Lateral malleolus fracture with tibio-talar instability
Lateral malleolus fracture with syndesmosis injury
Isolated medial malleolus fracture
Bimalleolar ankle facture
Trimalleolar ankle fracture
ORIF Ankle Fracture Contraindications
Soft tissue compromise - severe swelling
ORIF Ankle Fracture Alternatives
ORIF Ankle Fracture Pre-op Planning / Special Considerations
Timing of surgery is dictated by the status of the soft tissues. Ideally surgery is done before any true swelling or fracture blisters have developed. Delayed surgery done when blisters have resolved, skin wrinkles normally (average 14 days) has equivalent outcomes (Karges/Watson, JOT 1995;9:377).
Posterior malleolar fragments >25% of the plafond may be fixed via percutaneous clamp reduction through the medical mallellar fracture or direct reduction through a posterolateral or posteromedial approach.
Posterior approach only needed for large posterior malleolar fragments-prone position. Incision between Achilles and peroneal tendons. Avoid sural nerve. Find interval between FHL and peroneal tendons. FHL is medial and protects posterior tibial artery/nerve.
ORIF Ankle Fracture Technique
Sign operative site.
Pre-operative antibiotics, +/- regional block.
General endotracheal anesthesia
Supine position with bump under ipsilateral hip. All bony prominences well padded.
Well-padded tourniquet placed high on the thigh.
Prep and drape in standard sterile fashion.
document osteochondral injuries which should be saught during ORIF.
Lateral malleolar fixation provided with posterior antiglide plate +/- lag screws. (Lamontagne J, JOT 2002;16:498).
Peroneal tendon pathology: associated with low plate placement with a prominent screw head in the distal hole. (Weber M, Foot Ankle Int. 2005 Apr;26(4):281)
We discussed the risks of surgery including, but not limited to: incomplete relief of pain, incomplete return of function, nonunion, malnunion, painful hardware, hardware failure, compartment syndrome, CRPS, DVT/PE and the risks of anesthesia including heart attack, stroke and death.
ORIF Ankle Fracture Follow-up care
Post-op: bulky jones dressing, NWB, elevation
7-10 Days: Wound check, functional Air-Stirrup ankle brace (Aircast). Partial weight bearing as tolerated. Encourage daily active and passive range-of-motion exercises of the ankle and subtalar joints without the brace.
6 Weeks: Assess xrays for union. Progress with activity / PT. Driving: may drive after 9 weeks for right leg. (Egol KA, JBJS 2003;85A:1185). Swelling is common after ankle sprain or fx. Rx=compression stocking (sigvaris, Jobst) 20-30mmHg
3 Months: Begin sport specific rehab. Running, stair-climbing, and participation in sports are allowed only after a full range of motion of the ankle has been achieved
Physical function and role physical scores remain significantly lower than US norms at 24 months after operative fixation. Smoking history, presence of a medial malleolar fracture, lower levels of education are significant independent predictors of lower physical function up to 3 months postoperation.(Bhandari M, JOT 2004;18:338).
Average time to full weightbearing = 7weeks, return to work = 8weeks after surgery with early weight bearing protocol. 100% good results; Olerud score (90 +/- 13 points). (Simanski CJ, JOT 2006;20:108).