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Surgical Pearls

A Pertinent Guide To Treating Ankle Fractures

Ankle fractures occur in 122 to 187 people per 100,000 person-years depending on geographic location and tend to affect males and females in different age distributions.1,2 The majority of ankle fractures in females are age-related fragility fractures whereas ankle fractures affect most males while they are young to middle-aged.3 Many of these injuries are torsional in nature (versus axial), causing ligamentous and soft tissue damage in addition to osseous injury.1 

There are many different classification systems that describe ankle fractures and their pathophysiology. The most common systems include the Lauge-Hansen, Danis-Weber and AO Muller classifications.1 For pilon fractures (that are axial injuries), the Ruedi-Allgower and AO Muller classifications prevail. These classification systems provide information about the involved anatomic structures as well as mechanism of injury so they are valuable in deciding upon appropriate treatment.4 

Pertinent Preoperative Considerations 

When initially considering surgery for ankle fractures, one must optimize the preoperative health of the patient. The three largest risk factors include advanced age, complicated diabetes and peripheral vascular disease.5-7 A study of 57,183 patients showed that those with complicated diabetes who were surgically treated for ankle fractures were more than five times as likely to develop a post-op infection than those without diabetes.5 Furthermore, patients with complicated diabetes or peripheral vascular disease were 20 to 25 times more likely to have amputation following surgery for ankle fractures.5 Wukich and colleagues identified the presence of neuropathy and a hemoglobin A1c of greater than 8.0 percent as the greatest risk factors for developing a post-op infection in patients with diabetes.6 With regard to advanced age, a relatively more fragile soft tissue envelope combined with significant osteopenia or osteoporosis increases the risk of poor outcomes.7 

While controversial, the presence of fracture blisters (occurring in 6.6 percent of ankle fractures) or excessive edema are also important considerations.8 Many surgeons advocate for early surgery to prevent fracture blisters and if the fracture blisters are already present, they will either take a minimally invasive approach, or delay definitive fixation by 14 to 21 days to minimize the risks of dehiscence and infection. While there is mixed evidence for this strategy, it remains the consensus.9 

Lastly, it is important to ascertain specific patient activity levels and post-op expectations. Seventy to 80 percent of osteoarthritis of the ankle is secondary to prior trauma and fracture severity significantly impacts the development of ankle osteoarthritis.10 For example, fracture-dislocations carry a 30 percent higher risk of developing post-traumatic arthritis versus non-dislocations.10 Informing patients on potential sequelae that may occur from the initial injury will help set future expectations if post-traumatic arthritis develops. 

Essential Anatomic Landmarks: What You Should Know 

While ankle fractures can vary significantly in both complexity and presentation, there are several surgical principles that help optimize reduction and treatment. 

The first consists of awareness of vital structures. When addressing the fibula, awareness of the superficial peroneal nerve is key to minimizing potential nerve damage. In 72 percent of patients, the superficial peroneal nerve penetrates the crural fascia in the lower third of the leg, approximately 12.3 cm proximal to the ankle joint before coursing medially.11 This is well proximal to the surgical site in standard supination-external rotation (SER) injury variants. However, 28 percent of the time, the intermediate dorsal cutaneous nerve arises independently from the superficial peroneal nerve, 4.5 to 4.9 cm proximal to the ankle joint.11 

A prone posterolateral approach is often indicated when addressing the posterior malleolus in trimalleolar and posterior pilon variant fractures patterns. There are several anatomic landmarks to be mindful of and preserve. Approximately 8.4 +/-2.1 cm proximal to the intermalleolar line, the sural nerve passes from medial to lateral across the Achilles tendon.12 In addition, the small saphenous vein in 75 percent of individuals will lie just lateral to the sural nerve.12 One must also preserve the peroneal tendons and muscle bellies, specifically the peroneus brevis, with its lower lying muscle belly. 

When addressing a fractured medial malleolus, one should identify and avoid the great saphenous vein in the superficial fascia. The saphenous nerve, which is often difficult to visualize, often lies just posterior and divides into anterior and posterior branches three cm proximal to the ankle joint.13 Avoiding the great saphenous vein will help minimize postoperative edema, venous insufficiency or secondary lymphedema. 

Key Aspects Of Fibular Reduction 

A shortened or malreduced fibula is associated with poor outcomes and can cause lateral talar shift that can reduce tibiotalar contact area by 42 percent with just one mm of displacement.14 Fibular malreduction (whether laterally displaced, rotated or malaligned axially) increases pressure across the ankle joint, contributing to post-traumatic osteoarthritis.15 Therefore, adequate reduction and restoration of fibular length are two pillars of ankle fracture repair. 

After reflecting the periosteum from the fibula, surgeons should evacuate hematoma from the fracture site with a combination of curette, rongeur and Frazier suction tip. Manual distraction of the ankle joint can then help obtain anatomic alignment, particularly in cases with comminution. Once one has improved alignment, the surgeon can finely adjust lobster claw or pointed reduction clamps to gain length, derotate the distal segment(s) and temporarily hold the reduction. One may also employ provisional K-wire fixation to hold the reduction if necessary. 

If the fibula is still not at ideal length, the “push-pull” technique is an option.16 While there are multiple variations of this technique, the concept involves provisionally fixating the desired plate to the distal fibular fragment. Then after placing a screw pin in the proximal fibula (outside the plate) as an anchor, the surgeon can gradually open a laminar spreader to push the plate and therefore the fibular fragment out to length before stabilizing with a K-wire. 

Alternately, one may use a Hintermann retractor with 2.0 mm wires to serve in a similar fashion per surgeon preference. In our experience, attaching the fibular plate with two locking towers to the distal fibular fragment creates a joystick that can provide manual traction and manipulation of the fragments to achieve anatomic reduction and fibular length. 

For definitive fixation, ideally one to two interfragmentary screws (3.5mm cortical) crossing perpendicular to the fracture are preferable when possible. While we most commonly place our interfragmentary screws from anterior to posterior when possible, posterior to anterior placement is also an option and may minimize peroneal irritation.17 Ultimately, fracture location and pattern dictates interfragmentary screw placement and plate choice. General consensus dictates four to six cortices of screw purchase or two to three screws proximal (bicortical) and distal (unicortical in most supination-external rotation injury variants so as to not violate the ankle joint) to the fracture site. With the addition of a possible syndesmotic screw, this means the plate would need at least five holes.17 

While a one-third tubular plate may be adequate in many ankle fractures, there are often instances (such as a low-lying Weber B fracture) in which a one-third tubular plate does not provide enough real estate for two to three screws placed distal to the fracture site. In these cases, use of an anatomic plate allows for more screw placement choices as well as the option for locking screws distally.18 These qualities also make them appropriate for osteopenic bone or comminuted fractures as their locking options allow for maintenance of stability with only unicortical purchase. Furthermore, recent studies suggest that an interfragmentary screw may be unnecessary when using an anatomic plate since there is no significant difference in outcomes with regard to union and functional scores.19 

In cases of pure syndesmotic fixation, we recommend using a four-hole plate. This allows the surgeon to stabilize the plate to the fibula prior to fixating the syndesmosis. In our experience, a two-hole plate may rotate or possibly displace and alter syndesmotic fixation if it is not fixated to the fibula prior to syndesmotic fixation. 

How To Address The Medial Malleolus 

When addressing the medial malleolus, a more anteriorly placed distal curvilinear incision is key. This approach allows for more access to the preferred fixation site at the anterior colliculus.20 Femino and colleagues described the medial malleolus with three zones. Zone 1, comprising the anterior colliculus, allows for screw fixation with minimal to no risk of irritating the posterior tibial tendon. Screws placed in the intercollicular groove (zone 2) lie on average two mm from the posterior tibial tendon and screws placed in the posterior colliculus (zone 3) directly abut and can damage the posterior tibial tendon.20 

After ensuring adequate exposure, one should assess the medial malleolar fracture for any interposing periosteum.21 Inadequate debridement of interposing periosteal tissue and hematoma may lead to unacceptable reduction and increased risk for non-union.22 Therefore, many surgeons advocate for open reduction of the medial malleolus versus percutaneous fixation. After removing interposing tissue, we recommend using a 2.0 drill bit approximately two cm superior to the fracture site to create a small hole. This hole creates an anchor point for a pointed reduction clamp to aid in reducing the medial malleolar fracture. In addition to reduction clamps, employing a dental pick is extremely useful to help achieve anatomic alignment. Surgeons can also use the dental pick to “book open” the fracture site and assess the articular surface of the talus.23 

When it comes to medial malleolar fixation, we prefer to utilize two 4.0 mm cannulated screws at the anterior colliculus for transverse fractures. A second screw helps prevent axial rotation of the fracture fragment after fixation. Ideally, both screws should be slightly divergent. Studies show that placing divergent screws provides a biomechanically stronger construct than convergent or parallel screws for medial malleolar fractures.24 We typically choose fully-threaded screws. However, if one is using partially-threaded screws, length should not exceed an average of 30 to 35 mm. Keeping partially-threaded medial malleolar screws within this length allows for increased compression at the fracture site due to thread purchase at the physeal scar. This area is the densest portion of cancellous bone of the distal tibia.25 

In cases of osteopenia or osteoporosis, bicortical medial malleolar screws are an option as they facilitate superior biomechanical, radiographic and clinical outcomes due to additional cortical purchase.26 However, they often require a special preoperative request because the screw length required for bicortical fixation is typically over 60 mm and not available in standard ankle fracture surgical trays. When placing both medial malleolar screws, we recommend inserting the first screw one-third of the way followed by the second screw. Gradually alternating screw insertion helps minimize rotation of the fracture fragment while one is advancing the screws. 

A more comminuted medial malleolar fracture pattern, osteoporotic bone or a more obliquely-oriented fracture site are better suited to plate fixation versus screws. Free K-wires and small cannulated screws are often useful when reducing fragments. Additional 2.0 mm or smaller screws can be adjuncts to a plate to gain solid reduction. 

Emerging Concepts In Posterior Malleolar Reduction 

Traditionally, the prevailing thinking was that only posterior malleolar fractures greater than 25 percent warrant fixation. However, surgeons have increasingly shifted toward more aggressive fixation of the posterior malleolus 

due to its impact on syndesmotic stability with some advocating fixation of all posterior malleolar fractures regardless of size.27,28 Due to a 52 percent syndesmotic malreduction rate associated with transsyndesmotic screws and the fact that fixating the posterior malleolus restores 70 percent of pre-injury stability to the syndesmosis, we recommend fixing these fractures when they are present.29,30 

After making the decision to fix the posterior malleolus, a prone, posterolateral approach is best.27 Though this approach is more difficult than a supine lateral approach, it allows for direct visualization and reduction of the posterior malleolar fracture fragment.27 One can then use a buttress plate, which helps resist shear forces and is biomechanically stronger than posterior to anterior (P to A) or anterior to posterior (A to P) screws.27 

Furthermore, one may also utilize this approach to insert posterior antiglide/ buttress fixation of the fibula through the same incision. Antiglide plating of the fibula is stiffer and more biomechanically stable than lateral plating with less soft tissue irritation in comparison to lateral plating.31 This also carries no risk of screw penetration into the ankle joint. In our experience, one should take caution when selecting an antiglide plate for the fibula. The longer the plate, the greater the risk for peroneal tendon irritation at its inferior aspect. 

When plating the posterior malleolus, we recommend a 2.4 mm longitudinal plate or 2.4 mm T-shaped plate. This plate size minimizes postoperative repercussions with the posterolateral approach. A plate that is too wide and bulky is much more likely to cause impingement, especially if it encroaches upon the groove for the posterior tibial tendon at the medial tibia.32 While the posterolateral approach is great for anatomic posterior malleolar fracture reduction, it is not without disadvantages. There can be significant range of motion limitations postoperatively secondary to posterior fibrosis/scarring as well as the aforementioned tendon and capsular impingement problems.33 Placing the patient prone for surgery also places a greater cardiovascular risk on patients with significant comorbidities.34 

Therefore, for patients with significant compromising comorbidities and smaller posterior malleolar fractures, we recommend a transfibular approach, which allows the patient to remain supine. This is only amenable to supination-external rotation variants. The transfibular approach allows the surgeon to directly visualize and reduce the posterior malleolus through distraction of the fibular fracture. This direct visualization allows surgeons to free the posterior malleolar fracture site of adhesions and hematoma, facilitating easier and more accurate reduction.33 One then places percutaneous, bicortical, anterior to posterior positional or lag screws with cannulated technique. When placing guidewires and screws, the surgeon should exercise caution in order to avoid vital neurovascular structures anterior to the ankle joint. We recommend utilizing a hemostat to tease away these structures from the anterior tibial cortex. 

While fibular reduction and fixation may aid posterior malleolar reduction through ligamentotaxis, one should almost always ensure definitive posterior malleolar fixation first. Fixating the posterior malleolus requires intraoperative joint assessment for tibiotalar congruity with fluoroscopy. Hardware in the fibula can obscure the fluoroscopic view of the tibial plafond and therefore hinder posterior malleolar reduction. 

What Is The Best Approach To The Syndesmosis? 

After reducing and fixating an ankle fracture, it is important to stress the syndesmosis to check for any instability. Typically, one can perform stress external rotation or the hook test by pulling laterally on the fibula with reduction forceps. If the medial clear space widens to greater than four mm, tibiofibular overlap decreases to less than 10 mm or tibiofibular clear space increases to greater than six mm, additional fixation for the syndesmosis is likely necessary. 

When reducing the syndesmosis, the axis of compression can have a significant impact on malreduction.35 Phisitkul and team found the most accurate reduction of the syndesmosis when placing a large reduction clamp 10 mm above the ankle joint at both the lateral malleolar ridge and the anterior to posterior center of the tibia.35 Be careful not to overcompress. In their study, Phisitkul and co-authors noted that over-compression occurred in every reduction at an average of 0.9 mm.35 

Surgeons typically use fully-threaded cortical screws for surgical repair of the syndesmosis, which should be approximately two to four cm above the ankle joint. If too distal, syndesmotic screws risk violating the tibiofibular articulation. If too proximal, they can cause fibular bowing and syndesmotic malreduction.36 There is great debate as to whether syndesmotic screws should be tricortical or quadricortical. Tricortical screws allow for more physiologic motion but there is increased risk of hardware loosening.37 A quadricortical screw is stronger but there is a risk of breakage, and it may contribute to increased stiffness postoperatively. Despite this, there are not significant differences in range of motion, discomfort and postoperative functional outcomes between constructs.37 

More recently, suture button constructs have emerged for syndesmotic fixation. The literature shows that while suture button constructs have comparable complication rates and outcomes to syndesmotic screws, they require removal much less often.38 We prefer screw fixation for syndesmotic injuries with a Maisonneuve fracture as a screw holds the fibula out to length by preventing axial fibular pistoning. In patients with excessive instability or high activity levels, we prefer the hybrid technique of a screw and TightRope (Arthrex) in a four-hole plate. One can remove the screw after three months and replace with a TightRope. This alleviates any potential functional deficits from a rigidly malreduced or overcompressed syndesmosis from the screw fixation. 

When To Employ Minimally Invasive Techniques For Ankle Fractures 

In cases of osteopenia or osteoporosis, soft tissue compromise or a poor soft tissue envelope in general, minimally invasive techniques come into play. 

We frequently employ these techniques to treat ankle fractures in these types of patients with good results. This technique minimizes periosteal and soft tissue stripping at the fracture site, but may be associated with increased superficial peroneal nerve disruption.39 In addition, intramedullary fibular nailing becomes viable in cases of soft tissue compromise and fragility fractures of the ankle. It is also beneficial in staged pilon fractures in which the soft tissue envelope and multiple incisions are concerns.40 These techniques, however, can be more technically demanding with the added complexity of indirect or minimal visualization of the fracture sites. 

In Conclusion 

Though there are many techniques, tips and pearls to treat ankle fractures, an understanding of principles in physiology, reduction and fixation is key. This allows the surgeon to recognize when surgery is indicated and if so, utilize these pearls to optimize and tailor the surgical approach to the unique complexities of the fracture at hand in order to achieve the best outcome for the patient. 

Dr. Shaffer is a second-year podiatric resident at Mercy Hospital and Medical Center in Chicago. 

Dr. Hook is a Fellow of the American College of Foot and Ankle Surgeons, and a Clinical Instructor in Department of Podiatric Surgery and Biomechanics at Rosalind Franklin University in North Chicago, Ill. He is in private practice in Chicago. 

Dr. Wilson is in private practice in Crystal Lake, Hoffman Estates and Elgin, Ill. 

Surgical Pearls
By P. Tanner Shaffer, DPM, Jonathan Hook, DPM, MHA, FACFAS and Joseph G. Wilson, DPM

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36. Schepers T, van der Linden H, van Lieshout EMM, Niesten D-D, van der Elst M. Technical aspects of the syndesmotic screw and their effect on functional outcome following acute distal tibiofibular syndesmosis injury. Injury. 2014;45(4):775-779. 

37. Moore JA Jr, Shank JR, Morgan SJ, Smith WR. Syndesmosis fixation: a comparison of three and four cortices of screw fixation without hardware removal. Foot Ankle Int. 2006;27(8)567-572. 

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39. Bazarov I, Kim J, Richey JM, Dickinson JD, Hamilton GA. Minimally invasive plate osteosynthesis for treatment of ankle fractures in high-risk patients. J Foot Ankle Surg. 2018;57(3):494-500. 

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