A Closer Look At Arthroscopy For Ankle Fractures And Post-Fracture Defects

Graham A. Hamilton, DPM, and Travis L. Sautter, DPM

   One could then reduce the fracture either with reduction forceps and an arthroscopic check, or percutaneously secure the site with K-wires from the cannulated screw set. Using the wire technique, insert wires from the tip of the medial malleolus and advance the wires just proximal to the fracture line. One can then use the wires to “joystick” the fragments into place with arthroscopic visualization to verify reduction. Once you have achieved adequate reduction, you can advance the wires across the fracture site and insert screws if the wire position is optimal.

Case Study Two: Treating A Bimalleolar Ankle Fracture In A 33-Year-Old Male

   A 33-year-old male slipped on some stairs and sustained a closed bimalleolar fracture. At first glance, the plain radiographs demonstrate a fairly typical bimalleolar fracture. One might question whether arthroscopy is necessary.

   Intraoperatively, the surgeon noted a large lateral osteochondral fragment. We typically perform a 10-minute cursory arthroscopy prior to open reduction internal fixation (ORIF), given the high incidence of chondral and osteochondral lesions.

   Ferkel identified osteochondral lesions in almost 80 percent of the ankles that underwent ankle arthroscopy and operative fixation in conjunction with an acute ankle fractures.1

   Recently, Leontaritis and colleagues looked at 283 ankle fractures that had ORIF and underwent ankle arthroscopy.2 The researchers classified the ankle injuries according to the Lauge-Hansen criteria. Seventy-three percent had chondral lesions. Articular injuries were common in the more severe ankle fracture patterns. This included the pronation external rotation (PER) injuries and supination external-rotation (SER) type IV patterns.

Case Study Three: When A Pediatric Patient Has A Tillaux Fracture With Displacement

   A 12-year-old female sustained a closed fracture with a twisting injury while playing basketball. Her mortise radiographs demonstrated a Tillaux fracture with a 3 to 4 mm displacement. After surgeons removed the hematoma and debris, they could clearly visualize the fracture gap. They reduced the fracture and stabilized it with a reduction clamp utilizing a small anterolateral incision over the distal tibia. They checked the reduction with the arthroscope and manipulated the fragment to obtain articular congruity. Fixation can be with either cannulated or solid screws. For this patient, surgeons used a 3.5 mm solid lag screw.

   In 1898, John Poland performed an extensive study of epiphyseal separations about the ankle. He noted that ankle injuries in children differed from those in adults in three important ways.6

   • The growth plate forms a plane of weakness directing fracture lines in patterns different from those in adults.
   • Ligaments are stronger than bone so ligamentous injuries are less common in children.
   • Certain injures will affect growth.

   Remember that nearly 40 percent of physeal injuries reported in children are ankle fractures. More than half of these ankle fractures in children occur during sports activities.7

   A Tillaux injury almost always occurs in the adolescent within a year of complete closure of the distal tibial physis. This injury is a Salter-Harris type III fracture in which the lateral portion of the distal tibial physis is injured. The central and medial aspects of the tibial physis have closed, leaving the anterolateral aspect open and vulnerable to injury. An external rotation force on the foot may avulse the anterolateral quadrant of the tibial physis, which is bound to the fibula by the strong anterior tibiofibular ligament. This may result in a rectangular or pie-shaped fragment breaking off the distal tibial epiphysis.

Case Study Four: Treating A Triplane Fracture In A High School Football Player

   A healthy 15-year-old male sustained an injury in a high school football game. A CT scan confirmed a three-part intra-articular fracture. The coronal view noted no articular step-off but identified a 3 mm displacement. Three-dimensional CT reconstruction provided a very clear understanding of the fracture pattern.

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