Internal fixation of medial malleolar ankle fracture with ASNIS screws
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Most fractures of the medial malleolus occur as a component part of an injury pattern involving either the lateral malleolus and/or the posterior malleolus to varying degrees. However, a fracture of the medial malleolus can appear to occur in isolation. It is important to make sure that the energy imparted to the medial malleolus to create a fracture has not travelled through the distal tibia-fibular syndesmosis, the interosseous membrane and exited more proximally in the fibula as in the classic Maisonneuve injury. If this has been excluded, then the relatively uncommon injury of an isolated medial malleolar fracture can occur.
Using the Lauge-Hansen classification, these isolated medial malleolar fractures can occur with the foot either in supination or pronation with either a external rotational moment applied across the ankle or with the foot adducted or abducted. The pronation-abduction injury pattern is probably the most common mechanism for generating an isolated fracture. Herscovici described a 4-part fracture classification specifically for the medial malleolus which can offer guidance on how best to fix the varying fracture patterns. The relatively uncommon Type D injuries occur with supination and adduction creating a shearing force to the medial malleolus and leaving a more vertically oriented fracture line. In my opinion, these are unstable fractures that need internal fixation with an anti-glide buttress plate. Alternatively, multiple partially threaded screws can stabilise these fractures as long as they are placed perpendicular to the reduced fracture line. However, most isolated medial malleolar fractures exhibit a transverse fracture line either at the level of the tibio-talar joint line or immediately distal to it. Therefore, the common methods of fracture fixation are to apply compression either with two part-threaded cancellous screws or application of a tension band wiring technique. In this example, the former technique is employed using two Stryker partially threaded 4mm ASNIS screws.
Author: Mark Davies FRCS Tr & Orth
Institution: The Northern General Hospital Sheffield, UK.
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Question 1 of 11
Which one of the following statements is untrue about fractures of the medial malleolus?CorrectIncorrect
Question 2 of 11
Which one of the following statements is true about the treatment of isolated fractures of the medial malleolus?CorrectIncorrect
Question 3 of 11
Which one of the following treatment methods would be inappropriate for the definitive surgical treatment of the Herscovici Type D fracture patterns?CorrectIncorrect
Question 4 of 11
When considering an associated Maisonneuve-type injury, which one of the following structures is least likely to injured?CorrectIncorrect
Question 5 of 11
When performing internal fixation of an isolated medial malleolar fracture, which one of the following anatomic structures is not closely related to the fracture?CorrectIncorrect
Question 6 of 11
Which one of the following anatomic structures is least likely to interpose between the fracture fragments of the medial malleolus?CorrectIncorrect
Question 7 of 11
Which one of the following radiographic views would be least appropriate for assessing a patient with a fracture of the medial malleolus?CorrectIncorrect
Question 8 of 11
Which one of the following statements about the optimal positioning of the guide wires and screws is not true?CorrectIncorrect
Question 9 of 11
Which one of the following statements about the use of washers with screw fixation is not true?CorrectIncorrect
Question 10 of 11
Which one of the following intra-operative tests is the most appropriate for testing syndesmotic stability after fixing the fractured medial malleolus?CorrectIncorrect
Question 11 of 11
Which one of the following findings are most likely to co-exist with a severe supination adduction injury?CorrectIncorrect