questions
43

Ankle Fractures

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Topic updated on 08/07/16 11:37am
Introduction
  • Injury patterns
    • isolated medial malleolus fracture
    • isolated lateral malleolus fracture
    • bimalleolar and bimalleolar-equivalent fractures
    • posterior malleolus fractures
    • Bosworth fracture-dislocations
    • open ankle fractures
    • associated syndesmotic injuries
      • isolated syndesmosis injury 
Anatomy
  • Biomechanics
    • deltoid ligament (deep portion)
      • primary restraint to anterolateral talar displacement
    • fibula
      • acts as buttress to prevent lateral displacement of talus
Imaging
  • Radiographs
    • external rotation stress radiograph
      • most appropriate stress radiograph to assess competency of deltoid ligament
        • a medial clear space of >5mm with external rotation stress applied to a dorsiflexed ankle is predictive of deep deltoid disruption
      • more sensitive to injury than medial tenderness, ecchymosis, or edema
      • gravity stress radiograph is equivalent to manual stress radiograph
      • syndesmosis
        • decreased tibiofibular overlap 
          • normal >6 mm on AP view
          • normal >1 mm on mortise view
        • increased medial clear space 
          • normal less than or equal to 4 mm
        • increased tibiofibular clear space 
          • normal <6 mm on both AP and mortise views
    • radiographic measurements 
      • talocrural angle     
        • measured by bisection of line through tibial anatomical axis and another line through the tips of the malleoli
        • shortening of lateral malleoli fractures can lead to increased talocrural angle 
        • talocrural angle is not 100% reliable for estimating restoration of fibular length
          • can also utilize the realignment of the medial fibular prominence with the tibiotalar joint
Classification
  • Lauge-Hansen
    • based on foot position and force of applied stress/force
    • has been shown to predict the observed (via MRI) ligamentous injury in less than 50% of operatively treated fractures
Lauge-Hansen Class
Sequence
Supination - Adduction (SA)

  1. Talofibular sprain or distal fibular avulsion
  2. Vertical medial malleolus and impaction of anteromedial distal tibia
Supination - External Rotation (SER)

  1. Anterior tibiofibular ligament sprain
  2. Lateral short oblique fibula fracture (anteroinferior to posterosuperior)
  3. Posterior tibiofibular ligament rupture or avulsion of posterior malleolus
  4. Medial malleolus transverse fracture or disruption of deltoid ligament 
Pronation - Abduction (PA)
  1. Medial malleolus transverse fracture or disruption of deltoid ligament
  2. Anterior tibiofibular ligament sprain
  3. Transverse comminuted fracture of the fibula above the level of the syndesmosis
Pronation - External Rotation (PER)
    
  1. Medial malleolus transverse fracture or disruption of deltoid ligament 
  2. Anterior tibiofibular ligament disruption
  3. Lateral short oblique or spiral fracture of fibula (anterosuperior to posteroinferior) above the level of the joint
  4. Posterior tibiofibular ligament rupture or avulsion of posterior malleolus 

  • Anatomic / Descriptive 
    • isolated medial malleolar
    • isolated lateral malleolar
    • bimalleolar
    • trimalleolar
    • Bosworth fracture-dislocation (posterior dislocation of the fibula behind incisura fibularis)
  • Danis-Weber (location of fibular fracture)
    • A - infrasyndesmotic (generally not associated with ankle instability)
    • B - transsyndesmotic
    • C - suprasyndesmotic
  • AO / ATA
    • 44A - infrasyndesmotic
    • 44B - transsyndesmotic
    • 44C - suprasyndesmotic
General Treatment
  • Nonoperative
    • short-leg walking cast/boot
      • indications
        • isolated nondisplaced medial malleolus fracture or tip avulsions
        • isolated lateral malleolus fracture with < 3mm displacement and no talar shift
        • posterior malleolar fracture with < 25% joint involvement or < 2mm step-off
  • Operative
    • open reduction internal fixation
      • indications
        • any talar displacement 
        • displaced isolated medial malleolar fracture
        • displaced isolated lateral malleolar fracture
        • bimalleolar fracture and bimalleolar-equivalent fracture
        • posterior malleolar fracture with > 25% or > 2mm step-off q
        • Bosworth fracture-dislocations
        • open fractures
      • technique
        • goal of treatment is stable anatomic reduction of talus in the ankle mortise
          • 1 mm shift of talus leads to 42% decrease in tibiotalar contact area
        • see fracture patterns below for specific treatment
      • outcomes
        • overall success rate of 90%
          • prolonged recovery expected (2 years to obtain final functional result)
        • significant functional impairment often noted
        • worse outcomes with: smoking, decreased education, alcohol use, increased age, presence of medial malleolar fracture
        • ORIF superior to closed treatment of bimalleolar fractures
        • in Lauge-Hansen supination-adduction fractures, restoration of marginal impaction of the anteromedial tibial plafond leads to optimal functional results after surgery 
      • postoperative rehabilitation
        • time for proper braking response time (driving) returns to baseline at nine weeks for operatively treated ankle fractures  
        • braking travel time is significantly reduced until 6 weeks after initiation of weight bearing in both long bone and periarticular fractures of the lower extremity  q
Isolated Medial Malleolus Fracture
  • Nonoperative
    • short leg walking cast or cast boot
      • indications
        • nondisplaced fracture and tip avulsions
          • deep deltoid inserts on posterior colliculus
          • symptomatic treatment often appropriate
  • Operative
    • ORIF
      • indications
        • any displacement or talar shift
      • technique
        • lag screw fixation
          • lag screw fixation stronger if placed perpendicular to fracture line
        • antiglide plate with lag screw 
          • best for vertical shear fractures 
        • tension band fixation 
          • utilizing stainless steel wire
Isolated Lateral Malleolus Fracture
  • Nonoperative
    • short leg walking cast vs cast boot
      • indications 
        • if intact mortise, no talar shift, and < 3mm displacement
        • classically fractures with more than 4-5 mm of medial clear space widening on stress radiographs have been considered unstable and need to be treated surgically
          • recent studies have shown the deep deltoid may be intact with up to 8-10 mm of widening on stress radiographs
          • if the mortise is well reduced, results from operative and non-operative treatment are similar 
  • Operative
    • ORIF
      • indications
        • if talar shift or > 3 mm of displacement
        • can be treated operatively if also treating an ipsilateral syndesmosis injury
      • technique
        • open reduction and plating q
          • plate placement
            • lateral
              • lag screw fixation with neutralization plating
              • bridge plate technique
            • posterior
              • antiglide technique
              • lag screw fixation with neutralization plating
              • most common disadvantage of using posterior antiglide plating is peroneal irritation if the plate is placed too distally  
            • posterior antiglide plating is biomechanically superior to lateral plate placement
        • intramedullary retrograde screw placement
        • isolated lag screw fixation
          • possible if fibula is a spiral pattern and screws can be placed at least 1 cm apart
      • post-operative care
        • period of immobilization usually 4-6 weeks after ORIF
        • duration of immobilization should be doubled in Diabetic patients 
 Medial and Lateral (Bimalleolar) Fracture
  • Operative
    • ORIF
      • indications
        • any lateral talar shift
      • technique
        • fibula
          • need to fix with one of the options listed in section above
        • medial malleolus
          • fixation options
            • cancellous lag screws
            • bicortical screws 
            • tension band wiring
            • antiglide plate to treat a vertical medial malleolus fracture q
          • orient screws parallel to joint for vertical medial malleolar fracture (Lauge-Hansen supination-adduction fracture pattern) q   
 Functional Bimalleolar Fracture (deltoid ligament tear with fibular fracture)
  • Operative
    • ORIF of lateral malleolus
      • indications
        • examination has been shown to be largely unreliable in predicting medial injury
        • can see significant lateral translation of the talus in this pattern
      • technique
        • not necessary to repair medial deltoid ligament
        • only need to explore medially if you are unable to reduce the mortise
        • see isolated fibular fracture techniques above
Posterior Malleolar Fracture
  • Nonoperative
    • short leg walking cast vs cast boot
      • indications
        • < 25% of articular surface involved
          • evaluation of percentage should be done with CT, as plain radiology is unreliable
        • < 2 mm articular stepoff
        • syndesmotic stability
  • Operative
    • ORIF
      • indications
        • > 25% of articular surface involved
        • > 2 mm articular stepoff
        • syndesmosis injury
      • technique
        • approach
          • posterolateral approach  
          • posteromedial approach 
          • decision of approach will depend on fracture lines and need for fibular fixation
        • fixation
          • anterior to posterior lag screws to capture fragment (if nondisplaced)
          • posterior to anterior lag screw and buttress plate
          • antiglide plate
        • syndesmosis injury
          • stiffness of syndesmosis restored to 70% normal with isolated fixation of posterior malleolus (versus 40% with isolated syndesmosis fixation)
          • stress examination of syndesmosis still required after posterior malleolar fixation
          • posteroinferior tibiofibular ligament may remain attached to posterior malleolus and syndesmotic stability may be restored with isolated posterior malleolar fixation 
Bosworth Fracture-Dislocation
  • Overview
    • rare fracture-dislocation of the ankle where the fibula becomes entrapped behind the tibia and becomes irreducible
    • posterolateral ridge of the distal tibia hinders reduction of the fibula 
  • Operative
    • open reduction and fixation of the fibula in the incisura fibularis
      • indicated in most cases
Open Ankle Fracture
  • Operative
    • emergent operative debridement and ORIF
      • indicated if soft tissue conditions allow
    • external fixation
      • indications
        • soft tissue conditions and overall patient characteristics 
Associated Syndesmotic Injury
  • Overview
    • suspect injury in all ankle fractures 
      • most common in Weber C fracture patterns
      • fixation usually not required when fibula fracture within 4.5 cm of plafond
      • up to 25% of tibial shaft fractures will have ankle injury
  • Evaluation
    • measure clear space 1 cm above joint 
      • it has also been reported that there is no actual correlation between syndesmotic injury and tibiofibular clear space or overlap measurements
      • lateral stress radiograph has more interobserver reliability than an AP/mortise stress film
    • best option is to assess stability intraoperatively with abduction/external rotation stress of dorsiflexed foot
    • instability of the syndesmosis is greatest in the anterior-posterior direction
  • Treatment
    • operative
      • syndesmotic screw fixation
        • indications
          • widening of medial clear space
          • tibiofibular clear space (AP) greater than 5 mm 
          • tibiofibular overlap (mortise) narrowed
          • any postoperative malalignment or widening should be treated with open debridement, reduction, and fixation  
        • technique
          • length and rotation of fibula must be accurately restored 
          • outcomes are strongly correlated with anatomic reduction 
          • "Dime sign"/Shentons line to determine length of fibula   
          • open reduction required if closed reduction unsuccessful or questionable
          • one or two cortical screw(s) 2-4 cm above joint, angled posterior to anterior 20-30 degrees
          • lag technique not desired
          • maximum dorsiflexion of ankle not required during screw placement (can't overtighten a properly reduced syndesmosis)
        • postoperative
          • screws should be maintained in place for at least 8-12 weeks
          • must remain non-weight bearing, as screws are not biomechanically strong enough to withstand forces of ambulation
        • controversies
          • number of screws
            • 1 or 2 most commonly reported
          • number of cortices
            • 3 or 4 most commonly reported
          • size of screws
            • 3.5 mm or 4.5 mm screws
          • implant material (stainless steel screws, titanium screws, suture, bioabsorbable materials)
          • need for hardware removal
            • no difference in outcomes seen with hardware maintenance (breakage or loosening) or removal at 1 year
Diabetic Ankle Fractures (with or without Neuropathy)
  • Risks
    • prolonged healing
    • high risk of hardware failure
    • high risk of infection
  • Enhanced fixation  
    • multiple quadricortical syndesmotic screws (even in the absence of syndesmotic injury)
    • tibiotalar Steinmann pins
    • ankle spanning external fixation
    • augment with intramedullary fibula K-wires
    • stiffer, more rigid fibular plates (instead of 1/3 tubular plates)
      • compression plates
      • small fragment locking plates
  • Delay weightbearing   
    • maintain non-weightbearing postop for 8-12weeks (instead of 4-8 weeks in normal patients
Complications 
  • Wound problems (4-5%)
  • Deep infections (1-2%)
    • up to 20% in diabetic patients
      • largest risk factor for diabetic patients is presence of peripheral neuropathy  
  • Post-traumatic arthritis 
    • rare with anatomic reduction and fixation
    • corrective osteotomy requires anatomic fibular and mortise correction for optimal outcomes  

 

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Qbank (45 Questions)

TAG
(OBQ13.54) Figure A shows an isolated left ankle injury in an active 48-year-old recreational hockey player. Past medical history includes insulin dependent diabetes mellitus for 35 years. On physical examination the patient is unable to feel a 5.07 gm monofilament on the plantar aspect of his foot. His pedal pulses are palpable. Of the following options, what would be the recommended treatment? Topic Review Topic
FIGURES: A          

1. Closed reduction and casting for 6 weeks
2. Closed reduction and casting for 12 weeks
3. Open reduction and internal fixation with restricted weight bearing for 2 weeks
4. Open reduction and internal fixation with restricted weight bearing for 6 weeks
5. Open reduction and internal fixation with restricted weight bearing for 12 weeks

PREFERRED RESPONSE ▶
TAG
(OBQ13.261) A 27-year-old man presents to the emergency department with an ankle fracture. CT scans note anteromedial marginal impaction. Which radiograph (Figures A-E) would best correlate with this finding? Topic Review Topic
FIGURES: A   B   C   D   E  

1. Figure A
2. Figure B
3. Figure C
4. Figure D
5. Figure E

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TAG
(OBQ12.127) A 34-year-old female requests a second opinion following open reduction internal fixation (ORIF) of her left ankle three weeks ago. Which of the following is most appropriate step based on Figures A and B? Topic Review Topic
FIGURES: A   B        

1. Progressive weightbearing in 3-4 weeks based on radiographs
2. Deltoid ligament repair vs reconstruction
3. Revision ORIF of fibula with lengthening
4. Revision ORIF of fibula and syndesmosis
5. Removal of syndesmotic screws in 3-6 months

PREFERRED RESPONSE ▶
TAG
(OBQ11.17) A 25-year-old male sustains an ankle fracture dislocation and undergoes open reduction and internal fixation. He returns to clinic five months following surgery complaining of continued ankle pain and instability with weight bearing. His immediate post-operative AP radiograph is seen in Figure A. Which of the following could have prevented this patient from developing persistent pain? Topic Review Topic
FIGURES: A          

1. Deep deltoid ligament repair
2. Quadricortical syndesmotic screw fixation
3. Restoration of fibular length and rotation
4. Lateral collateral ligament complex repair
5. Use of two syndesmotic screws

PREFERRED RESPONSE ▶
TAG
(OBQ10.5) A 32-year-old female sustains the injury shown in Figure A. What is the most reliable method to evaluate the competence of the deltoid ligament? Topic Review Topic
FIGURES: A          

1. Medial ankle tenderness
2. Medial ankle ecchymosis
3. Squeeze test
4. Stress radiography of the ankle
5. Canale view radiograph

PREFERRED RESPONSE ▶
TAG
(OBQ10.40) In an isolated ankle syndesmotic injury, the fibula is unstable in the incisura fibularis of the tibia. In what direction is the fibula most unstable? Topic Review Topic

1. Anterior-posterior
2. Medial-lateral
3. Proximal-distal
4. Rotational
5. Equivalent instability in all axes

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TAG
(OBQ10.121) A 34-year-old man sustains a twisting injury to his left ankle playing soccer. Radiographs from the ER are provided in figures A and B. Four hours later, he undergoes open reduction internal fixation. An intraoperative fluoroscopy image is provided in figure C. Which of the following is the best method to assess the integrity of the syndesmosis? Topic Review Topic
FIGURES: A   B   C      

1. Measurement of medial clear space widening
2. Measurement of the tibiofibular overlap
3. Anterior drawer test with comparison to the contralateral ankle
4. External rotation stress radiograph
5. Evaluation of the syndesmosis on preoperative CT scan

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TAG
(OBQ09.17) A 34-year-old male falls off of a ladder and sustains the ankle injury shown in Figure. Which of the following is unique with this particular ankle fracture pattern and must be recognized by the operating surgeon to optimize outcomes? Topic Review Topic
FIGURES: A          

1. Marginal impaction of the anteromedial tibial plafond
2. Syndesmosis diastasis
3. Deltoid ligament tear
4. Posterolateral osteochondral lesion of the talus
5. Fibular overlengthening

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TAG
(OBQ09.52) In which of the following radiographs of different types of ankle fractures should the medial malleolus be treated with screw fixation directed parallel to the ankle joint? Topic Review Topic
FIGURES: A   B   C   D   E  

1. Figure A
2. Figure B
3. Figure C
4. Figure D
5. Figure E

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TAG
(OBQ09.70) Following operative repair of lower extremity long bone and periarticular fractures, what is the time frame for patients to return to normal automobile braking time? Topic Review Topic

1. 6 weeks after initiation of weight bearing
2. 4 weeks postoperatively
3. 8 weeks from the date of injury
4. Once full range of motion of the ankle and knee exist
5. At the time of bony union

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TAG
(OBQ09.121) A 31-year-old male sustains an irreducible ankle fracture-dislocation with the foot maintained in an externally rotated position. An AP and lateral radiograph are shown in figures A and B respectively. The attempted post reduction AP and lateral are shown in C and D. What structure is most likely preventing reduction? Topic Review Topic
FIGURES: A   B   C   D    

1. Anterior-inferior tibiofibular ligament
2. Posterior-inferior tibiofibular ligament
3. Peroneus brevis tendon
4. Posterolateral ridge of the tibia
5. Flexor hallucis longus tendon

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TAG
(OBQ09.173) In the Lauge-Hansen classification system, a pronation-abduction ankle fracture has what characteristic fibular fracture pattern? Topic Review Topic

1. Transverse fracture below the level of the syndesmosis
2. Short oblique fracture running from anteroinferior to posteriosuperior
3. Short oblique fracture running from posteroinferior to anteriosuperior
4. Comminuted fracture at or above the level of the syndesmosis
5. Wagstaff fracture

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TAG
(OBQ09.204) An 18-year-old football player presents to the emergency department after sustaining an ankle injury. His radiograph is shown in figure A. What is the most appropriate definitive treatment? Topic Review Topic
FIGURES: A          

1. Open reduction and internal fixation of the medial malleolus with syndesmosis reduction and suture-button repair
2. Repair of the anterior talo-fibular ligament
3. Open reduction internal fixation of the fibula with syndesmosis reduction and suture-button repair
4. Open reduction internal fixation of the medial malleolus and fibula
5. Open reduction internal fixation of the fibula and medial malleolus with syndesmosis reduction and suture-button repair

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TAG
(OBQ09.259) Presence of diabetes-induced peripheral neuropathy has been shown to be an independent risk factor for postoperative complications of which of the following injuries? Topic Review Topic

1. Distal radius fractures
2. Patella fractures
3. Metatarsal fractures
4. Ankle fractures
5. Distal femoral fractures

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TAG
(OBQ08.81) A 19-year-old male sustains the injury shown in Figure A while skiing. Injury to what structure should be evaluated intraoperatively during fixation of the fibula? Topic Review Topic
FIGURES: A          

1. Deltoid ligament
2. Syndesmosis
3. Proximal fibula
4. Calcaneofibular ligament
5. Posterior tibial tendon

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TAG
(OBQ08.93) A 35-year-old male with a pronation abduction ankle injury would have which of the following radiographs? Topic Review Topic
FIGURES: A   B   C   D   E  

1. Figure A
2. Figure B
3. Figure C
4. Figure D
5. Figure E

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TAG
(OBQ08.210) A 68-year-old female sustains a closed ankle fracture and is treated with open reduction and internal fixation. Her postoperative radiographs are shown in Figure A. Widening of the tibia-fibular clear space with external rotation stress would be a result of injury of which structure? Topic Review Topic
FIGURES: A          

1. Anterior ankle joint capsule
2. Syndesmosis
3. Anterior talofibular ligament
4. Posterior tibial tendon
5. Calcaneofibular ligament

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TAG
(OBQ07.39) The Cotton test evaluates which of the following structures? Topic Review Topic

1. Calcaneofibular ligament
2. Lateral ulnar collateral ligament of the elbow
3. Ligamentum flavum
4. Anterior talofibular ligament
5. Ankle syndesmosis

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TAG
(OBQ07.88) After undergoing the treatment seen in Figure A, when should a patient be expected to safely operate the brakes of an automobile? Topic Review Topic
FIGURES: A          

1. 6 weeks
2. 2 -4 weeks
3. 6 months
4. 8-9 weeks
5. 3 months

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TAG
(OBQ07.223) Appropriate treatment of the bimalleolar ankle fracture shown in Figure A includes which of the following? Topic Review Topic
FIGURES: A          

1. Bridge plating of the fibula with oblique medial malleolar screws
2. Antiglide plating of the fibula with oblique medial malleolar screws
3. Intramedullary fibular screw with medial malleolar tension banding
4. Fibular plating with open correction of plafond impaction with medial malleolar antiglide plate
5. Fibular plating with open correction of syndesmosis and oblique medial malleolar screws

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TAG
(OBQ06.28) A 34-year-old woman twists her right ankle stepping off the city bus. An AP ankle radiograph is provided in Figure A. Which of the following statements accurately describe this radiograph? Topic Review Topic
FIGURES: A          

1. The tibiofibular overlap is less than 3 mm
2. The fibula demonstrates a Weber C fracture pattern
3. The tibiofibular clear space is less than 4 mm
4. The fracture is consistent with a Lauge-Hansen pronation-external rotation injury pattern
5. The medial clear space is greater than 5 mm

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TAG
(OBQ06.85) The talocrural angle of an ankle mortise x-ray is formed between a line perpendicular to the tibial plafond and a line drawn: Topic Review Topic

1. perpendicular to the medial clear space
2. parallel to the talar body
3. between the tips of the malleoli
4. perpendicular to the shaft of the fibular
5. parallel to the subtalar joint

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TAG
(OBQ06.115) Lateral malleolus fractures can be treated with a variety of techniques, including posterior antiglide plating or lateral neutralization plating. What is an advantage of using lateral neutralization plating instead of posterior antiglide plating? Topic Review Topic

1. Decreased joint penetration of distal screws
2. Increased rigidity
3. Decreased need for delayed hardware removal
4. Decreased peroneal irritation
5. Improved distal fixation

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TAG
(OBQ06.140) The Lauge-Hansen classification of ankle fractures identifies characteristic fracture patterns based on mechanism of injury. What is the mechanism for the fracture pattern shown in Figure A? Topic Review Topic
FIGURES: A          

1. Supination-External Rotation
2. Pronation-External Rotation
3. Pronation-Abduction
4. Supination-Adduction
5. Supination-Abduction

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TAG
(OBQ06.250) What is the most appropriate plating technique utilized for the medial malleolus fracture typically seen in a displaced supination-adduction ankle fracture? Topic Review Topic

1. Tension band plating
2. Antiglide plating
3. Bridge plating
4. Neutralization plating
5. Submuscular plating

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TAG
(OBQ05.89) When comparing the fibular plating techniques shown in Figures A and B, the plate position shown in Figure B is associated with which of the following? Topic Review Topic
FIGURES: A   B        

1. Increased stiffness
2. Increased strength
3. Decreased rate of hardware prominence
4. Increased risk of intra-articular screw penetration
5. Increased peroneal tendinitis

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TAG
(OBQ05.205) Coupled with reduction of the syndesmosis, which of the following interventions is most important when surgically addressing the ankle malunion shown in Figure A? Topic Review Topic
FIGURES: A          

1. Placement of an osteochondral allograft
2. Fibular lengthening osteotomy
3. Calcaneofibular ligament release
4. Medial malleolar shortening osteotomy
5. Deltoid ligament imbrication

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TAG
(OBQ04.23) A 32-year-old taxi driver sustains a displaced supination external rotation ankle injury after slipping off of a curb. He subsequently undergoes surgical fixation, and a post-operative radiograph is shown in Figure A. At the eight-week postoperative visit, you are asked to fill out a return to work form. How long from today’s visit will his braking time be expected to return to normal? Topic Review Topic
FIGURES: A          

1. Two weeks ago
2. One week from now
3. Three weeks from now
4. Six weeks from now
5. Eight weeks from now

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TAG
(OBQ04.49) A 33-year-old male is involved in a motor vehicle accident and suffers a right pilon fracture. Which part of the structures labeled on the distal tibia in the axial CT scan shown in Figure A attaches to the posterior tibiofibular ligament? Topic Review Topic
FIGURES: A          

1. A
2. B
3. C and B
4. D
5. A and D

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TAG
(OBQ04.243) A 32-year-old female sustained a bimalleolar ankle fracture and was treated with open reduction and internal fixation four months ago. A radiograph of her ankle is shown in Figure A. Recommended management should consist of? Topic Review Topic
FIGURES: A          

1. Physical therapy for ambulation assistance and proprioception training
2. Short leg bracing
3. Revision open reduction and internal fixation with open syndesmosis reduction
4. Addition of syndesmosis screw from fibula to tibia
5. Open medial ankle ligament reconstruction

PREFERRED RESPONSE ▶
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11/27/2015
195 responses
http://upload.orthobullets.com/cases/2418/03fba91e-c268-4d69-a81c-c57e32c753e5_1.jpg http://upload.orthobullets.com/cases/2418/31158c5a-9a24-42f5-b30c-9e0825af8771_2.jpg http://upload.orthobullets.com/cases/2418/b5574669-fddc-4ebd-9ee6-063c2c10ba4c_3.jpg
HPI - Trauma 7 years ago, in another state, treated with reduction and casting only. A...
poll
10/29/2015
299 responses
http://upload.orthobullets.com/cases/2354/4197de05-4a64-46c0-b748-d267f774c347_m_lowerext_20150912_093552.jpg http://upload.orthobullets.com/cases/2354/1dc1fd2b-7281-4b09-bfc0-35d457c84422_m_lowerext_20150912_093603.jpg
HPI - Last evening, I had an interesting case of the commonly encountered "someone rol...
poll
9/12/2015
30 responses
http://upload.orthobullets.com/cases/2292/img_20150720_132918.jpg http://upload.orthobullets.com/cases/2292/img_20150720_132841.jpg http://upload.orthobullets.com/cases/2292/img_20150720_132836.jpg
HPI - Fall at home 01 week back
poll Management options
7/20/2015
77 responses
http://upload.orthobullets.com/cases/2278/preop_oblique_ankle_picpick.jpg http://upload.orthobullets.com/cases/2278/preop_lateral_ankle_picpick.jpg http://upload.orthobullets.com/cases/2278/6_weeks_postop_oblique_ankle_picpick.jpg
HPI - Healthy woman, she received a tombstone on her rear leg and injured her left ank...
poll Would you rather do ORIF to the fibula despite the intact syndesmosis
7/7/2015
74 responses
http://upload.orthobullets.com/cases/2267/wp_20150620_001.jpg http://upload.orthobullets.com/cases/2267/wp_20150620_002.jpg http://upload.orthobullets.com/cases/2267/wp_20150620_007.jpg
HPI - Sustained closed injury left ankle in a RTA on 18 Jun 2015.
poll Implant of choice for fibular fracture
6/21/2015
301 responses
http://upload.orthobullets.com/cases/2157/ankle6.jpg http://upload.orthobullets.com/cases/2157/ankle 5.jpg http://upload.orthobullets.com/cases/2157/ankle7.jpg
HPI - A 64 year old female patient presented to our dept. complaining of pain in the r...
poll How would you proceed?
2/23/2015
298 responses
http://upload.orthobullets.com/cases/2138/ankle_frx_syndesmosis.jpg http://upload.orthobullets.com/cases/2138/ankle_syndesmosis_postop.jpg http://upload.orthobullets.com/cases/2138/ankle_syndesmosis_postop2.jpg
HPI - 22 yo fall on ice. how would you treat this fracture pattern with fibula fractur...
poll How would you treat this fracture pattern with fibula fracture 13cm proxima...
2/4/2015
435 responses
http://upload.orthobullets.com/cases/2089/1.jpg http://upload.orthobullets.com/cases/2089/2.jpg http://upload.orthobullets.com/cases/2089/3.jpg
HPI - While running the patient twisted his ankle and had an immediate onset of pain a...
poll How would you treat this patient?
12/23/2014
12931 responses
http://upload.orthobullets.com/cases/2054/9aug_1.jpg http://upload.orthobullets.com/cases/2054/9aug2.jpg http://upload.orthobullets.com/cases/2054/17aug1.jpg
HPI - This lady has got bilateral feet ulcers and bad skin conditions of both leg and...
poll How would you manage this fracture?
10/28/2014
416 responses
http://upload.orthobullets.com/cases/1978/img-20140709-wa0007.jpg http://upload.orthobullets.com/cases/1978/img-20140709-wa0008.jpg http://upload.orthobullets.com/cases/1978/img-20140709-wa0009.jpg
HPI - Twisting ankle trauma caused complete tibiotalar dislocation with comminuted dis...
poll What is the best method to treat the fibular fracture ? (Plz dont ask for f...
7/24/2014
293 responses
http://upload.orthobullets.com/cases/1953/pre1.jpg http://upload.orthobullets.com/cases/1953/pre2.jpg http://upload.orthobullets.com/cases/1953/post1.jpg
HPI - Four months old badly displaced fracture ankle treated conservatively somewhere...
poll How to treat the fracture
6/26/2014
66 responses
http://upload.orthobullets.com/cases/1931/ankle_fracture.jpg
HPI - A 58 year-old lady, well in herself, sustained 2 1/2 years ago, an open fracture...
poll What is the appropriate treatment method?
6/1/2014
91 responses
http://upload.orthobullets.com/cases/1917/20140519_131427.jpg http://upload.orthobullets.com/cases/1917/20140519_161226.jpg http://upload.orthobullets.com/cases/1917/20140519_161210.jpg
HPI - A 15 years old football player injury his ankle during a match because of a fall...
poll How would you treat this injury?
5/20/2014
124 responses
http://upload.orthobullets.com/cases/1915/ap_pre.jpg http://upload.orthobullets.com/cases/1915/lat_pre.jpg http://upload.orthobullets.com/cases/1915/ap_post2.jpg
HPI - Twisting injury of ankle
poll Treatment options for this fracture
5/20/2014
186 responses
http://upload.orthobullets.com/cases/1895/meh_trimalq.jpg http://upload.orthobullets.com/cases/1895/meh_trimal.jpg http://upload.orthobullets.com/cases/1895/meh_trimal_f.jpg
HPI - twisting injury on stairs today.attempts by another referring hospital at closed...
poll What would be your next step in management following review of the CT scan?
5/2/2014
492 responses
http://upload.orthobullets.com/cases/1863/ant_synd3.jpg http://upload.orthobullets.com/cases/1863/ant_synde2.jpg http://upload.orthobullets.com/cases/1863/ant_syndesm.jpg
HPI - fall 3 days ago seen at another centre was put in a slab and advised to see the...
poll plan of treatment
4/6/2014
227 responses
http://upload.orthobullets.com/cases/1807/2008 ap.jpg http://upload.orthobullets.com/cases/1807/2008 lat.jpg http://upload.orthobullets.com/cases/1807/ap 2014.jpg
HPI - Several months painfull left ankle, no new trauma. Progressive pain after playin...
poll What should we do?
2/28/2014
240 responses
http://upload.orthobullets.com/cases/1786/pre01.jpg http://upload.orthobullets.com/cases/1786/pre02.jpg http://upload.orthobullets.com/cases/1786/pre03.jpg
HPI - Patient presented with a lateral malleolus fracture, SER IV, Weber B, about a we...
poll What is your choice for fixation of such fracture? (initial treatment)
2/12/2014
3201 responses
http://upload.orthobullets.com/cases/1727/19-12-13 (f).jpg http://upload.orthobullets.com/cases/1727/19-12-13 (p).jpg http://upload.orthobullets.com/cases/1727/19-12-13 (p) (2).jpg
HPI - LEFT ANKLE INJURY ON MOTOR VEHICLE ACCIDENT. NO OTHER INJURIES.
poll Would you fix the fibula fracture?
12/26/2013
690 responses
http://upload.orthobullets.com/cases/1668/ankle 2 .jpg http://upload.orthobullets.com/cases/1668/ankle.jpg
HPI - fall from height
poll what is the suggested ttt ?
10/25/2013
558 responses
http://upload.orthobullets.com/cases/1652/1.jpg http://upload.orthobullets.com/cases/1652/2.jpg http://upload.orthobullets.com/cases/1652/3.jpg
HPI - 2003 ankle fracture 2008 tka yesterday accidental trauma
poll How would you treat it?
10/5/2013
120 responses
http://upload.orthobullets.com/cases/1613/rtg 12-2011.jpg http://upload.orthobullets.com/cases/1613/rtg 6-2013 lateral.jpg http://upload.orthobullets.com/cases/1613/rtg 6-2013 ap.jpg
HPI - 2008 ORIF of previous trimalleolar ankle fracture 2009 Hardware removal + arth...
poll What is your treatment choice?
9/3/2013
86 responses
http://upload.orthobullets.com/cases/1563/029.jpg http://upload.orthobullets.com/cases/1563/030.jpg
HPI - H/O Road traffic injury 2 days back, presented to us with closed left trimalleol...
poll What fixation u suggest for posterior malleoli and medial malleoli,if patie...
7/20/2013
276 responses
http://upload.orthobullets.com/cases/1291/20121015_202544.jpg http://upload.orthobullets.com/cases/1291/20121015_202634.jpg
HPI - Fall from standing,24 hours ago , due to an obstacle
poll How would you treat this fracture?
10/16/2012
152 responses
http://upload.orthobullets.com/cases/1273/photo(1).jpg http://upload.orthobullets.com/cases/1273/photo(3).jpg http://upload.orthobullets.com/cases/1273/photo(2).jpg
HPI - vehicular accident 6 hours before he reached hospital.
poll for open grade 3 ankle dislocation choice of treatment to stablize ankle a...
9/16/2012
175 responses
http://upload.orthobullets.com/cases/1231/1.jpg http://upload.orthobullets.com/cases/1231/ap1.jpg http://upload.orthobullets.com/cases/1231/3.jpg
HPI - Fell off bicycle 4 weeks prior to presentation. Seen elsewhere and was recommend...
poll How would you treat this patient
6/20/2012
231 responses
http://upload.orthobullets.com/cases/1084/untitled.jpg http://upload.orthobullets.com/cases/1084/ttc 6a.jpg http://upload.orthobullets.com/cases/1084/ttc 6b.jpg
HPI - 62 y/o diabetic male about 12 days out from ORIF ankle at an outside hospital....
poll What would you do with this failure?
11/8/2011
326 responses
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This is an example of the Cotton test for ankle syndesmosis injury.
7/7/2014
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This is an example of bimalleolar ankle fracture fixation using bicortical media...
1/29/2012
1658 views
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the following text is written in handbook of fracture by Zuckerman while th...
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