Fractures of the Lower Extremity

Classification

Ankle fractures can be classified purely along anatomic lines as monomalleolar, bimalleolar, or trimalleolar. The Lauge-Hansen classification attempted to associate specific fracture patterns with the mechanism of injury and proposed a detailed classification, with each broad classification subdivided into four groups ( Box 54.1 ). According to this classification, most fractures are supination-eversion, supination-adduction, pronation-abduction, and pronation-eversion injuries. In this classification system, the term eversion is a misnomer; it more correctly should be external or lateral rotation . The first word in the designation refers to the foot’s position at the time of injury; the second word refers to the direction of the deforming force.

The most common mechanism is supination-eversion (supination-external rotation). The identifying feature is a spiral oblique fracture of the distal fibula and a rupture of the deltoid ligament or fracture of the medial malleolus. The supination-adduction type of injury is characterized by a transverse fracture of the distal fibula and a relatively vertical fracture of the medial malleolus. The pronation-abduction mechanism produces a transverse fracture of the medial malleolus and a short oblique fracture of the fibula that appears relatively horizontal on the lateral radiograph. The pronation-eversion (pronation-external rotation) mechanism is characterized by a deltoid ligament tear or a fracture of the medial malleolus and a spiral oblique fracture of the fibula relatively high above the level of the ankle joint. Analysis of the fracture configuration, and hence the mechanism of forces producing the fracture, is especially important if closed reduction and immobilization are planned as definitive treatment. Generally, the mechanism of forces producing the fracture is reversed by the closed reduction manipulation; for example, if the fracture is produced by a supination, eversion, or external rotation mechanism, reduction is achieved by a pronation, inversion, or internal rotation manipulation.

Some authors caution against using the Lauge-Hansen classification alone to determine treatment and recommend that treatment be based on a clinical determination of stability. O’Leary and Ward described an abduction-external rotation mechanism that resulted in fracture of the medial malleolus and avulsion of the deltoid ligament, emphasizing the difficulty in determining the full extent of injury after high-velocity impact. This injury results from initial abduction and external rotation, followed by violent adduction that fractures the medial malleolus. Whitelaw et al. recommended evaluation of ankle joint stability by the anterior drawer and talar tilt tests after bony stabilization and surgical repair of any concomitant ligamentous disruption.

The Danis-Weber classification ( Fig. 54.1 ) is based on the location and appearance of the fibular fracture. Type A fractures are caused by internal rotation and adduction that produce a transverse fracture of the lateral malleolus at or below the plafond, with or without an oblique fracture of the medial malleolus. Type B fractures are caused by external rotation resulting in an oblique fracture of the lateral malleolus, beginning on the anteromedial surface and extending proximally to the posterolateral aspect. The injury may include rupture or avulsion of the anteroinferior tibiofibular ligament, fracture of the medial malleolus, or rupture of the deltoid ligament. Approximately 80% to 90% of lateral malleolar fractures fall into the Danis-Weber type B category. Type C fractures are divided into abduction injuries with oblique fracture of the fibula proximal to the disrupted tibiofibular ligaments (C-1) and abduction-external rotation injuries with a more proximal fracture of the fibula and more extensive disruption of the interosseous membrane (C-2). Type C injuries may involve a medial malleolar fracture or a deltoid ligament rupture. Fracture of the posterior malleolus may accompany any of the three types. The AO classification divides the three Danis-Weber types further for associated medial injuries ( Box 54.2 ). Malek et al. reported high interobserver and intraobserver reliability using the Danis-Weber classification system of 78% and 85%, respectively.

Authors have demonstrated that there is considerable interobserver variability between the classification systems for ankle fractures. In addition, although the Lauge-Hansen and Danis-Weber classifications have proved useful for understanding the mechanisms of injury and planning treatment, neither has been shown to have prognostic significance. Furthermore, the Lauge-Hansen classification scheme has demonstrated limitations in predicting associated soft-tissue injuries when evaluated with MRI.

Isolated Fractures of the Medial and Lateral Malleoli

Medial Malleolar Fracture

Nondisplaced fractures of the medial malleolus usually can be treated with cast immobilization; however, in individuals with high functional demands, internal fixation may be appropriate to hasten healing and rehabilitation. Herscovici et al. obtained a high rate of union and functional outcome with conservative management of isolated medial malleolar fractures. Displaced fractures of the medial malleolus should be treated operatively because persistent displacement allows the talus to tilt into varus. Avulsion fractures involving only the tip of the medial malleolus are not as unstable as fractures involving the axilla of the mortise and do not require internal fixation, unless displacement is significant. Delayed internal fixation can be done if symptoms warrant. Fixation of the medial malleolus usually consists of two 4-mm cancellous lag screws oriented perpendicular to the fracture. Some authors have advocated fixation with bicortical 3.5-mm lag screws, rather than 4-mm cancellous screws, because biomechanical data suggest increased construct strength ( Fig. 54.2A ).

Smaller fragments can be fixed with one lag screw and one Kirschner wire to prevent rotation ( Fig. 54.2B ). Fragments that are too small or comminuted for screw fixation can be stabilized with two Kirschner wires and a tension band ( Fig. 54.2C ). Alternatively, minifragment screws have become readily available and are an excellent option for stabilization of smaller fractures. Vertical fractures of the medial malleolus require horizontally directed screws or antiglide plating techniques ( Fig. 54.2D and E ). Dumigan et al. demonstrated that fixation of vertical medial malleolar fractures with neutralization plating is biomechanically advantageous.

Although stainless steel implants are used most commonly for medial malleolar fractures, the safety and efficacy of bioabsorbable implants have been investigated. The main theoretical advantage of these implants is that they reduce the incidence of late implant removal stemming from persistent prominence or tenderness around the screw heads. Although bioabsorbable implants have been used successfully, with no differences in outcomes noted between stainless steel and polyglycolide, drainage from sterile sinuses has been reported in 5% to 10% of patients, possibly related to the breakdown of polyglycolide. Also, in a series of 2528 patients, a 4.3% occurrence rate of clinically significant local inflammatory tissue reaction has been reported. Bioabsorbable implants are discussed in more detail in Chapter 53 .

Our preference is for metallic implants, typically screws or screw and plate combination, depending on the fracture morphology. Absorbable implants have a role in the treatment of associated articular fragments but are not a substitute for traditional internal fixation options.

Stress Fracture of the Medial Malleolus

Stress fractures of the medial malleolus usually present as localized pain, swelling, and tenderness over the medial ankle. Initially, they may not be apparent on radiographs but usually can be demonstrated on bone scan, CT, or MRI. Often stress fractures become apparent on follow-up radiographs. Shelbourne et al. recommended internal fixation for fractures that are immediately apparent on radiographs and cast immobilization for those only apparent on bone scans. Stress fractures of the medial malleolus have a high risk of progression to complete fracture, delayed union, or nonunion. Often aggressive treatment, including surgery, is necessary.

Bimalleolar Fracture

Bimalleolar ankle fractures disrupt the medial and lateral stabilizing structures of the ankle joint. Displacement reduces the tibiotalar contact area and alters joint kinematics. Closed reduction can often be accomplished but not maintained in anatomic position as swelling subsides. Nonunion has been reported in approximately 10% of bimalleolar fractures treated by closed methods, although these are not always symptomatic. Twenty percent of bimalleolar fractures involve intraarticular injuries to the talus and tibia; these injuries go untreated when closed methods are used. Randomized, prospective, and long-term follow-up studies of bimalleolar or bimalleolar-equivalent ankle fractures have shown superior results of operative over nonoperative treatment. A long-term follow-up study also showed superior results after operative treatment of supination-external rotation stage IV fractures. Tile and the AO group recommended ORIF of both malleoli for almost all bimalleolar fractures.

For most displaced bimalleolar fractures, we also recommend ORIF of both malleoli. Most Weber type B and type C lateral malleolar fractures are stabilized with plate and screw fixation. In some patients, lateral implants in the ankle may become symptomatic; however, in one study only half the patients had relief of pain after implant removal. Posterior plating of Weber type B fractures of the lateral malleolus using an antiglide technique has been advocated to avoid the possibility of intraarticular screws, decrease the incidence of palpable implants, and provide a stronger construct. In a prospective series of 32 patients, there were no nonunions, malunions, wound complications, loss of fixation, or intraarticular or palpable screws. Four patients had transient peroneal tendinitis, and in two patients the plates were removed because of symptoms caused by a poorly placed lag screw. Weber et al. documented peroneal tendon lesions precipitated by posterior antiglide plating of the lateral malleolus. In their series, 30% of patients demonstrated peroneal tendon injury at the time of implant removal. However, only 22% of these patients had symptoms preoperatively. The authors concluded that the tendon lesions correlated with distal plate placement and screw insertion through the most distal hole of the plate and therefore advocated either avoiding distal implant placement or removing the plate early.

Implant prominence also may be decreased in some lateral malleolar fractures by using a lag screw–only technique ( Fig. 54.3 ). Several authors have reported successful treatment of lateral malleolar fractures with lag screw–only fixation, with no nonunions, loss of reduction, or soft-tissue complications. They cite less implant prominence and pain compared with patients who had plate fixation for similar injuries. Ideal candidates are patients younger than 50 years with a simple oblique lateral malleolar fracture and minimal comminution that allows the placement of two lag screws at least 1 cm apart.

Augmenting plate fixation with intramedullary Kirschner wires in osteopenic fibular fractures has been recommended in one study; 89% had minimal or no pain. In a biomechanical study, plates supplemented by Kirschner wires had an 81% greater resistance to bending than plates alone and twice the resistance to motion in torsional testing.

Operative treatment of periarticular fractures in general, ankle fractures in particular, probably is limited to two time periods: early and late. ORIF may be possible within the first 12 hours after injury but may not be possible again for 2 to 3 weeks because of excessive swelling, but this can be variable. Delayed closure and even skin grafting may be necessary when too much swelling exists at surgery. Equally good functional results have been found with immediate and delayed ORIF of Danis-Weber type B bimalleolar or bimalleolar equivalent ankle fractures, with no differences in complications, adequacy of reduction, range of motion, or operative time, although hospitalization was briefer and pain was diminished with immediate surgery in one study. Although delayed surgery may be technically more difficult, it is justified in patients with severe closed soft-tissue injury or fracture blisters. If open reduction of a fracture-dislocation is delayed, immediate closed reduction of the dislocation and splinting are mandatory to prevent skin necrosis.

Syndesmotic Injury

Injuries to the syndesmotic complex continue to be a center of controversy and continuing focus. Syndesmotic injuries are most commonly caused by pronation-external rotation, pronation-abduction and, infrequently, supination-external rotation mechanisms (Danis-Weber type C and type B injuries). These forces cause the talus to abduct or rotate externally in the mortise, leading to disruption of the syndesmotic ligaments.

Anatomic restoration of the distal tibiofibular syndesmosis is essential. If the fibular fracture is above the level of the distal tibiofibular joint, this joint is assumed to be disrupted and must be anatomically reduced. In the past, internal fixation of all syndesmotic injuries was considered mandatory, but a cadaver study showed that disruption of the syndesmosis did not cause ankle instability if no medial injury was involved. If a medial lesion was present, syndesmotic injuries extending more than 4.5 cm proximal to the ankle joint altered joint mechanics, but syndesmotic injuries extending less than 3 cm proximal to the ankle joint did not. Syndesmotic disruptions of 3.0 to 4.5 cm produced variable results. These findings suggested that syndesmotic fixation was unnecessary if the disruption extended less than 3 cm above the plafond or if the medial and the lateral injuries were stabilized by fixation of the medial malleolus or repair of the deltoid ligament.

A prospective study evaluating syndesmotic screw fixation of Weber type C ankle fractures in which the lateral malleolar fracture was located within 5 cm of the ankle joint found that syndesmotic screw fixation was not necessary if the fracture was anatomically reduced and was immobilized for 6 weeks postoperatively. This has not yet been extensively evaluated clinically, however. Others have more recently proposed an “anatomic” restoration of the syndesmosis, citing repair of the deltoid ligament and posteroinferior tibiofibular ligament to be equivalent to trans-syndesmotic fixation from a functional outcome perspective, but with improved syndesmotic reductions noted.

There is general agreement that syndesmotic fixation is indicated for (1) syndesmotic injuries associated with proximal fibular fractures for which fixation is not planned and that involve a medial injury that cannot be stabilized and (2) syndesmotic injuries extending more than 5 cm proximal to the plafond. Whether syndesmotic fixation should be used in lateral malleolar fractures located 3 to 5 cm from the ankle joint in which the medial injury (deltoid ligament) is not repaired remains controversial. If a high fibular fracture associated with a syndesmotic injury is not fixed, restoration of fibular length can be difficult to determine accurately. Furthermore, fixation of midshaft fibular fractures with associated syndesmotic injuries demonstrates improved biomechanical characteristics when compared with syndesmosis fixation alone.

The integrity of the syndesmosis can be evaluated intraoperatively by performing an external rotation stress test and Cotton test. Cotton described this test to determine incompetence of the ankle syndesmosis intraoperatively. Distraction is applied to the fibula with a bone hook to try to separate it from the tibia, to which an opposing force has been applied to prevent tibial motion. If no significant motion is noted between the distal tibia and fibula, the syndesmotic ligaments are intact. If more than 3 to 4 mm of lateral displacement occurs, syndesmotic fixation is necessary. Intraoperative radiographs should show a clear space of less than 5 mm between the medial wall of the fibula and the lateral wall of the posterior tibial malleolus. Persistent widening indicates an unreduced syndesmosis. A cadaver study showed that syndesmotic disruption, measured as posterior displacement of the fibula on an external rotation stress lateral radiograph, correlated more closely with anatomic diastasis than did displacement on stress mortise radiographs. Stark et al. recommended intraoperative external rotation stress evaluation for unstable Weber B fractures after identifying a 39% incidence of syndesmotic instability after lateral malleolar fixation.

Various methods have been used to fix the syndesmosis. Most commonly screws are inserted through the lateral malleolus and into the distal tibia. These screws not only hold the joint anatomically reduced but also stabilize the lateral buttress of the ankle mortise. If screw fixation is chosen, either one or two 3.5-mm or 4.5-mm cortical screws are necessary; both have been found to be equivalent biomechanically. Two syndesmotic screws have been found to provide more secure fixation than one screw, and the use of two screws has been suggested in large or noncompliant patients. The syndesmotic screw should be placed through both cortices of the fibula and either one or two cortices of the tibia. In a survey of members of the Orthopaedic Trauma Association and the American Orthopaedic Foot and Ankle Society, Bava et al. sought to identify the current state of syndesmotic injury management. Fifty-one percent used 3.5-mm cortical screws, 24% used 4.5-mm cortical screws, and 14% routinely used a suture fixation device. Forty-four percent used one screw, 44% used two screws, and the remainder was undecided. The most common construct was use of 3.5-mm screws engaging four cortices that were routinely removed at 3 months. Bioabsorbable screws also have been used for fixation of the syndesmosis and have shown comparable results to metallic implants. Suture bridge techniques have gained in popularity. The proposed benefit is decreased implant issues requiring secondary intervention and dynamic stabilization. Retrospective data have demonstrated some loss of syndesmotic reduction at short-term follow-up. Implant prominence and suture knot irritation can still occur. A recent meta-analysis demonstrated improved functional outcomes as well as lower rates of broken implants and syndesmotic malreduction with the use of suture button fixation when compared to traditional syndesmotic screws.

Whether and when syndesmotic screws need to be removed are controversial subjects. Recommendations in the literature range from routine removal of the screw before weight bearing is allowed (in 6 to 8 weeks) to removal after the fracture has healed only if symptoms develop. Advocates of screw removal contend that the syndesmotic fixation disrupts ankle mechanics by restricting the normal external rotation of the fibula that occurs with dorsiflexion. Removing the screw too early may allow recurrent diastasis of the syndesmosis, however. Syndesmosis displacement has been reported when the screw was removed before weight bearing was allowed, and screw breakage has been reported with weight bearing with the screw in place. If tricortical fixation is used, the screw usually loosens rather than breaks and may not disrupt normal ankle mechanics. If fixation through four cortices is used, both ends of the screw can be removed easily if breakage occurs. In general, late diastasis of the syndesmosis creates a much more difficult clinical problem than broken screws; it is advisable to leave the screw in place for at least 12 weeks. Furthermore, another study revealed that at 1-year follow-up there was no difference in clinical outcome of patients with intact or removed syndesmotic screws. In fact, the subset with broken screws had improved clinical outcomes; therefore, the authors recommended not removing intact or broken syndesmotic screws. We have transitioned toward not routinely removing syndesmotic fixation unless the ankle is symptomatic, primarily with stiffness limiting dorsiflexion. However, a recent small series has questioned the effect of syndesmotic screw removal, citing no significant improvements in dorsiflexion after implant removal.

The syndesmosis must be anatomically reduced and held with provisional Kirschner wires or a reduction clamp before the syndesmotic screws are inserted. Miller et al. noted a significant decrease in syndesmotic malreductions in a cohort of patients in whom the syndesmosis was directly viewed during reduction. We also advocate open reduction of the syndesmosis with direct viewing. The reduction can therefore be performed manually and maintained with a reduction clamp, in contrast to using the clamp to effect reduction, which can introduce rotational malreduction. The screw should be positioned 2 to 3 cm proximal to the tibial plafond, directed parallel to the joint surface, and angled 30 degrees anteriorly so that it is perpendicular to the tibiofibular joint. If the screw is placed too far proximally, it may deform the fibula and cause the mortise to widen. If the screw is not parallel to the joint, the fibula may shift proximally. If the screw is not perpendicular to the tibiofibular joint, the fibula may remain laterally displaced. The AO group recommended a fully threaded syndesmotic screw in a neutralization mode or position; however, others have suggested that a lag screw provides more secure fixation. Traditionally, it was recommended to maximally dorsiflex the ankle during syndesmotic fixation to prevent postoperative limitation of motion; however, there are data refuting this finding and noting that maximal dorsiflexion may induce an external rotation moment risking malreduction. A cadaver study found no loss of dorsiflexion when lag screws were used for fixation of the syndesmosis with the ankle in plantarflexion. Others have illustrated that postoperative radiographic measurements are unreliable markers of syndesmotic reduction, which is better assessed with CT.

If a small plate has been used to fix the fibular fracture, this transfixing screw can be one of the screws used to secure the plate to the lateral side of the fibula ( Fig. 54.4 ). The reduced and fixed fibula must meet the three requirements for satisfactory function listed earlier in this section. Occasionally, the syndesmotic ligaments may avulse a small fragment of bone. If this is the case, syndesmotic stabilization can be accomplished by lag screw or minifragment fixation through this fragment.

Egol et al. evaluated outcomes after unstable ankle fractures with regard to the effects of syndesmotic fixation. They determined that at 1-year follow-up patients who underwent syndesmotic fixation had poorer outcomes than those who had malleolar fracture fixation alone.

Deltoid Ligament Tear and Lateral Malleolar Fracture

A deltoid ligament tear accompanied by a fracture of the lateral malleolus is caused by the same mechanism that produces bimalleolar fractures, that is, supination with external rotation of the foot. Instead of the medial malleolus being fractured, however, the deltoid ligament is torn, allowing the talus to displace laterally ( Fig. 54.7 ). Usually the anterior capsule of the ankle joint is also torn. The deltoid ligament, especially its deep branch, is important to the stability of the ankle because it prevents lateral displacement and external rotation of the talus. A deltoid ligament tear should be suspected if a fracture of the lateral malleolus is accompanied by tenderness, swelling, and hematoma on the medial side of the ankle. Historically, medial-sided ankle tenderness would lead the clinician to suspect a deltoid ligament disruption in the presence of a lateral malleolar fracture. However, it has been established that there is no statistically significant relationship between medial tenderness and deep deltoid ligament rupture. A routine anteroposterior radiograph may show no lateral displacement of the talus, but a radiograph made when the ankle is stressed into supination and external rotation shows displacement and tilting of the talus in the ankle mortise and a wide medial clear space (>4 mm). This radiograph should be obtained with the ankle in neutral position. With the ankle in plantarflexion, the narrowest portion of the talus is within the mortise, which may appear to be wide even without injury. Alternatively, a gravity external rotation stress radiograph can be obtained.

Closed treatment of these injuries is difficult because the talus tends to shift in the mortise. A 1-mm lateral shift of the talus can reduce the effective weight-bearing area of the talotibial articulation by 20% to 40%, and a 5-mm shift can reduce it by 80%. If closed treatment is chosen, the patient must be followed closely for displacement. Optimal treatment of this injury is controversial. Provided that the condition of the skin and the patient’s age and general condition permit, ORIF of the fibula, with or without repair of the deltoid ligament, can be done. Nonoperative treatment also is feasible but requires careful radiographic monitoring to ensure maintenance of a congruent ankle mortise. If only the deltoid ligament tear is repaired, the talus is likely to become displaced laterally after surgery despite the use of a cast. If only the fibular fracture is repaired, the deltoid ligament may be caught between the medial malleolus and the talus, preventing accurate reduction, or the ligament may be relaxed after healing. One-year functional outcomes after nonoperative management are equivalent to ORIF of stress positive lateral malleolar fractures. However, complications may include residual medial clear space widening and lateral malleolar delayed union or nonunion.

Many surgeons advocate fixation of the fibula without routine exploration of the medial side, unless the reduction is blocked. We have found, however, that some fibers of the deltoid ligament can become trapped between the medial malleolus and the talus, even with a seemingly acceptable reduction, and this may lead to late displacement. Medial exploration requires little further surgical dissection; it allows the surgeon to ensure that the deltoid ligament has been cleared from the mortise, and it provides access for repair of the deltoid ligament if desired. We do not routinely repair the deltoid ligament and explore the medial side only in select cases, most often in injuries with a wide medial clear space and delayed presentation, because medial joint access may be required to restore a congruent tibiotalar joint.

Fractures of the lateral malleolus can be stabilized by several different methods, the most common being the use of a one third tubular plate and 3.5-mm cortical or locking screws. Long oblique fractures can be stabilized with lag screws alone. Fractures below the tibial plafond (Danis-Weber type A fracture) can be stabilized by a malleolar lag screw or with Kirschner wires and tension band fixation. We also have used oblique Kirschner wires placed from the distal fibular fragment into the tibia. Intramedullary devices can be used to stabilize transverse lateral malleolar fractures, but these rods do not prevent rotation. Interlocking intramedullary rods have been developed for the fixation of fibular fractures.

Irreducible Fracture or Fracture-Dislocation

Anatomic reduction of fractures around the ankle is essential for acceptable functional results. One lesion that appears innocent but is nevertheless crippling if left untreated is the widened ankle mortise. Specifically, a widened ankle mortise is lateral displacement of the talus and the fibula that leaves an interval between the talus and the intact medial malleolus. In this lesion, the deltoid ligament has been avulsed or torn and either the distal fibula has been fractured or the distal tibiofibular ligaments have been torn.

It may be impossible to reduce the gap by closed methods. The end of an avulsed deltoid ligament may be caught between the medial malleolus and the talus ( Fig. 54.8 ). Less often, a deltoid ligament tear or an avulsion fracture of the tip of the medial malleolus may release the posterior tibial tendon and sometimes the tibial nerve and posterior tibial vessels and allow them to become trapped between the medial malleolus and the talus ( Fig. 54.9 ). These obstructions must be removed surgically, and then the deltoid ligament tear or avulsion and any fracture of the lateral malleolus can be repaired (see Technique 54.1).

Occasionally, the posterior tibial tendon is interposed between the torn parts of the deltoid ligament and impairs healing ( Fig. 54.10 ). In more severe fracture-dislocations, the posterior tibial tendon may be displaced far laterally between the distal tibia and fibula.

A lesion described by Bosworth ( Fig. 54.11 ) may be the cause of failure to reduce a posterior fracture-dislocation of the ankle. The distal end of the proximal fragment of the fibula may be displaced posterior to the tibia and locked by the tibia’s posterolateral ridge; the bone cannot be released by manipulation because of the pull of the intact interosseous membrane. The fibula is exposed, and a periosteal elevator is used to release the bone; considerable force may be necessary. The fibular fracture is fixed as described in Technique 54.1.

Trimalleolar Fracture

Trimalleolar fractures require open reduction more often than any other type of ankle fracture. The results of treatment of trimalleolar fractures usually are not as good as the results obtained for bimalleolar fractures. Trimalleolar fractures usually are caused by an abduction or external rotation injury. In addition to fractures of the medial malleolus and fibula, the posterior lip of the articular surface of the tibia is fractured and displaced, allowing posterior and lateral displacement and external rotation with supination of the foot. The medial malleolus may remain intact, with a tear of the deltoid ligament occurring instead of a malleolar fracture.

The same principles and indications for open reduction as previously outlined for bimalleolar fractures apply to trimalleolar fractures. Indications for open reduction of the posterior malleolus or posterior tibial fragment depend on its size, displacement, and, most important, its perceived contribution to stability of the injured ankle. A 50-degree external rotation view can be used for the most accurate assessment of the size and displacement of the posterior malleolar fragment. Historically, if the fragment of the posterior malleolus involves more than 25% to 30% of the weight-bearing surface, it should be anatomically reduced and held with internal fixation. Often, satisfactory reduction of the posterior tibial fragment, if small, occurs with anatomic and rigid fixation of the fibula because this fragment most often is posterolateral and attached to the fibula by the posterior tibiofibular ligament. Gardner et al. showed in a cadaver model that fixation of the posterior malleolus imparts syndesmotic stability to a greater extent than syndesmotic screws. If the posterior tibial fragment is small, a proximally displaced position may be of little consequence, but even the slightest posterior subluxation of the talus on the articular surface of the tibia is unacceptable. If there is a persistent step-off or gap of more than 2 to 3 mm or persistent posterior instability, open reduction is warranted. The posterior and proximal displacement of the tibial fragment creates an offset at the fracture. With the foot displaced posteriorly, this irregularity in the articular surface of the tibia is brought against the weight-bearing surface of the talus, and with motion and weight bearing severe traumatic arthritis develops. We routinely treat the posterior malleolus as part of the ankle injury complex because of its contribution to ankle stability. Very small fractures can be treated nonoperatively if ankle stability is proven, and frequently reduce well with anatomic fibular reconstruction. Our preference for larger displaced fragments is ORIF, and the decision for fixation should be made in the context of the extent of articular involvement and the expected contribution to restoring ankle stability.

Posterior Tibial Lip Fracture

Fractures of the posterior lip of the tibia usually are associated with fractures of the medial and lateral malleoli, and the approach to the posterior malleolus may depend on what additional open reductions are required. Most often, an anteromedial incision is made to fix a fractured medial malleolus, and a posterolateral incision is used to fix the posterior lip of the tibia and the lateral malleolar fracture. If the posterior fragment is located more medially, a posteromedial approach can be used to treat the medial and posterior malleolar fractures. Alternatively, a separate posteromedial or posterolateral incision can be made adjacent to the Achilles tendon to allow indirect or direct reduction.

Preoperative CT scans are mandatory for evaluation of fracture morphology, including size, location, and any associated marginal impaction of the posterior malleolar fragment. The posterior lip fracture often reduces after reduction of the fibula. If this does not occur and internal fixation is necessary because of the size of the fragment or the presence of posterior instability, the posterior lip fracture should be reduced and internally fixed before reduction of either the medial or the lateral malleolus. The objective is to restore anatomically the articular surface of the distal tibia. Reduction and fixation of either malleolus reduce the distractibility of the tibial and talar joint surfaces, making exposure more difficult. Distraction of the tibiotalar joint can be increased by inserting a large Steinmann pin transversely through the calcaneus, to which a traction bow is applied. An assistant can distract the tibiotalar joint significantly using this technique if neither malleolus has been reattached. Alternatively, a large distractor may be of benefit. If the posterior malleolar fragment is small, a screw directed from posterior to anterior or a fully threaded screw placed by lag technique should be used because a partially threaded screw placed from anterior to posterior may leave screw threads crossing the fracture site. Preoperative planning, including CT scans, facilitates understanding of the orientation of the posterior malleolar segment and therefore aids in selection of an appropriate surgical approach and fixation. The frequent posterolateral position of this fragment often permits fixation through a posterolateral approach.

Fracture of the Anterior Tibial Margin at the Ankle Joint

These fractures can be viewed as transitional fractures between traditional ankle fractures and pilon fractures, which typically are the result of axial loading. The treatment of fractures of the anterior margin of the tibia is about the same as that for the posterior margin, although in reverse. The fractures differ in one respect, however. Because fractures of the anterior margin usually are caused by a fall from a height that results in the foot and ankle being forcefully dorsiflexed, crushing of the articular surface of the tibia is likely to be more severe in these fractures. Perfect restoration of the articular surface of the tibia may be impossible. When necessary, associated fractures of the medial and lateral malleoli are treated as described previously. Surgery should be performed within the first 24 hours or delayed until the soft tissue is in good condition. CT is instrumental in preoperative templating to be prepared for treating segments of marginal impaction.

Ankle Fractures in Patients With Diabetes

Although malleolar fractures historically have been considered to be relatively benign injuries, operative treatment in patients with complicated diabetes mellitus is associated with significant complications. Significantly increased risk of unplanned readmission, unplanned reoperation, and mortality has been demonstrated. These patients often are older and may have peripheral vascular disease or peripheral neuropathy, which complicates their care. Complications have been reported to be as high as 43% compared with 15.5% in patients without diabetes. Complications may include deep and superficial infection, loss of fixation, malunion, wound necrosis, and amputation. Although diabetic patients treated nonoperatively have shown a high frequency of loss of reduction and malunion, they can be relatively minimally symptomatic. Nonoperative treatment is recommended for malleolar fractures in older diabetic patients with low functional demands. However, if surgical treatment of the ankle fracture is indicated, it should not be delayed or avoided simply because the patient is diabetic. Inadequate immobilization may lead to rapidly developing neuropathy. If the ankle fracture is nondisplaced or minimally displaced and has a stable configuration, closed management with prolonged casting is an acceptable alternative, but only with close supervision. If the fracture is displaced, and either considerable manipulation is necessary to reduce it or molding is required to maintain the reduction, an open approach with internal fixation is recommended. Regardless of the method of treatment, prolonged immobilization often is necessary to prevent the development of neuropathic complications.

In contrast, a study by Guo et al. compared patients with preoperatively neglected type 2 diabetes and a nondiabetic matched cohort and found no significant increase in postoperative infection after immediate operative stabilization of closed ankle fractures. Jones et al. demonstrated that operatively treated ankle fractures in diabetic patients without comorbidities had comparable complication rates to nondiabetic patients. The presence of diabetic comorbidities and, in particular, a history of Charcot arthropathy increased the likelihood of complications. In one large series, Costigan et al. reported 84 patients who underwent ORIF for acute closed ankle fractures. Open fractures, insulin dependence, patient age, and fracture type affected outcome, and 83% of patients with absent pedal pulses and 92% of patients with preoperative neuropathy developed complications. Others have shown that operatively treated ankle fractures in diabetic patients are associated with higher rates of mortality and length of hospital stay, as well as total hospital charges. Ayoub reported the results of tibiotalar arthrodesis in 17 diabetic patients with unstable bimalleolar ankle fractures complicated by Charcot arthropathy. Results were better with surgery within 3 to 6 months of onset, with absence of dense peripheral neuropathy, and in patients with satisfactory extremity oxygenation. Amputation was required in 17.6% of patients.

We typically use standard fixation techniques in patients with controlled diabetes and unstable ankle fractures. However, in certain patients who are deemed at increased risk for fixation failure, the fixation strategy may be modified in the interest of obtaining rigid fixation. These include bicortical medial malleolar fixation, placement of multiple transfibular or transtibial syndesmotic position screws, adjuvant external fixation, and application of locking plate technology ( Fig. 54.13 ).

Open Ankle Fractures

Open ankle fractures caused by indirect injury are two to four times more likely to be open medially than laterally. Several studies have shown the advantages of primary internal fixation of open ankle fractures, including Gustilo type III wounds, compared with either closed immobilization with delayed fixation or immediate provisional fixation with Kirschner wires. We also prefer immediate internal fixation after surgical debridement. If the wound is severely contaminated, a temporary external fixator can be placed spanning the ankle and open reduction can be done when the wound is judged to be clean and swelling has decreased. Ngcelwane noted dirt and grass at the syndesmosis in some medial wounds, possibly sucked in by the vacuum created by dislocation of the ankle; he recommended a lateral incision for cross irrigation, especially for displaced Danis-Weber types B and C fractures with gas shadows. In addition to internal fixation, a temporary external fixator that spans the ankle joint can be used to make wound care easier. The fixator can be removed when soft-tissue healing is complete.

Although most patients (80%) can be expected to return to work after the fracture has healed, only approximately 18% return to their preinjury recreational level. The rate of deep infection in open ankle fractures is approximately 5%. We have found that open ankle fractures, especially fracture-dislocations, in diabetic patients, especially patients with neuropathy, are problematic and frequently become infected or have implant failure, sometimes resulting in amputation. Supplemental external fixation is advisable in these patients.

Unstable Ankle Fracture-Dislocation

Childress described a method that may be useful for unstable fracture-dislocations in the ankle when the usual treatment is inadvisable. This situation most often arises when an abrasion or superficial infection is present where an incision usually would be made for open reduction. Childress recommended this technique only as a last resort but found it useful several times. The ankle is stabilized by a pin inserted through the calcaneus into the medullary canal of the tibia. Our preferred method of stabilization is application of a uniplanar external fixator with inclusion of the forefoot if warranted to prevent forefoot equinus posturing should a frame become necessary for definitive management. Use of a percutaneous tibiotalocalcaneal pin has been reserved for very rare instances in which existing implants preclude external fixation placement and stability is necessary for soft-tissue protection. We have modified the procedure so that the pin is directed to exit the anterior distal tibial metaphysis to facilitate later extraction should the implant fail. This pin can be directed from the calcaneal tuberosity, posterior to the talus, to enter the distal tibia, therefore remaining extra articular. We have used this technique to supplement more standard fixation when the patient is at risk for equinus contracture of the ankle or for stabilization of an injury before debridements.

Tibial Pilon Fracture

Tibial pilon fractures encompass a spectrum of skeletal injury ranging from fractures caused by low-energy rotational forces to those precipitated by high-energy axial compression forces usually resulting from motor vehicle accidents or falls from a height. Rotational variants typically have a more favorable prognosis, whereas high-energy fractures frequently are associated with open wounds or severe, closed, soft-tissue trauma. The fracture may have significant metaphyseal or articular comminution or diaphyseal extension. Classification of these fractures is important in determining their prognosis and choosing the optimal treatment. The fibula is fractured in 85% of these patients, and the degree of talar injury varies.

Rotational fracture of the ankle can be viewed as a continuum, progressing from single malleolar fractures to bimalleolar fractures to fractures involving the distal tibial articular surface. Lauge-Hansen described a pronation-dorsiflexion injury that produces an oblique medial malleolar fracture, a large anterior lip fracture, a supraarticular fibular fracture, and a posterior tibial fracture. Giachino and Hammond described a fracture caused by a combination of external rotation, dorsiflexion, and abduction that consisted of an oblique fracture of the medial malleolus and an anterolateral tibial plafond fracture. These fractures generally have little comminution, no significant metaphyseal involvement, and minimal soft-tissue injury. They can be treated similarly to other ankle fractures with internal fixation of the fibula and lag screw fixation of the distal tibial articular surface through limited surgical approaches.

Classification systems have been devised to describe more accurately the wide range of distal tibial articular fractures. The AO/OTA classification system provides a comprehensive description of distal tibial fractures. Type A fractures are extraarticular distal tibial fractures, which are subdivided into groups A1, A2, and A3, based on the amount of metaphyseal comminution. Type B fractures are partial articular fractures in which a portion of the articular surface remains in continuity with the shaft; these are subdivided into groups B1, B2, and B3, based on the amount of articular impaction and comminution. Type C fractures are complete metaphyseal fractures with articular involvement; these are subdivided into groups C1, C2, and C3, based on the extent of metaphyseal and articular comminution ( Fig. 54.14 ).

Another commonly used system is that proposed by Rüedi and Allgöwer, which divides plafond fractures into three categories. Type I fractures are nondisplaced cleavage fractures that involve the joint surface; type II fractures have cleavage-type fracture lines with displacement of the articular surface but minimal comminution; type III fractures are associated with metaphyseal and articular comminution.

Studies have shown these classification systems to have only moderate interobserver reliability; nevertheless, they have proved to have some prognostic value. Treatment of fractures with little displacement or comminution (Rüedi and Allgöwer type I and type II spiral fractures) has yielded much better functional results with far fewer complications than treatment of the more severe fracture patterns (Rüedi and Allgöwer type III, AO types B3 and C3).

Intraarticular fractures of the distal tibia have been treated by a variety of methods, including plaster immobilization, traction, lag screw fixation, ORIF with plates, and external fixation with or without limited internal fixation. A variety of external fixators have been used: traditional half-pin fixators spanning the ankle, articulated half-pin fixators that allow ankle motion, half-pin fixators that do not span the ankle, and hybrid fixators that combine tensioned wires with half-pins in the tibial diaphysis and do not span the ankle joint. Hybrid frames may be composed of rings proximally and distally (Ilizarov, Monticell-Spinelli).

As a result of disappointing results after acute definitive management, staged protocols have been advocated consisting of temporary external fixation spanning the ankle joint, followed by ORIF with plates and screws after the condition of the soft tissues has improved, usually 2 to 3 weeks after injury. Percutaneous or minimally invasive plating techniques have been developed. Primary arthrodesis has been performed in selected severe fractures with extensive articular comminution and talar injury. In these patients, functional results are likely to be poor with attempts at anatomic restoration, which may not be feasible. There is some overlap in the indications for these differing methods of treatment. The surgeon’s preference and experience should play a role in preoperative decision making.

Several variables must be considered when devising a treatment strategy. One must understand the mechanism of injury because this can reflect on the amount of associated soft-tissue damage. The fracture type should be determined according to the amount and location of displacement, comminution, impaction, and diaphyseal involvement. Fracture extension into the tibial diaphysis and ipsilateral fractures of the foot or tibia may influence the choice of treatment. Some authors have advocated early limited fixation of the fracture extensions into the diaphyseal region for certain fractures to facilitate later staged reconstruction. Radiographs of the contralateral ankle may be beneficial as a template for articular reconstruction.

In addition to plain radiographs, CT scans are extremely useful for determining accurately the direction of fracture lines, the size and displacement of articular fragments, and the extent of articular comminution and impaction. CT scans also are useful in planning surgical incisions and trajectory for screw or fine wire fixation. Traction can be applied using a calcaneal traction pin and Bohler frame or a uniplanar spanning external fixator. Radiographs in traction show the extent to which the articular surface can be reduced by ligamentotaxis. As a result, typically the CT scan should be obtained after the application of an external fixator. Unless a form of external fixation may be considered as definitive treatment, an acutely chosen preoperative CT scan can assist in planning placement of limited internal fixation. Any impacted segments need to be reduced by open or limited open methods. Anatomic reduction may be impossible in some severely comminuted fractures.

The severity of soft-tissue injury should be clearly defined. Open injuries can be classified according to the Gustilo system. Although less obvious than open wounds, closed soft-tissue injuries can be quite severe and can adversely affect the functional outcome, especially if unrecognized.

The extremity should be examined carefully for signs of vascular injury, swelling, fracture blisters, soft-tissue crushing, closed degloving, and compartment syndrome. Blood-filled fracture blisters indicate more extensive cutaneous damage than blisters filled with clear fluid. The Tscherne classification system can be used to describe closed soft-tissue injury. Patient characteristics, such as smoking, alcoholism, peripheral vascular disease, and diabetes, should also be considered.

The ultimate goals of tibial pilon fracture management are restoring an anatomic articular surface, restoring mechanical alignment, maintaining joint stability, achieving fracture union, and regaining functional and pain-free weight bearing and motion, while avoiding complications. Ideal results are not attainable in some patients because of the severity of articular comminution and soft-tissue injury or comorbidities. Poor prognostic indicators are articular comminution (AO C3 and Rüedi-Allgöwer type III fracture), talar injury, severe soft-tissue injury, poor reduction of the articular surface, unstable fixation, and postoperative wound infection.

Many investigators have reported poorer results in the more severe fracture patterns. Anatomic reduction has a better prognosis than a fair or poor reduction but does not guarantee a good result. Some degree of arthrosis has been shown to develop in anatomic reductions; however, in fair or poor reductions (>2 mm of displacement), more severe arthrosis can be expected. In a series of 37 AO type B3 and C3 fractures treated with external fixation and delayed internal fixation of the articular surface, Dickson, Montgomery, and Field identified a subset of patients with “ground-glass” comminution, which was defined as more than three pieces of articular surface less than 2 mm in size seen on CT scan. Posttraumatic arthritis developed in 10 (38%) of the 26 ankles with ground-glass comminution and in none of the ankles without it. Overall, 17% of anatomically reduced fractures (5 of 29) developed arthritis, whereas five of seven nonanatomically reduced fractures developed arthritis.

In recent years, there has been a greater emphasis on functional outcome. Although there is no disagreement that anatomic reduction is desirable, the impact of anatomic reduction on overall outcome is less clear. An analysis of the effect of severity of injury and fracture reduction on clinical outcome found no correlation with clinical ankle score. In addition, no correlation has been found between radiographic arthrosis and clinical results. Williams et al. found that although radiographic arthrosis was related to injury severity and quality of reduction, there was no significant relationship between these variables and the 36-Item Short Form Health Survey (SF-36) score, clinical ankle score, or return to work. Functional outcome was more closely related to socioeconomic factors. Patients with a higher level of education were more likely to return to work and had higher ankle scores. The predictors of clinical outcome seem to be multifactorial and are not fully understood.

Other studies have found pilon fractures to have a negative long-term effect on general health as measured by the SF-36. Stiffness, swelling, persistent pain, and the use of an ambulatory aid were some of the reasons. Forty-three percent of previously employed patients were no longer employed, and of this subgroup, 68% attributed their inability to work to the pilon fracture. Poorer results were correlated with having two or more comorbidities and treatment with external fixation. Fractures treated with external fixation had more impairment of range of motion and worse pain scores than fractures treated with ORIF. External fixation tended to be used in more severe injuries (AO type C).

Factors to consider in the formulation of a treatment plan include the fracture pattern, soft-tissue injury, patient comorbidities, fixation resources, and surgical experience. The degree of articular comminution, talar damage, and soft-tissue injury is dictated by the injury; however, the surgeon does have some influence over other prognostic factors. The goal should be to obtain the best possible articular reduction and axial alignment while respecting the soft tissues. If the articular surface does not reduce by ligamentotaxis, some form of open reduction usually is indicated after the soft tissues have recovered. Fracture union can be enhanced by bone grafting areas of impaction, bone loss, or extensive metaphyseal comminution. The frequency of wound healing problems and infection can be decreased by recognizing open and closed soft-tissue injury and not operating through compromised soft tissue. In some cases, the surgeon must achieve a balance between the goals of anatomic reduction and prevention of wound complications. Anatomic reduction often is more difficult to achieve after a delay of 2 to 3 weeks; however, surgical incisions through swollen, contused soft tissues can lead to disastrous results, which may require free tissue transfer or even amputation.

Nondisplaced fractures, such as AO types A1, B1, and C1, have been treated successfully with operative and nonoperative methods. These are the only fracture types in which cast immobilization alone may be suitable. If casting is chosen, the patient should be observed closely for displacement, and weight bearing should be restricted for at least 8 to 12 weeks if the joint is nonarthritic. Calcaneal traction alone often is helpful in temporarily stabilizing severe fractures associated with soft-tissue swelling, but it seldom is used for definitive treatment. External fixation accomplishes the same goal of fracture reduction through ligamentotaxis and allows the patient to be mobilized. Limited fixation with 3.5- or 4.0-mm screws, inserted after either percutaneous or limited open reduction, combined with external fixation or minimally invasive plating techniques may be adequate treatment for AO types B1, B2, and stable C1 fractures.

Two-Stage Delayed Open Reduction and Internal Fixation

The high incidence of wound complications after ORIF of pilon fractures reported in the 1980s and in the early to mid-1990s is attributable to operating through a poor soft-tissue envelope. In an effort to improve overall results, protocols for staged ORIF were developed, and these have decreased the frequency of wound complications and infections associated with plating of pilon fractures. Initially, the fibula is plated and an external fixator is placed, spanning the ankle. Preoperatively, the proposed incision for tibial reduction is planned and the fibular incision is placed so that the skin bridge between the two incisions is at least 7 cm, although smaller soft-tissue bridges have been shown to be tolerable. If the soft tissue overlying the fibula is compromised, fibular plating should be delayed. External fixation pins should be placed well away from planned incisions and out of the zone of injury and potential plate fixation.

Watson et al. described a two-pin “traveling traction” type of external fixator that is useful in this situation. An AO delta frame spanning the ankle or a medial half-pin fixator consisting of one half-pin in the talus, one half-pin in the calcaneus, and two half-pins in the tibial shaft have been recommended; however, the use of a talar pin may compromise certain surgical approaches. Tibial pilon open reduction is done after the soft tissues have improved and swelling has decreased (usually between 10 and 21 days). Skin wrinkling and healing of fracture blisters are clinical indicators of improved soft-tissue condition. Careful soft-tissue handling and low-profile plates are recommended. When the soft-tissue swelling has significantly diminished, anatomic reduction and internal fixation can be done with fewer wound complications than with early ORIF.

Several authors have recommended staged protocols for treatment of complex pilon fractures with severe soft-tissue injuries. Patterson and Cole described immediate fibular fixation and placement of a medial spanning external fixator, followed at an average 24 days later by removal of the fixator and ORIF. Of 22 type C3 pilon fractures, 21 healed within an average of 4.2 months with no infections or soft-tissue complications. These authors cited as advantages of this protocol (1) better soft-tissue management, because the first stage aims to obtain anatomic fibular realignment and restore anatomic length of the distal tibia with little disruption of the soft tissues, and (2) the ability to obtain anatomic realignment of the articular surface under direct vision in the second stage. Disadvantages include the need for a large soft-tissue dissection initially and the difficulty of reduction techniques and maneuvers in a fracture 3 weeks or more after injury. Patterson and Cole also cautioned against creating large soft-tissue dissections and bone stripping.

Blauth et al. compared three different treatment methods in 51 patients with predominantly AO type C pilon fractures. They found no significant difference among the methods in regard to soft-tissue infection. There was no statistical correlation between arthritis and soft-tissue injury or treatment group. There was a trend toward better range of motion, less pain, more frequent return to previous occupation, and increased ability to return to leisure activities in the staged treatment group; however, it was not statistically significant. Based on these results, the authors stated a preference for the staged procedure in patients with severe soft-tissue compromise that involved limited screw fixation of the articular surface through stab incisions and spanning external fixation followed by a less invasive plating technique after soft-tissue healing.

Most pilon injuries are treated in staged fashion owing to the reported decrease in associated complications. However, investigation continues to further our understanding of these difficult fractures in an effort to minimize soft-tissue complications and maximize treatment results. Graves et al. revealed that the larger soft-tissue envelope associated with obesity resulted in a trend toward increased wound complications. White et al. evaluated 95 OTA 43.C-type tibial pilon fractures, 88% of which were managed within 48 hours of injury, and found results comparable to those previously reported for other treatment modalities. The lateral approach has been advocated for treating certain fracture patterns in a staged fashion, as have combined posteromedial and posterolateral approaches. Boraiah et al. reported outcomes of open pilon fractures treated with ORIF in a staged fashion. Despite a 3% and 5% deep and superficial infection rate, respectively, functional outcome scoring for most patients was poor. Harris et al. determined that patients sustaining a type C3 fracture developed more complications, required secondary interventions, and had worse functional scoring at a mean follow-up of 98 months.

Plating Technique

Open anatomic reduction and rigid fixation with plate and screw devices can be used effectively to treat tibial pilon fractures if strict attention is paid to fracture reduction and soft-tissue management. This technique is suitable for low-energy fractures with large displaced fragments, little comminution, and no diaphyseal extension ( Fig. 54.15 ). An extremity with minimal swelling and a good soft-tissue envelope is of paramount importance if complications are to be prevented. Skin wrinkling is a good indication that edema has subsided. Soft-tissue handling must be meticulous, and strict “no-touch” techniques have been advocated. The most prudent course is temporization with placement of an external fixator until the soft tissues can be definitively treated. Formal open plating techniques should be used cautiously in open fractures and Rüedi and Allgöwer type III fractures (AO type C3) because of the high reported incidences of poor results and complications.

Minimally Invasive Plating

In an effort to decrease the wound complications associated with traditional open plating techniques, less invasive methods of plating have been developed. The fracture is primarily reduced by ligamentotaxis, and further reduction and plating are performed through limited incisions. Open medial plating has been found to disrupt the blood supply of the distal tibia to a greater extent than percutaneous plating, which might predispose to delayed union or nonunion.

Borens et al. reported their results in 17 patients treated with minimally invasive plating of selected tibial pilon fractures with a low-profile medial plate. All fractures healed. Results were rated as excellent in eight patients (47%), fair in seven patients (41%), and poor in two patients (12%). The authors concluded that this technique was effective and reduced soft-tissue complications associated with open plating of pilon fractures. They advocated the use of this technique in a staged protocol.

Minimally invasive plating techniques have been further enhanced with the widespread development of precontoured locking-plate technology, particularly those with outriggers to target proximal fixation. We do not routinely perform open reduction of the fibular component during the initial setting and prefer to maintain length through application of an external fixator alone, particularly if the fibular fracture is highly comminuted. Alternatively, a small anterolateral surgical approach can be used for articular reduction and then fixation can be done in submuscular fashion and proximal fixation percutaneously positioned. This can be done with a medially based large distractor for facilitation of reduction. The anterolateral approach is described in Chapter 1 . Care must be taken to ensure adequate soft-tissue bridging if a separate incision is necessary to treat the fibula. When the anterolateral approach is used, a separate incision occasionally is needed to place a percutaneous small medial plate if the fracture pattern demands.

Understanding the typical morphology of tibial pilon fractures is paramount to devising an appropriate reduction strategy, whether the fibula is fixed acutely or not. Mapping of tibial pilon fractures has revealed characteristic fracture fragments that can be identified in most fractures. These consist of anterolateral, medial, and posterolateral fragments, with a central component that may be significantly comminuted. As with many ankle fractures, reduction of the fibular component can improve the reduction of the posterior fragment. These fragments must be recognized whether a formal open or a limited technique is used. With open approaches, the reduction sequence (after fixation of the fibula in many cases) begins posteriorly and then progresses medially, followed by central reduction, and finally the anterolateral fragment.

Treatment