissuesAnkle Soft Tissues

Ligaments connect ankle on medial & lateral sidesLigaments connect ankle on medial & lateral sides Important for stabilityImportant for stability

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AnatomyAnatomyAnkle Soft TissuesAnkle Soft Tissues

Fibula connected to tibia by fibrous Fibula connected to tibia by fibrous band of tissue called syndesmosisband of tissue called syndesmosis

Also important for stabilityAlso important for stability

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Ankle FracturesAnkle Fractures

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Ankle FracturesAnkle Fractures

HistoryHistory Twisting injuryTwisting injury Immediate pain – lateral and/or medialImmediate pain – lateral and/or medial Difficulty weight-bearingDifficulty weight-bearing

Physical examinationPhysical examination Malleolar pain (posterior & anterior)Malleolar pain (posterior & anterior) Difficulty weight-bearingDifficulty weight-bearing SwellingSwelling Neurovascular involvementNeurovascular involvement

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Ankle FracturesAnkle FracturesRadiographsRadiographs

Ankle Series: AP, mortise, Ankle Series: AP, mortise, laterallateral

““Rule out” other injuries:Rule out” other injuries: Osteochondral injuries Lateral process fracture Anterior calcaneus fracture Base of 5th MT fracture

AP

Lateral

Mortise

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Ankle FracturesAnkle FracturesClassificationClassification

Weber / AO Classification based on level of fibula fractureWeber / AO Classification based on level of fibula fracture

A – Below syndesmosisA – Below syndesmosis

B – At syndesmosisB – At syndesmosis

C – Above syndesmosisC – Above syndesmosis

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Simple Classification: Simple Classification: Stable & UnstableStable & Unstable

Stable fracturesStable fractures Most commonly involve Most commonly involve

medial or lateral side onlymedial or lateral side only

Talus remains anatomic Talus remains anatomic relative to tibiarelative to tibia

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Simple Classification:Simple Classification:Stable & UnstableStable & Unstable

Unstable fracturesUnstable fractures Disruption of 2 or more Disruption of 2 or more

aspects of the mortise -- aspects of the mortise -- bone and/or ligamentbone and/or ligament

Talus may sublux or be Talus may sublux or be dislocated from tibiadislocated from tibia

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Stable ExamplesStable Examples

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Unstable ExamplesUnstable Examples

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Indications for SurgeryIndications for SurgeryAnkle FracturesAnkle Fractures

Inability to obtain or maintain an Inability to obtain or maintain an anatomic mortise (unstable anatomic mortise (unstable fracture pattern)fracture pattern)

Open fracturesOpen fractures

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Basic Set-UpBasic Set-UpAnkle FracturesAnkle Fractures

Supine position most commonSupine position most common Occasionally prone for direct approach to posterior Occasionally prone for direct approach to posterior

malleolusmalleolus Bump beneath ipsilateral buttocks (allows easier Bump beneath ipsilateral buttocks (allows easier

approach to fibula)approach to fibula) TourniquetTourniquet Prep / drape to above knee Prep / drape to above knee Pre-op antibioticsPre-op antibiotics Fluoroscopy or X-rayFluoroscopy or X-ray

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General ConsiderationsGeneral Considerations

Small size of ankle bones = dictates implant sizesSmall size of ankle bones = dictates implant sizes

Multiple complex 3-D articulations Multiple complex 3-D articulations

Weight bearing structure subject to high stresses Weight bearing structure subject to high stresses (2 – 5x body weight)(2 – 5x body weight)

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General ConsiderationsGeneral Considerations

Limited soft tissue coverageLimited soft tissue coverage

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InstrumentationInstrumentationAnkle FracturesAnkle Fractures

Small fragment setSmall fragment set Cannulated screwsCannulated screws K-wiresK-wires Cerclage wire Cerclage wire PowerPower Have mini-frag availableHave mini-frag available

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Ankle FractureAnkle Fracture Surgical TxSurgical Tx

TypeType One malleolusOne malleolus

BimalleolarBimalleolar

Tri-malleolarTri-malleolar

TreatmentTreatment Fix fibula with screw / Fix fibula with screw /

TB wire / plateTB wire / plate

Plate fibula, lag screw tibia Plate fibula, lag screw tibia (medial malleolus)(medial malleolus)

Plate fibula, lag screw tibia, Plate fibula, lag screw tibia, fix posterior if >20 - 25% fix posterior if >20 - 25% articular surface involvedarticular surface involved

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Implant ConsiderationsImplant ConsiderationsLateral MalleolusLateral Malleolus

One-third tubular plate & One-third tubular plate & 3.5 mm cortex screws3.5 mm cortex screws

LateralLateral PosteriorPosterior

3.5mm compression plate for 3.5mm compression plate for unstable fracturesunstable fractures

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Implant ConsiderationsImplant ConsiderationsLateral MalleolusLateral Malleolus

Locking plates -- lateral or posterolateral Locking plates -- lateral or posterolateral Osteoporotic boneOsteoporotic bone Unstable fracturesUnstable fractures Distal fracturesDistal fractures

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Implant ConsiderationsImplant ConsiderationsLateral MalleolusLateral Malleolus

Hook PlateHook Plate

Used to obtain purchase Used to obtain purchase in very distal fibula fracturesin very distal fibula fractures

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Implant ConsiderationsImplant Considerations Posterior MalleolusPosterior Malleolus

Posterior to anterior Anterior to posteriorPosterior to anterior Anterior to posterior

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Implant ConsiderationsImplant ConsiderationsMedial MalleolusMedial Malleolus

Two partially threaded 4.0 mm Two partially threaded 4.0 mm cancellous screwscancellous screws

K-wiresK-wires Cerclage wire for tension band Cerclage wire for tension band

techniquetechnique

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Syndesmosis FixationSyndesmosis FixationIndicationsIndications

Syndesmotic instability after Syndesmotic instability after fixation of malleolusfixation of malleolus

Consider if fibula fracture Consider if fibula fracture > 4 cm above joint line & > 4 cm above joint line & Maisonneuve’s fractureMaisonneuve’s fracture

Have bone hook on back table Have bone hook on back table to check stabilityto check stability

Have large frag screws & Have large frag screws & instruments available instruments available

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Implant ConsiderationsImplant ConsiderationsSyndesmosisSyndesmosis

Surgeons choice of large or small fragment Surgeons choice of large or small fragment fully threaded screws, one or twofully threaded screws, one or two

NotNot inserted as lag screw, but as a inserted as lag screw, but as a positioning screw (threads engage positioning screw (threads engage all cortices)all cortices)

Secures position of fibula next to tibia Secures position of fibula next to tibia allowing torn syndesmotic tissues to healallowing torn syndesmotic tissues to heal

May be removed in 6 - 12 weeksMay be removed in 6 - 12 weeks

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Implant ConsiderationsImplant ConsiderationsSyndesmosisSyndesmosis

Have pelvic forceps on Have pelvic forceps on back tableback table

May need longer plates May need longer plates than in small frag set:than in small frag set: 1/3 tubular, compression 1/3 tubular, compression

or specialty fibula plateor specialty fibula plate

Bioresorbable screwsBioresorbable screws

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Case #1Case #1Age: 81 Gender: FemaleCause of Injury: FallFixation: 3.5mm LCP Lateral Distal Fibula Plate

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Case #2Case #2 Age: 64 Gender: FemaleCause of Injury: FallFixation: 3.5mm LCP Lateral Distal Fibula Plate

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SummarySummary

ReviewedReviewed ankle anatomy ankle anatomy Identified the indications & treatment Identified the indications & treatment

goals for ORIF of ankle fracturesgoals for ORIF of ankle fractures Summarized the implant optionsSummarized the implant options

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ThankThank YouYou