Rockwood Adults CH64

2864

SECTION FOUR • Lower Extremity

Ankle fracture

Bimalleolar or trimalleolar

Medial malleolus

Lateral malleolus

Suprasyndesmotic

Interfrag screw and neutralization plate or IM nail (simple fracture)

Bridge plate or IM nail (comminuted fracture)

As for medial and lateral malleoli

Posterior malleolus >25%

Cancellous screws or plate

Fibular fracture and deltoid rupture

Fibular and medial malleolar fractures

K-wires and tension band (small fragment)

2 transverse screws or antiglide plate (adduction fracture)

2 cancellous screws

Internal fixation as described Diastasis screws

Fracture in distal third

Fracture in proximal two-thirds

Fibular fixation and diastasis screw(s)

Diastasis screw(s)

Algorithm 64-2.  Authors’ preferred operative treatment of ankle fractures.

Ankle fracture with posterior subluxation of the talus despite medial and lateral malleolar fixation (which is more common where there is more than 25% of the posterior mal- leolus) should be managed operatively, either with percuta- neous anterior to posterior screws or posterior plating. Where there is clear widening of the syndesmosis with talar instability we advise surgical stabilization. Where the fibular fracture is within the distal third we prefer to fix the fibular fracture as an aid to reduction of the syndesmosis, and to ensure that the distal fragment does not angulate when the syndesmosis screw is tightened.

In this situation we prefer to use a fibular nail to avoid extensive dissection, particularly as the fibula is usually comminuted and requires to be bridged. Furthermore, we have found that once the distal fragment has been secured to the nail with the AP screw it is relatively easy to manip- ulate the fragment into position using the jig as a handle. Where the fracture is in the middle or proximal third of the fibula we do not expose or fix the fracture directly. Like most authors, we have found it difficult to judge the mortise reduction fluoroscopically and we prefer an open reduction.

Perioperative Management Considerations Timing of Surgery

particularly in patients with fracture blisters (Fig. 64-25), 363 although direct evidence for this is lacking. 191 On the con- trary, Høiness and Strømsøe 155 have reported increased rates of wound infection and longer hospital stay in patients undergo- ing late fixation when compared with patients undergoing early

Many authors have recommended delaying surgery until any traumatic edema has settled to avoid soft tissue complications,