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Review Article *Corresponding author Lisa Zhang, Department of Podiatry, University Hospital, G142. 150 Bergen St. Newark, NJ 07103, USA, Tel: 908- Radiographic Evaluation, 577-2543; Email: Submitted: 15 March 2018 Fixation Principles, and Post- Accepted: 23 June 2017 Published: 25 June 2017 ISSN: 2475-9112 Operative Management of Copyright © 2017 Zhang et al. Ankle Fractures OPEN ACCESS 1 2 Lisa Zhang * and Ritchard Rosen Keywords 1Department of Podiatry, University Hospital, Newark, USA • Fracture blisters 2Department of Podiatric Surgery, Holy Name Medical Center, USA • Neutralization plate • Posterior-antiglide plate • Tension banding Abstract • Direct approach Radiographically, ankle fractures can be evaluated on the anterior-posterior (AP) view • Early weight bearing with the talocrural angle, and on the mortise view, by Shenton’sline, the dime sign, and talar tilt. Displaced fractures > 2 mm, lateral malleolar fractures that are shortened, rotated, or angulated, and bimalleolar and trimalleolar fractures require fixation. Principles of fixation include a proper soft tissue envelope without fracture blisters present at incision sites. Due to the formation of soft callus, fractures should be fixated within the first two weeks of injury. The lateral is the dominant fracture, and must be pulled out to length, which will pull other ligamentous attachments to proper alignment. Lateral malleolar fixation may be accomplished by a neutralization plate or posterior anti-glide plate; a locking plate may also be used in osteoporotic . Medial malleolar fixation can be accomplished by two screw cancellous fixation or tension banding, the latter especially useful in smaller, comminuted fractures. Although 25% articular surface of the tibiotalar joint in posterior malleolar fractures has been traditionally used as a landmark, new literature suggests that proper anatomical alignment and fixation of fragments < 25% may aid in reducing the syndesmosis. Due to the large variability in posterior malleolar fractures on radiographs, CT may be beneficial in preoperative assessment. Posterior malleolar fragments may be fixated through the direct approach with a cancellous screw directed from posterior to anterior. Early weight bearing in a select population of post- operative patients increases ankle range of motion, as well as increases general mental and physical functioning scores.

INTRODUCTION Ankle fractures account for 9% of all fractures and as such, [2]. According to Ramsey and Hamilton, 1 mm of talar shift are one of the most common lower extremity fractures [1]. The can result in a 42% decrease in tibiotalar contact. Tibiofibular annual incidence of ankle fractures is between 107 and 184 per overlap from the medial fibula to the lateral border of the 100,000 people [1]. The most common mechanisms of ankle onanterior the mortise should view. It be is lessnoted than by the10 mm(1) talocrural on anterior-posterior angle. A line fractures are falls and inversion/eversion injuries, followed by is(AP) drawn view parallel of the ankle. to the Shorteningarticular surface of the offibula the distalcan be tibia, evaluated and a sports injuries. Ankle fractures are classified by both the Danis- cadaveric studies. The soft tissue should be not overlooked in medialline is drawnangle isperpendicular the talocrural to angle. the first. The Atalocrural second lineangle is shoulddrawn Weber system and Lauge-Hansen system, the latter based on connecting the most distal aspects of the malleoli. The superior- history, and level of activity should all be considered when clinical evaluation. The patient’s age, co-morbidities, smoking Abe second83 +/- 4 method degrees. of Two determining degrees of shortening shortening iswhen by evaluatingcompared to that of the contralateral is an indication of fibular shortening. consideringRADIOGRAPHIC surgical fixation EVALUATION of the fracture. (2) Shenton’s line. The contour of the subchondral bone of the A rigorous radiographic analysis should be performed of each . Widening of the medial clear space > 4 mm tibial plafond and tibial subchondral bone of the fibula should be indicates deltoid ligament injury and lateral talar transposition ofa curved, the curve unbroken is noted. line. Proximal With shortening disruption of ofthe this fibula, line a and broken any Shenton line is seen, and proximal migration of the fibular aspect

Cite this article: Zhang L, Rosen R (2017) Radiographic Evaluation, Fixation Principles, and Post-Operative Management of Ankle Fractures. JSM Foot Ankle 2(3): 1029. Zhang et al. (2017) Email:

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[3]. A third method of determining shortening is the (3) dime and by 16 days in hemorrhagic fracture blisters [7]. If an incision sign,divergence in which > 2 mm an unbroken indicates rotation curve connecting and shortening the recess of the infibula the isepithelization made into a isfracture expected blister, by 13 wound days inhealing serous complications fracture blisters, and measurementdistal tip of the of fibula ankle and instability the lateral on theprocess mortise of the view talus is theshould (4) infection may develop. A standard protocol of blister de-roofing talarbe seen tilt, [1].measured If broken, by lines fibular drawn shortening along the is dome present. of the A fourth talus week.and application In a prospective of Silver study, Sulfadiazine in 47 patients cream with can lower promote extremity re- and tibial plafond. The degree of lateral opening is measured. epithelization allowing surgery to precede with a delay of one These lines should be parallel, or within three degrees of parallel [3]. On the lateral view, a line in the center of the tibia should fractures in which serous and hemorrhagic blisters were de- intersect with the lateral process of the talus. If not seen, this roofed with subsequent application of Silver Sulfadiazine cream, indicates either anterior of posterior displacement of the tibia. with a mean follow-up for 27 weeks, 82.3% (37 of 45) of patients ofhad soft an uncomplicated tissue injury is post-operative often greater thancourse the and blister healed itself, without and FRACTURES REQUIRING FIXATION incisionskin or woundplacement complications should be made[7]. In with diabetic caution, patients, especially the zonewith hemorrhagic blisters [7]. displacedIsolated < 2non-displaced mm lateral malleolar fibular fractures fractures without with no angulation, talar shift GOALS OF REDUCTION areshortening stable orinjuries rotation can do be not managed require conservatively.fixation. Isolated Isolated mildly length and restoration of the ankle mortise. In a bimalleolar Two goals of reduction are restoration of the fibular displacedfibular fractures or mildly with displaced displacement < 2 mm greater medial thanmalleolar 2 mm fractures or with due to the Vassal Principle. Proper anatomical alignment of doangulation, not require shortening, operative and management. rotation require Bimalleolar fixation. fractures Non- or trimalleolar ankle fracture, the fibula should be fixated first only one break in the ring, such as with an isolated lateral asthe a fibulabuttress, allows keeping the otherthe talus fractures in the to mortise. align into On placelateral due view, to often require fixation, especially if displaced. When there is evaluationsoft tissue of and reduction ligamentous of the attachments. posterior spike The is fixed evidence fibula of actsthe potentialmalleolar for or isolateddisplacement, medial and malleolar thus, less fracture indication - especially for open if non-displaced, non-shortened, or non-angulated - there is less talusfibula from out toresuming length. its According anatomical to Yablon,position. impingement In 53 patients of with the in the ring as seen with bimalleolar fractures, the potential for lateral malleolus on the proximal fibular fragment prevented the displacementreduction internal exists, fixation thus making (ORIF). surgical However, management with two a breaks more attractive option [4]. If greater than 25% of the articular surface ina bimalleolar which soft tissueankle fracture,interposition anatomic prevented fixation replacement was achieved of the by of the tibiotalar articular surface or a > 2 mm step off is noted, medialplate fixation malleolus of the when lateral the malleolus, lateral malleolus and there was was reduced no instance [8].

Assessment of restoration of the ankle mortise can be assessed then ORIF is traditionally indicated for posterior malleolar byIn pullingradiographic the fibula measurements out to length, of thethe medialankle mortise clear space is restored. <4 mm thatfractures absolute [5]. articular However, congruity recent studiesis established. in the An literature often missed have advocated for fixing smaller posterior malleolar fractures so posterior (AP) view 1 cm superior to the ankle joint, and talar tiltafter < reduction,10 degrees. tibia-fibula As with all (tib fractures, fib) overlap> the goal 10 mmof rigid, on anterior- internal spacefracture or is syndesmoticthe Maisonneuve diastasis. fracture, Clinical a proximal exam fibular is warranted fracture. Initial ankle films may only show a widening of the medial clear Maisonneuve fracture was not diagnosed in 11.32% (12) of fixationPRINCIPLES and anatomic IN LATERAL reduction should MALLEOLAR be achieved. FIXATION 106with cases examination [6]. It is of important the proximal to obtain fibula. and In three carefully studies, review the Reduction of the lateral malleolar fracture can accomplished proximal tibia-fibula (tib-fib) films, as well as carefully evaluate thewith distal plating. fragment With ais neutralizationachieved with internalplate, a lagrotation screw with is used a bone to the syndesmosis on ankle films. When a Maisonneuve fracture is neutralize bending, shear and rotational forces. Distraction of diagnosed, the proximal fibular fracture does not require fixation Kirschner (K) wire. Lag screw compression is achieved with a 3.5 as only 10-15% of the weight of the leg is bore by the fibula. In clamp. The fracture may be temporarily fixated with a 0.062 thesePRINCIPLES cases, fixation OF ofFIXATION the syndesmosis is warranted. is used, the former for shorter fractures, the latter for fractures Timing withcortical a longerscrew, bicortical. pattern. Three A five holes,or six hole or six one cortices, third tubular are placed plate proximal to the fracture site to achieve proper plate stability. The injury, due to presence of soft callus formation. Often, the earlier Fixation should be accomplished within the first two weeks of distal aspect of the plate, the distal plate holes are in the vicinity of theneutralization ankle joint. plate It is importantis placed laterally that the ondistal the most fibula. screws At the do most not importantfixation is exception accomplished, exists. the If less the soft soft tissue callus envelope is encountered, is not and the less the need for re-osteotomy of the fracture site. One of the ankle joint with resultant arthritis and cartilage damage. Lockingpurchase screws the medial may cortex be placed of the distally fibula, toto preventprevent penetration appropriate for fixation, surgery is to be delayed. If fracture into the ankle joint. blisters - seen more commonly with high energy ankle fractures – are encountered, surgery is delayed until re-epithelization. Re- JSM Foot Ankle 2(3): 1029 (2017) 2/5 Zhang et al. (2017) Email:

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In contrast to the lateral neutralization plate, a posteriorly justplaced proximal buttress to plate the – fracture the anti-glide site is plate the trick – has screw indications [2]. The in posteriorsurface in tibiotalar regards to joint improved involvement American at least Orthopedic had some Foot origin and remainingosteoporotic screws bone. aid The in first the reductioncortical screw of the inserted posterior in spike.the hole In inAnkle cadaveric (AOFAS) studies, scores with [13]. the The authors origins noting for fixation the maximum if 25-35% loss of of contact area of the ankle joint as 35% of posterior malleolar distal fragment from overriding when force is applied to the long involvement for specimens that were tested in neutral position. axisthe anti-glide of the bone. plate, In a the biomechanical plate is fixated study to theby Schaffer bone to preventand Manoli, the

arthritisHowever, was the associated authors acknowledgedwith an inadequately that in reduced terms posterior of actual in short oblique fractures of the distal fibula, the system using fragmentclinical experience, [14]. In a a therapeutic high rate of study, post-traumatic the authors degenerative found that glidelateral plate, plate the for value fixation was failed 77.2%, when P < the0.001 torque [9]. Thereached superiority 64.3% of the force that produced the fracture. In contrast, with the anti- ranges of bone strengths, and less evident for stronger bone, with fixation of the posterior malleolar fracture with the attached, of the anti-glide plating was most evident along low and middle intact posterior inferior tibiofibular ligament (PITFL) had equal Foot and Ankle Outcomes Score (FAOS) as those fixated with implications for fixation in osteoporotic bone. An alternative transyndesmotic screw fixation [15]. This concept was supported conventionalto the anti-glide contoured plate isplate, the the locking locking plate, system which showed acts higher as an by another prospective study, in which 108 supination-external torque‘internal to external failure fixator’. and maximum When a locking torque plate levels, was and compared provided to rotation type-IV (SER IV) fractures were treated operatively, including posterior malleolar fractures of all sizes [16]. Instead of traditional fragment size, the rationale for fixation of the posterior improvedPRINCIPLES fixation IN strength MEDIAL in osteoporotic MALLEOLAR bone [10].FIXATION malleolus was to restore syndesmotic stability. Anatomic fixation Reduction of the medial malleolus can be accomplished by of the posterior malleolus was hypothesized to restore the operativefunction of CT the scans posterior were inferior used to tibiofibular assess ankle ligament joint congruity. (PITFL), Medial malleolar cannulated screws are often used. Once the and thereby, restore the function of the syndesmosis. Post- fractureK-wires, istension curetted banding, and reduced, 4.0 cancellous a bone clamp screws, is placed or hook across plates. the tip of the medial malleolus and the tibia proximal to the fracture. articularAnkles were surface considered gap >2 incongruent mm. With a with follow >2 upmm for articular 21 months, step- 87%off, with of patients the presence had a congruent of intra-articular ankle, and loose 33% bodies,had incongruity or with drilled through the cannulated system, with insertion of two 4.0 cannulatedTwo parallel screws. K-wires Tension are inserted banding across can the be fracture used with fragmented, small or comminuted medial malleolar fractures. Similar to insertion of regardson post-operative to symptoms CT. (P The = 0.012), group withpain (Particular = 0.004), incongruity and activities had ofsignificantly daily living worse (P = Foot 0.038). and ThisAnkle correlation Outcome Scores between (FAOS) articular with medial malleolus. A 4.0 fully threaded cancellous ‘bone screw’ 4.0 cannulated screws, two parallel K-wires are inserted into the reductions - especially with that of the posterior malleolus – with is inserted 2-3 cm above the fracture site in the concave aspect foundstatistically that the significant fracture lines clinical associated outcomes with shows posterior that advantage malleolar of the tibia, tension wire applied across the screw and K-wire fracturesof CT in evaluationwere highly of variable trimalleolar [17]. A fractures. large fragment Haraguchi extending et al., in a ‘figure of 8’ fashion, and lastly, the bone screw is tightened to the medial malleolus existed in almost 20% of the posterior medial[2]. The malleolarK-wires are fractures bent, cut with medial screws and andflush tensionwith the banding medial malleolar fracture in the study, which used CT to evaluate the foundmalleolus. that A the 2016 mean randomized time for radiographicstudy comparing osseous the unionfixation was of extent and involvement of the posterior malleolar fracture. Some posterior malleolar fractures were found to involve almost banding, P< 0.03 [11]. This faster radiographic union may be the entire medial malleolus. The great variability of posterior 11.8 weeks in screw fixation, compared to 9.4 weeks in tension was four times stronger than cancellous malleolar screws in resistingattributed pronation to Ostrum forces and and Litsky’s applying finding compression that tension forces banding [12]. fractures.malleolar fractures In addition, and thedifficulty recent in literatureassessing the gives extent credence on plain to films gives credence to obtaining pre-operative CT in trimalleolar fractures in osteoporotic bone. surface in establishing absolute joint congruity to restore the Tension banding may be especially effective in small, non-vertical syndesmosis.fixating posterior malleolar fractures < 25% of the articular PRINCIPLES IN POSTERIOR MALLEOLAR FIXATION either through the direct or the indirect approach. The indirect Although traditionally 25% of the articular involvement approachFixation can of be the accomplished posterior malleolar through the fragment lateral is incision, achieved in through radiographic analysis has been used to determine if exposure is accomplished by placing a bone screw posterior to radiographs can underestimate articular involvement and which a bone screw is inserted anterior to posterior [2]. Direct fixation is necessary, more recent literature has shown that incision. The thread hole is drilled from posterior to anterior fragments <25% may be warranted. In a retrospective cohort usinganterior, a 2.5 through drill bit, either and a after posterior-medial measuring, aor 4.0 posterior-lateral mm partially studycomminution involving of 45 such patients fractures who underwent and that fixationsurgical ofrepair smaller of a trimalleolar fracture, statistically better outcomes were obtained threaded cancellous screw is inserted. It is important to confirm with intraoperative fluoroscopy and clinical palpation that JSM Foot Ankle 2(3): 1029 (2017) 3/5 Zhang et al. (2017) Email:

Central Bringing Excellence in Open Access anteriorly, the screw is of correct length and not prominent. operative weight bearing is not surprisingly advocated in the Additional screws prevent rotation and provide further stability. recent literature. Plates can also be used with screws superior to the fracture, blocking superior displacement of the posterior fragment with an DISCUSSION & CONCLUSION antiglide or buttress effect [2]. The posterolateral approach, with Radiographic analysis of ankle fractures for displacement, the patient placed prone, has been extensively described in the shortening, angulation and rotation are important for determining literature. The advantage is that it allows direct reduction of the isolated lateral or medial malleolar fractures can be treated with the posterior malleolus was more frequent with direct reduction if operative treatment is necessary. Non-displaced, non-angulated inposterior 83% of fragment. the cases, In compared a study by Huberto indirect et al, anatomicreduction, reduction in 27% of of a displaced, rotated, angulated, or shortened lateral malleolar the cases [18]. The direct approach also allows gravity to be an conservative management. However, conservative management young and athletic patient. The talocrural angle, Shenton’s line buttress plate, preventing axial load or shear forces during weight offracture the ankle, may the lead dime to sign, post-traumatic and talar tilt arthritis, aid in determining especially in the a bearing.intraoperative Through aid, the and posterolateral allows supplementation incision, antiglide of fixation plating with of a extent of shortening, angulation, and displacement. the fibula is possible, placing the plate on the posterior aspect of weeks. After two weeks, it often necessary to make an osteotomy In our institution, fractures are ideally fixated within two the fibula with superior biomechanical forces compared to the through the fracture, which clinically shows healing with the formation of soft callus. Although fracture blisters are relatively preoperativelateral neutralization CTs in trimalleolar plate, and fracturesaids in capturing to evaluate the the posterior extent andfibular fracture spike. patternIn conclusion, of the it posterior may be advantageous malleolar fracture to consider due to is not unexpected. The soft tissue envelope should be thought of asrare an in organ ankle as fractures, important with as high-energybone in these injuries cases, andtheir in presence regions posterior malleolar fractures < 25% in which articular step off > 2high mm variability is noted, ifin osseous patterns. interposition The surgeon of may the consider fracture fixationis seen on of prevents long term complications. of incision placement, waiting until the skin has epithelized the syndesmosis. Posterior malleolar fractures > 25% require CT. Fixation of these smaller fragments < 25% can aid in reducing Different plating techniques exist for fixation of the lateral ORIF, as traditionally described. The direct approach through malleolar fracture. With a neutralization plate, the plate is partiallythe posterolateral threaded screw incision directed has the from benefit posterior that to gravity anterior. aids in corticesplaced laterally,should be and placed an proximal inter fragmentary to the plate screw to achieve neutralizes plate reduction, and fixation can be achieved with a 4.0 cancellous stability.bending andWith rotational an antiglide forces. plate, With the the plate neutralization is placed posteriorly, plate, six EARLY WEIGHT BEARING which has indications for osteoporotic bone due to its superior biomechanical strength in weaker bone. Locking plates are also subset of patients facilitates rehabilitation by preventing stiffness, commonly used in osteoporotic bone, with the locking plate calf Earlyatrophy, weight and bearing decreases after osteoporotic operative management changes associated in a specific with disuse osteopenia [19]. This subset excludes diabetics, to whom serving as an ‘internal external fixator’. include hook plating, two cancellous malleolar screws, and Commonly used fixation techniques for the medial malleolus the adage ‘double the time offloading, double the fixation’ applies. tension banding. Two cancellous malleolar screws are more up,It also in 110 excludes patients syndesmotic of operative fixation ankle and fractures, posterior 56 malleolar patients banding may prove superior in osteoporotic, comminuted werefixation. allowed In a randomized, to weight controlled bear early, study while with 54 12 patientsmonth follow- were boneadvantageous with smaller in vertical fragments non-comminuted due to its superior fractures, biomechanical and tension allocated as late weight bearing [15]. All patients were initially strength. group, patients were allowed to weight bear as tolerated at two weeksnon-weight in a controlledbearing in anklea plaster walker cast (CAM), for two and weeks. were In instructed the early to perform range of motion exercises for up to four times a day. surface,Fixation but of recent the posterior literature malleolus highlights has the traditionally importance been of At six weeks, the patients in the early group weaned off the CAM based on fragment size of > 25% of the tibiotalar articular

malleolararticular congruity. fracture. It Preoperative would not be CTs disadvantageous may prove beneficial to order in sixfor weeksthe next after 2-4 surgery, weeks. theIn the early late group group, had the better patients ankle remained range of assessing the true size, extent, and involvement of the posterior motionnon-weight scores, bearing at 41 for degrees a total versus of six weeks29 degrees in the respectively, plaster cast. P At < the posterolateral approach has been described in the literature, 0.0001 [20]. In addition, the patients in the early group also had preoperative CTs with trimalleolar fractures. Fixation through cancellous partially threaded screw inserted from posterior to anteriorwith the is benefitoften used, of directand may visualization be supplemented of the by fracture. an additional One higher Olerud-Molander ankle function scores, P = 0.0007. Lastly, screw to prevent rotation, or a buttress plate to prevent shear

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10.

Zahn RK, Frey S, Jakubietz RG, Jakubietz MG, Doht S, Schneider P, et al. bootdiabetic allows patient, the patient for patients to continue with non-syndesmotic range of motion and exercises non- posterior malleolar fixation. Earlier transition into a CAM walking A contoured locking plate for distal fibular fractures in osteoporotic at home, decreasing stiffness. It has shown to have statistically 11. bone: a biomechanical cadaver study. Injury. 2012; 43: 718-725. Mohammed A, Abbas K, Mawlood A. A Comparative Study in Fixation significant improvements of ankle function, increased ankle Methods of Medial Malleolus Fractures Between Tension Bands physical functioning of the patient. At our institution, patients are 12. Wiring and Screw Fixation. Springerplus. 2016; 5: 530. range of motion, and significant improvements in mental and to weight bearing as tolerated based on interval healing on Ostrum RF, Litsky AS. Tension band fixation of medial malleolus transitioned from non-weight bearing to partial weight bearing 13. fractures. J Orthopó Trauma. á1992; 6: 464-468. Mingo-Robinet J, L pez-Dur n L, Galeote JE, Martinez-Cervell C. Ankle bearing.radiographic films. In adherence to AO principles, early and safe fractures with posterior malleolar fragment: management and results. mobilization can be accomplished with early protected weight 14. J Foot Ankle Surg. 2011; 50: 141-145. area of the ankle. The contribution of the posterior malleolus. J Bone REFERENCES Macko VW, Matthews LS, Zwirkoski P, Goldstein SA. The joint-contact 1. 15. Joint Surg Am. 1991; 73: 347-351. Singh R, Kamal T. Ankle Fractures: A Literature Review of Current 2. Treatment Methods. J Orthopedics. 2014; 4: 1-5. Miller AN, Carroll EA, Parker RJ, Helfet DL, Lorich DG. Posterior th malleolar stabilization of syndesmotic injuries is equivalent to screw 1754.Southerland J, Boberg J, Downey M, Nakram A, Rabjohn L. Mc Glamry’s: 16. fixation. Clin Orthop Relat Res. 2010; 468: 1129-1135. Comprehensive Textbook of Foot and Ankle Surgery. 4 Edn. 1752- 3. Berkes M, Little M, Lazaro L, Pardee N, Schottel P, Helfet D. Articular Ankle. 2nd Congruity is Associated with Short-Term Clinical Outcomes of Kitaoka H. Master Techniques in : The Foot and Operatively Treated SER IV Ankle Fractures. J Bone Joint Surg Am. 4. Edn. 501-502. 17. 2013; 19: 1769-1775.

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Cite this article Zhang L, Rosen R (2017) Radiographic Evaluation, Fixation Principles, and Post-Operative Management of Ankle Fractures. JSM Foot Ankle 2(3): 1029.

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