Postero-lateral plating of pronation-external rotation ankle fracture (posterior malleolar fixation) surgical technique
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Most ankle fractures are stable meaning that, under physiological loading, the bony and ligamentous stabilisers of the ankle joint are sufficiently intact allowing normal positioning and motion of the talus in the mortise. Stable ankle fractures do not require surgical treatment.
Some unstable fractures can be reduced and held in a suitable cast such that the reduction is maintained whilst fracture union takes place. However, achieving and maintaining reduction in some ankle fractures is not possible and it is these unstable fractures that require internal fixation. Medial injuries such as deltoid ligament or medial malleolar fractures often impact upon fracture stability. Posteriorly, fractures of the posterior tibial plafond or posterior malleolus are often associated with unstable fracture patterns. Laterally, a proximal fibula fracture or evidence of disruption of the distal tibio-fibular syndesmosis are often features seen in unstable ankle fractures.
Orthopaedic trauma dogma has previously taught that the indication to fix a posterior malleolar ankle fracture is determined by the size of the fragment (oft quoted as 25-33% of the AP dimension). The real indication for fixation of these fracture fragments is to restore stability to an unstable fracture pattern. Quite often it is clear that the presence of a large fragment is an indication but the other reason for restoring stability by fixing these fragments is to reverse the pattern of injury especially in a dislocation.
In my hands, the posterolateral approach is the workhorse to fix these fractures but significant propagation of the fracture lines into the medial malleolus may necessitate a separate posteromedial approach. Both of these approaches allow anatomic reduction of the joint surface and the application of appropriate fixation. It is for this reason that I never use screws placed from anterior to posterior.
In this case, a 48-year old female sustained a closed injury to her right ankle after slipping. She sustained a closed, pronation external rotation ankle fracture pattern and her soft tissues were in good health when taken to the operating theatre within 24 hours of injury.
Author: Mark B Davies FRCS (Tr & Orth)
Institution: The Northern General Hospital, Sheffield.
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Question 1 of 14
Which one of the following ankle fracture patterns is not an indication for open reduction and internal fixation?CorrectIncorrect
Question 2 of 14
Which one of the following clinical scenarios would not warrant the application of a temporary monolateral external fixator?CorrectIncorrect
Question 3 of 14
Which one of the following structures are not encountered when performing a postero-lateral approach to the ankle?CorrectIncorrect
Question 4 of 14
When performing a postero-lateral approach to the ankle with the patient positioned prone, which of the following structures can be difficult to approach?CorrectIncorrect
Question 5 of 14
Which of the following structures is at risk when placing a retractor around the medial border of the distal tibia?CorrectIncorrect
Question 6 of 14
Which one of the following reduction manoeuvres is not helpful in achieving reduction of a large posterior malleolar fracture fragment?CorrectIncorrect
Question 7 of 14
In which of the following ways is the plate functioning when fixing the posterior malleolus?CorrectIncorrect
Question 8 of 14
Which one of the following is unlikely to prevent anatomic reduction of a medial malleolus fracture?CorrectIncorrect
Question 9 of 14
Which one of the following structures is not integral to the distal tibial syndesmosis?CorrectIncorrect
Question 10 of 14
Which one of the following is not a sound reason for pre-operative CT scanning of ankle fracture dislocations?CorrectIncorrect
Question 11 of 14
Which of the following is not a complication of iatrogenic sural nerve injury?CorrectIncorrect
Question 12 of 14
Which one of the following statements about instrumenting ankle fractures from a postero-lateral approach is not true?CorrectIncorrect
Question 13 of 14
Which one of the following is not a perceived benefit of early ankle range of motion exercises after anatomic reduction and rigid internal fixation of an unstable ankle fracture?CorrectIncorrect
Question 14 of 14
When setting up the patient in a prone position in the operating theatre, which one of the following statements is not true?CorrectIncorrect