import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Location**: Emerges from lateral compartment in distal third of leg, 10-12cm above lateral malleolus. **Protection**: Identify before lateral incision, anterior retraction. **Location**: Anteromedial leg and ankle, subcutaneous anterior to medial malleolus. **Protection**: Incision anterior to malleolar apex, identify and retract. **Location**: Posterior to lateral malleolus, subcutaneous, runs with small saphenous vein. **Protection**: Avoid posterior lateral dissection, identify in posterolateral approach. **Location**: Posteromedial ankle, under flexor retinaculum between FDL and FHL in tarsal tunnel. **Protection**: Stay lateral in posterolateral approach, never medial to FHL. **Location**: Posterior to lateral malleolus in retrofibular groove. **Protection**: Identify and retract anteriorly, plate posterolateral not directly lateral. **Location**: Runs in groove on posterior tibia under posterior malleolus fragment. **Protection**: Identify and protect medially in posterolateral approach. ## Indications for Trimalleolar ORIF ### Absolute Indications - Displaced trimalleolar fracture with **talar shift** or mortise incongruity - Weber B or C fibula fracture with **medial clear space widening >4mm** - Posterior malleolus >**25% articular surface** on CT (some argue >2mm displacement any size) - **Open fracture** (emergency debridement, fracture stabilisation) - **Irreducible fracture-dislocation** (interposed soft tissue) ### Relative Indications - Posterior malleolus 20-25% with step-off >2mm - Syndesmotic instability after fibula fixation - Young, active patient with any displacement - Bilateral fractures (need early mobilisation) ### Contraindications to Immediate ORIF - **Severe soft tissue swelling** (wait for wrinkle sign - typically 7-14 days) - Fracture blisters over surgical approach (wait for re-epithelialisation) - Active infection, significant medical instability - Peripheral vascular disease with non-healing potential - Non-ambulatory patient with minimal symptoms (relative) ## Pre-operative Assessment ### Imaging Protocol | View | Assessment | |------|------------| | AP | Fibula fracture level, medial clear space | | Lateral | Posterior malleolus size, talar subluxation | | Mortise (15-20° IR) | Mortise congruity, tibiofibular clear space | | CT scan | Posterior malleolus size, impaction, syndesmosis | ### Classification Systems **Weber Classification** (fibula fracture level): - **Type A**: Below syndesmosis - stable, usually non-operative - **Type B**: At syndesmosis level - stability variable (50% syndesmotic injury) - **Type C**: Above syndesmosis - unstable, syndesmosis disrupted **Lauge-Hansen Classification** (mechanism-based): - **Supination-External Rotation (SER)**: Most common (40-75%), Weber B - **Pronation-External Rotation (PER)**: Weber C, high fibula, syndesmotic injury - **Pronation-Abduction (PAB)**: Weber C, bending wedge fibula fragment - **Supination-Adduction (SAD)**: Weber A, vertical medial malleolus ### Critical Measurements - **Tibiofibular clear space**: <6mm (measured 1cm above plafond) - **Tibiofibular overlap**: >6mm on AP, >1mm on mortise - **Medial clear space**: Should equal superior clear space (~4mm) - **Fibular length**: 12-15mm from tip to plafond - **Posterior malleolus**: Measure on CT sagittal (% of articular surface) ## Consent Discussion ### Procedure-Specific Risks - **Post-traumatic arthritis** (10-30% - higher with cartilage damage, residual displacement) - **Hardware irritation requiring removal** (20-40%, especially medial screws) - **Wound complications** (5-10% - dehiscence, superficial infection) - **Nerve injury** (5-15% - usually neuropraxia, recovery expected) - **Syndesmotic stiffness** (if over-tightened or malreduced) - **DVT/PE** (2-10% - standard trauma risk) - **Nonunion** (<5% with proper technique) - **Malunion** (5-15% - if fibular length/rotation suboptimal) ### Expected Outcomes - 80-90% good to excellent results with anatomic reduction - Return to walking without aids: 3-4 months - Return to sport/heavy labour: 6-12 months - Some permanent stiffness common but usually functional ### Alternative Treatments - Non-operative: only for stable, minimally displaced fractures - External fixation: for severe soft tissue compromise, as temporary measure - Primary arthrodesis: very rare, only for severe comminution in elderly ## Operating Theatre Setup ### Patient Positioning - **Supine** with bump under ipsilateral hip (15-20° internal rotation aids fibula exposure) - Alternatively, radiolucent triangle under knee - **Lateral decubitus** if direct posterior approach to posterior malleolus planned - Thigh tourniquet at 350mmHg (elevate to exsanguinate, avoid Esmarch over fracture) - Free drape entire leg to allow manipulation ### Image Intensifier - Position perpendicular to table for true mortise view - Mortise view requires 15-20° internal rotation of leg OR external rotation of C-arm - Ensure can obtain AP, lateral, and mortise views before prepping ### Instruments Required | Category | Items | |----------|-------| | Reduction | Pointed reduction clamps, Weber clamp, dental pick, K-wires | | Fibula | One-third tubular plate (7-8 hole), precontoured fibular locking plate | | Screws | 3.5mm cortical screws, 2.7mm cortical screws for lag | | Medial | 4.0mm partially threaded cancellous screws, medial malleolar plate | | Posterior | 3.5mm cortical screws, mini-fragment plate if needed | | Syndesmosis | 3.5mm cortical screw (long), suture button device (TightRope) | | General | Periosteal elevator, bone clamps, drill guide, depth gauge | ### Three-Incision Approach 1. **Lateral longitudinal** over fibula (8-10cm) 2. **Anteromedial** curved anterior to medial malleolus (5-7cm) 3. **Posterolateral** between fibula and Achilles (6-8cm) - if needed for posterior malleolus ### Step 1: Preoperative Planning and Imaging Assessment Review AP, lateral, and mortise X-rays. CT scan is **essential for posterior malleolus** assessment - determines size (% articular surface), number of fragments, impaction, and syndesmotic injury. Apply Weber classification for surgical planning. Assess syndesmosis on CT (widening, fibular diastasis). Measure tibiofibular clear space (>6mm = injury). Plan incisions and fixation strategy. **Exam Key**: CT is ESSENTIAL for posterior malleolus - X-rays underestimate fragment size. Measure on sagittal CT as percentage of tibial plafond. Posterior malleolus is attachment site of PITFL (posterior inferior tibiofibular ligament) - fixation restores syndesmotic stability. ### Step 2: Patient Positioning and Tourniquet Position supine with bump under ipsilateral hip for 15-20° internal rotation (aids lateral approach). Apply thigh tourniquet at 350mmHg - exsanguinate by elevation (avoid Esmarch compression over fracture site). Free drape to allow full manipulation. Position C-arm for mortise view - leg 15-20° internal rotation OR C-arm externally rotated. Mortise view is the KEY intraoperative assessment. The leg must be internally rotated 15-20° to see the mortise en face. If positioning is wrong, you cannot assess reduction quality. ### Step 3: Fibula Exposure and Reduction Make **lateral longitudinal incision** (8-10cm) centred over fracture, typically distal third of fibula for Weber B. Incise fascia, identify and protect **superficial peroneal nerve** if visible anteriorly. Identify peroneal tendons posteriorly and retract. Expose fracture with periosteal elevator - minimal stripping to preserve blood supply. Clear fracture site of haematoma and debris. **Critical**: Restore **fibular length** (measure from tip to plafond - normally 12-15mm). Restore **rotation** (posterior surface flat, anterior ridge sharp). Provisional reduction with pointed reduction clamp or K-wires. **Exam Quote**: "The fibula is the key to the ankle." Fibular length and rotation determine mortise congruity. Too short = lateral talar shift, mortise widening. Malrotated = abnormal biomechanics. Use contralateral ankle X-ray as template if available. ### Step 4: Fibula Plate Application Select **one-third tubular plate** or precontoured locking fibular plate (3.5mm system). Position plate **posterolaterally** (not directly lateral) - reduces hardware prominence, protects peroneal tendons. **For oblique fractures**: Lag screw first **perpendicular to fracture line** (interfragmentary compression), then neutralisation plate. **For transverse fractures**: Compression through plate using eccentric screw placement or separate lag screw if obliquity allows. **Minimum 6 cortices** (3 screws) proximal and distal to fracture. Check length and rotation before final tightening. Avoid screws penetrating syndesmosis proximally. **Technique Point**: Lag screw must be perpendicular to fracture line for optimal compression. Plate then acts as neutralisation device protecting the lag screw. Modern trend toward locking plates in osteoporotic bone for angular stability. ### Step 5: Posterior Malleolus - Assessment and Decision Reassess posterior malleolus on fluoroscopy after fibula fixation. **Indications for posterior malleolus fixation**: 1. >25% articular surface (traditional threshold) 2. >2mm step-off or displacement (increasingly favoured) 3. Persistent syndesmotic instability after fibula fixation 4. Large fragment preventing talus reduction **Approach options**: - **Posterolateral** (most common): Between peroneals (lateral) and FHL (medial) - internervous plane - **Direct posterior**: Prone or lateral position - best visualisation - **Through lateral incision**: Percutaneous AP screws ### Step 6: Posterolateral Approach to Posterior Malleolus If posterolateral approach chosen: Incision between lateral malleolus and Achilles tendon (6-8cm). Dissect between peroneal tendons (retract laterally - superficial peroneal nerve) and FHL (retract medially - tibial nerve). Identify posterior malleolus fragment attached to PITFL. **Protect FHL** - runs in groove directly under fragment. Reduce fragment anatomically under direct vision. Elevate if impacted (use tamp, may need bone graft). Provisional K-wire fixation. The posterolateral approach is an internervous plane: peroneals (superficial peroneal nerve) lateral, FHL (tibial nerve) medial. Stay in this interval. The sural nerve is subcutaneous posterolaterally - identify and protect. ### Step 7: Posterior Malleolus Fixation **Fixation options**: 1. **Anterior-to-posterior lag screws** (GOLD STANDARD): - Start 1-2cm above joint line on anterior tibial metaphysis - Direct posteriorly toward fragment - 3.5mm or 4.0mm cortical screws - Two parallel screws provide rotational stability - Best bone purchase (metaphyseal to cortical) 2. **Posterior-to-anterior screws** (percutaneous): - Easier insertion but weaker purchase (cortical only) - Useful for smaller fragments 3. **Buttress plate** (if large fragment or comminution): - Mini-fragment plate from posterolateral approach - Provides additional stability **Exam Key**: AP lag screws are preferred - better bone purchase, can achieve true lag effect. The starting point is anterior tibial metaphysis (good cancellous bone), directing posteriorly to engage dense posterior cortical fragment. ### Step 8: Medial Malleolus Exposure Make **anteromedial curved incision** (5-7cm) just **anterior to medial malleolar apex** - this protects saphenous nerve/vein which are more anterior. Identify and protect great saphenous vein and saphenous nerve (variable anatomy - may be in field). Incise periosteum and expose fracture. Clear debris from fracture site. Reduce anatomically - articular surface and medial plafond must be perfect. **Anatomy Point**: Saphenous nerve provides sensation to medial foot and ankle. Injury causes painful dysaesthesia. Position incision anterior to malleolar apex (not directly over prominence) to minimise risk. ### Step 9: Medial Malleolus Fixation **Fixation determined by fracture pattern**: | Pattern | Fixation | Rationale | |---------|----------|-----------| | **Oblique/Transverse** | 2 × 4.0mm partially threaded cancellous screws parallel, perpendicular to fracture | Lag compression across fracture | | **Vertical (SAD)** | Buttress plate (one-third tubular or medial malleolar) | Tension forces pull screws out - plate essential | | **Comminuted** | Bridge plate with screws in intact bone only | Span comminution, maintain length | | **Small fragment** | Tension band wiring (2 K-wires + figure-8 wire) | Alternative if screws won't hold | Ensure anatomic articular reduction before final fixation. Countersink screw heads to reduce hardware prominence. Vertical medial malleolar fractures (SAD pattern) **MUST** have plate fixation. Screws alone will fail - the tension forces from deltoid ligament pull the screws superiorly out of the fragment. ### Step 10: Syndesmosis Assessment After all fractures fixed, assess **syndesmotic stability**: 1. **Cotton test**: Grasp fibula with bone clamp, apply lateral stress. Should be <2mm translation compared to opposite side. 2. **External rotation stress**: Under fluoroscopy, externally rotate foot - assess tibiofibular clear space widening. 3. **Direct palpation**: If posterolateral approach used, palpate anterior and posterior tibiofibular ligaments. 4. **Imaging criteria** (mortise view): - Tibiofibular clear space <6mm (measured 1cm above plafond) - Tibiofibular overlap >6mm on AP, >1mm on mortise **Key Point**: Posterior malleolus fixation often stabilises syndesmosis because the fragment is attachment site of PITFL. After posterior malleolus fixation, 50% of previously unstable syndesmoses become stable. Always retest after all fracture fixation. ### Step 11: Syndesmosis Fixation (if unstable) If Cotton test positive or imaging criteria not met, syndesmosis requires fixation: **Technique for syndesmotic screw**: 1. Position screw **2-4cm above joint line** (above syndesmosis, not through it) 2. Angle **25-30° anterior to posterior** (parallel to joint line) 3. **Compress fibula into incisura** with clamp before drilling 4. Ensure fibula is **correctly positioned** - not too anterior (restricts dorsiflexion) or posterior (restricts plantarflexion) 5. Foot in **neutral dorsiflexion** (not forced dorsiflexion - overtightens syndesmosis) 6. **3.5mm cortical screw**, 3 cortices (tricortical) or 4 cortices (quadricortical) 7. One screw usually sufficient; two if severely unstable **Alternative**: Suture button device (TightRope) - allows physiologic micromotion, lower hardware removal rate. Fibula must be correctly positioned in incisura before screw insertion. Malreduction is the most common syndesmotic fixation error. Use direct visualisation or CT if uncertain. Fibula too anterior = restricted dorsiflexion. Fibula too posterior = restricted plantarflexion. ### Step 12: Final Reduction Assessment Obtain comprehensive fluoroscopic images and critically assess: **Mortise view** (15-20° IR): - Medial clear space = Superior clear space (both ~4mm) - Symmetric talar dome within mortise - Tibiofibular clear space <6mm - Tibiofibular overlap >6mm **AP view**: - No talar shift - Fibular length restored (12-15mm to plafond) - No step at posterior malleolus **Lateral view**: - No anterior/posterior talar subluxation - Posterior malleolus reduced (<2mm step) - Tibiotalar joint congruent **Exam Mantra**: "If ANY parameter is wrong - FIX IT NOW." Accepting residual displacement leads to post-traumatic arthritis. Perfect reduction determines outcome. 1mm of lateral talar shift decreases tibiotalar contact area by 42%. ### Step 13: Closure and Post-operative Care Irrigate all wounds thoroughly. Layered closure: periosteum/fascia with absorbable sutures, subcutaneous layer, skin with interrupted nylon or subcuticular. Consider small drain if significant posterolateral dissection. Apply bulky padded dressing with **plaster backslab** in neutral position (90° dorsiflexion, hindfoot neutral). Elevate limb above heart level. Initiate DVT prophylaxis (LMWH 40mg daily or aspirin depending on protocol). ## Rehabilitation Timeline | Timeframe | Activity | Goals | |-----------|----------|-------| | Day 1-14 | NWB in backslab, elevation, ankle pumps | Wound healing, swelling control | | 2 weeks | Suture removal, transition to CAM boot | Begin gentle ROM exercises | | 2-6 weeks | NWB in CAM boot, active ROM exercises | Regain dorsiflexion/plantarflexion | | 6-8 weeks | Progressive weight-bearing if healed | Confirm radiographic union | | 8-12 weeks | Full weight-bearing, intensive physiotherapy | Strengthen, proprioception | | 3-4 months | Return to driving, light activities | Functional recovery | | 6-12 months | Return to sport/heavy labour | Full recovery | ## Syndesmotic Screw Management - **Quadricortical screw**: Consider removal at 3-4 months if symptomatic or before high-demand activity - **Tricortical screw**: Often left in situ - may break with weight-bearing (acceptable) - **Suture button**: No removal needed - **Modern evidence**: Routine removal not mandatory if asymptomatic ## Follow-up Schedule - 2 weeks: Wound check, suture removal, X-ray - 6 weeks: Clinical and radiographic assessment, advance weight-bearing - 3 months: Assess union, consider syndesmotic screw removal if indicated - 6 months: Functional assessment - 1 year: Long-term assessment, screen for arthritis 1. Court-Brown CM, McBirnie J, Wilson G. Adult ankle fractures--an increasing problem? Acta Orthop Scand. 1998;69(1):43-47. 2. Tornetta P, Axelrad TW, Sibai TA, Creevy WR. Treatment of the stress positive ligamentous SE4 ankle fracture: incidence of syndesmotic injury and clinical decision making. J Orthop Trauma. 2012;26(11):659-661. 3. Gardner MJ, Demetrakopoulos D, Briggs SM, Helfet DL, Lorich DG. The ability of the Lauge-Hansen classification to predict ligament injury and mechanism in ankle fractures: an MRI study. J Orthop Trauma. 2006;20(4):267-272. 4. Miller AN, Carroll EA, Parker RJ, Borber SP, Mauricio L, Helfet DL. Direct visualization for syndesmotic stabilization of ankle fractures. Foot Ankle Int. 2009;30(5):419-426. 5. Sagi HC, Shah AR, Sanders RW. The functional consequence of syndesmotic joint malreduction at a minimum 2-year follow-up. J Orthop Trauma. 2012;26(7):439-443. 6. Ramsey PL, Hamilton W. Changes in tibiotalar area of contact caused by lateral talar shift. J Bone Joint Surg Am. 1976;58(3):356-357. 7. Gardner MJ, Brodsky A, Briggs SM, Nielson JH, Lorich DG. Fixation of posterior malleolar fractures provides greater syndesmotic stability. Clin Orthop Relat Res. 2006;447:165-171. 8. Clanton TO, Paul P. Syndesmosis injuries in athletes. Foot Ankle Clin. 2002;7(3):529-549. 9. Norkus SA, Floyd RT. The anatomy and mechanisms of syndesmotic ankle sprains. J Athl Train. 2001;36(1):68-73. 10. Andersen MR, Frihagen F, Hellund JC, Madsen JE, Figved W. Randomized trial comparing suture button with single syndesmotic screw for syndesmosis injury. J Bone Joint Surg Am. 2018;100(1):2-12.

Ankle Fracture ORIF - Trimalleolar

Ankle Fracture ORIF - Trimalleolar