Transsyndesmotic, posterior, lateral simple, and medial fractures

 

 

Marked soft-tissue swelling, medical compromise, vascular disease, nonambulant patient

General considerations
Nonoperative treatment of ankle fractures is usually reserved for inherently stable fractures, but can be indicated for unstable fractures in the presence of local, or general, contraindications to surgery.

Indications

• Marked soft-tissue swelling
• Medical compromise
• Vascular disease
• Nonambulant patient
• Undisplaced fractures
• Patient not fit for surgery
• Peripheral vascular diseases
• Poor state of soft tissues

Contraindications

• Dislocated or unstable joint
• Inadequate reduction and unstable syndesmosis
• Shortening of the fibula
• Joint subluxation
• Significant articular posterior fragment
• Open fractures with severe soft-tissue injury

Advantages

• Full weight bearing possible
• Relatively good stability

Disadvantages

• Risks of cast complications (eg, pressure ulcer, nerve compression)
• Risks of immobilization
• Risk of secondary displacement and post-traumatic arthrosis
• Risk of malunion
• Possible longer period of rehabilitation

 

 

Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF)

General considerations
In a polytrauma patient it takes too much time to reconstruct the ankle-joint anatomically.
However, joint instability increases soft-tissue insult and should be eliminated. In patients with excessive swelling, or severe soft-tissue injuries early ORIF could cause further damage to the soft tissues.
With an external fixator, the joint can be reduced and provisionally stabilized in an adequate position, while awaiting decrease of swelling. Later anatomical reconstruction by ORIF becomes possible.

The modular external fixator maintains the length and holds the foot in a neutral position without a tibiotarsal transfixation.

Further indications

• Displaced, unstable fractures
• Open fractures with severe soft-tissue injury

Contraindications

• Patient not fit for surgery
• Low demand patient
• Peripheral vascular diseases or poor soft tissues

Advantages

• Stabilization of the joint
• Early functional recovery

Disadvantages

• Risk of pin-track infection
• Risk of soft-tissue breakdown
• Failure to control large posterior fragment

 

 

Damage control in polytrauma, excessive soft-tissue swelling (prelude to ORIF)

General considerations
In a polytrauma patient it takes too much time to reconstruct the ankle joint anatomically.
However, joint instability increases soft-tissue insult and should be eliminated. In patients with excessive swelling, or severe soft-tissue injuries early ORIF could cause further damage to the soft tissues.
With an external fixator, the joint can be reduced and provisionally stabilized in an adequate position, while awaiting decrease of swelling. Later anatomical reconstruction by ORIF becomes possible.

Further indications

• Displaced, unstable fractures
• Open fractures with severe soft-tissue injury

Contraindications

• Patient not fit for surgery
• Low demand patient
• Peripheral vascular diseases or poor soft tissues

Advantages

• Stabilization of the joint
• Early functional recovery

Disadvantages

• Risk of pin-track infection
• Risk of soft-tissue breakdown
• Failure to control large posterior fragment

 

 

Most fractures when the patient is fit and soft tissues do not preclude surgery

Indications

• Displaced, unstable fractures
• Osteoporotic bone
• Open fractures with severe soft-tissue injury
• Loss of reduction after nonoperative treatment

Contraindications

• Poor general condition of the patient (high anesthetic risk)
• Low demand patient
• Peripheral vascular diseases
• Poor state of soft tissues

Advantages

• Anatomical reduction of the joint
• Early functional recovery
• Good long-term results

Disadvantages

• Skin irritation through bulky implant
• Risk of wound infection
• Risk of soft-tissue breakdown
• Distal positioning of the plate on the distal fragment limited by peroneal tendons
• Risk of injury to peroneal tendons