Sports Medicine: Just the Facts

CHAPTER 64 • TIBIAL AND ANKLE FRACTURES 381

• Nondisplaced, stable ankle fractures and stable,
  reduced ankle fractures can be managed nonopera-
  tively with great success. Once swelling is reduced,
  long leg casting is indicated with transition to short
  leg cast or fracture bracing after 4 to 6 weeks (Marsh
  and Saltzman, 2001). Diabetics are a special sub-
  group of patients that may need more time in the
  long leg cast before adequate bone growth is evident
  and are less likely candidates for operative interven-
  tion. Recent studies suggest that diabetics have
  higher postoperative complication rates when com-
  pared to nondiabetics. Blotter et al reported a 43%
  complication rate in diabetics as compared to a 15%
  complication rate in nondiabetics (Blotter et al,
  1999). Diabetics also demonstrate a higher postoper-
  ative infection rate after ankle surgery as reported by
  Flynn et al in 2000 (Flynn, Rodriguez-del, and Piza,
  2000).


• Displaced, unstable, open, or unreducible ankle
  fractures must be treated operatively with reduc-
  tion and internal or external fixation. Studies have
  been unable, however, to demonstrate that the
  accuracy of ankle fracture reduction determines
  better long term outcome or reduces the amount of

intra-articular contact stresses (Vrahas, Fu, and

Veenis, 1994).

• Open fractures require emergent orthopedic consult
  and it is very likely that they will be taken to the oper-
  ating room immediately. Studies have shown that
  most open ankle fractures are associated with wounds
  less than 1 cm long and that infection rates after oper-
  ative treatment of these fractures is comparable to
  infection rates seen in the treatment of closed frac-
  tures. Chapman and Mahoney demonstrated in their
  series of open ankle fractures in which immediate fix-
  ation was achieved, that the rate of infection in open
  fracture wounds less than 1 cm was 2% and the rate of
  infection in open fracture wounds with extensive soft
  tissue damage and wounds greater than 1 cm was 29%
  (Chapman and Mahoney, 1976).


• The most important aspects of ankle fracture manage-
  ment are to immediately reduce dislocated ankles
  prior to radiographic study, clean and dress open
  wounds in a proper sterile fashion, document and
  evaluate neurovascular status, and apply a posterior
  splint with a U-shaped component at the ankle when
  transporting the patient or preparing them for further
  work-up by an orthopedic surgeon.

TABLE 64-4 Classification Systems of Ankle Fractures

FRACTURE
CLASSIFICATION TYPE LOCATION OF FRACTURE ASSOCIATED INJURIES

Syndesmosis likely intact

Syndesmosis likely intact

Likely disruption of syndesmosis with positive

squeeze test

Stage 1: Tear of lateral ligaments

Stage 2: Fracture of medial malleolus

Stage 1: Rupture of anterior tib-fib ligament

Stage 2: Spiral or oblique fracture of lateral

malleolus

Stage 3: Posterior tibial fracture

Stage 4: Fracture of medial malleolus or torn

deltoid ligament

Stage 1: Torn deltoid ligament

Stage 2: Syndesmotic disruption and posterior

tibial fracture

Stage 3: Oblique fracture of fibula above

mortise

Stage 1: Torn deltoid ligament

Stage 2: Syndesmotic disruption

Stage 3: Spiral fracture of fibula above mortise

Stage 4: Posterior tibial fracture

Intact or possible avulsions medial and posterior

Tib-fib ligaments torn; possible avulsions

medially and posteriorly

Syndesmosis always torn; deltoid ligament torn

Below ankle mortise and tibiofibular

articulation

At level of mortise and tibiofibular

articulation

Above level of mortise and tibiofibular

articulation

Transverse fracture of lateral malleolus

Avulsion fracture of lateral malleolus

Medial malleolus

Medial malleolus

Fibula at or below plafond

Fibula at plafond extending proximally

Fibula above plafond

A

B

C

Supination-adduction

Supination-external rotation

Pronation-abduction

Pronation-external rotation

A

B

C

Danis-Weber

Lauge-Hansen

AO