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Download Ankle fracture fixation - Peggers Super Summaries
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Peggers’ Super Summary of Ankle Fracture fixation Indications: FRACTURE REASONS – all unstable fractures which include Talar shift Bimalleolar fractures Weber c Weber b with instability or shortening > 2mm Open fractures Syndesmosis disruption >20% of posterior malleolus or > 2mm articular step or talar subluxation PATIENT REASONS Patients unable to remain non weight bearing – there may be a subgroup in which the hindfoot nail may be of benefit Peripheral neuropathy Examination: Associated injuries o Talus o Calcaneous o 5th MT base o Lisfranc Neurovascular examination Reduction of deformity Skin assessment Imaging 1cm above ankle joint there should be > 1mm tibia-fibula overlap Medial clear space <5mm initially or on stress views Anatomy: LATERAL ANKLE Superficial branch of peroneal nerve – 6-8cm proximately from tip crosses fibula Sural nerve running posteriorly Anterior inferior tibio-fibular ligament Fibular calcaneal ligaments Peroneal tendons MEDIAL ANKLE Spahenous nerve and vein – running anteriorly to MM Tibialsis posterior tendon running directly behind MM Deltoid ligament POSTERIOR ANKLE Sural nerve – posterolaterally Achilles FHL – only muscle belly at ankle level level Medial n/v bundle MEDIAL to FHL Preoperative Planning: RADIOGRAPHICALLY AP / LAT / Mortice at 200 IR CT for posterior malleolus or Pillon SOFT TISSUES Operate before soft tissue swelling or blisters Delayed ORIF after soft tissue resolves Equipment AO small fragment set If osteoporotic low profile locking plate 3.5mm cortical and 4.0 cancellous screws II and radiolucent table Operative Room Planning INTRODUCTION Confirm Consent / Mark / WHO form / Abx at induction POSITION Supine Tourniquet Sand bag under ipsilateral hip II on contralateral side DRAPING Antiseptic solution to Knee Perforated drape Glove over toes Drape to mid lower leg Surgical Approach LATERAL Mark outline of fibular and draw midline vertical line Careful 6-8cm proximately for superficial peroneal nerve Full thickness flaps direct lateral incision and AVOID using retractors Incise anteriorly to peroneal tendons and retract them posteriorly (incising fascia off the peroneals will give access for anteglide plate posteriorly) Visualise fracture site and talar dome using periosteal elevators or curette Reduction forceps to reduce the fracture NB failure to achieve reduction must use II to see if talus fails to reduce – a medial incision may be used to remove deltoid from joint space A lag screw ideally placed posteriorly or through the neutralisation plate are options A lag screw is placed by over drilling near cortex 3.5mm placing chimney pot in hole and 2.5mm far cortex Tap Measure hole Countersink near cortex Place cortical screw Use neutralisation plate at side or as antiglide at back 3 screws must be used either side of the fracture site with distal screws going into distal fibular as cancellous screws to avoid penetration of articular surface MEDIAL Mark the outline to the MM and mark a central direct approach to the MM curving anteriorly distally Care to preserve the long saphenous nerve and vein A periosteal elevator or curette explore the fracture site and remove periosteum Displace the MM to view talar dome Wash and irrigate Reduction forceps Hold with k wire II to confirm reduction 2x 4.0mm partially threaded cancellous screws with thread in the distal metaphysis and dense old growth plate region 2x medial 4.0mm drill bits can be used to maintain reduction with simultaneous holes whilst the other is converted into a screw NB Small MM fragment a tension band technique with a proximal screw and wire can be used as an alternative Page 1 of 2 Peggers’ Super Summary of Ankle Fracture fixation POSTEROLATERAL Can address the fibular and posterior malleolus with the same incision Mark the longitudinal vertical midpoint between the lateral Achilles and the back of the fibular. Dissection is between the Achilles and the peroneal tendons CAREFUL to dissect the sural nerve Dissect deeper between FHL and the peroneal tendons FHL PROTECTS the medial n/v bundle Fracture haematoma and periosteum clear Lag screw and antiglide plate are typically used REDUCTIONS TOOLS Crab claw reduction forceps Pointed reduction forceps Syndesmosis Repair: NB accurate fixation of the fibula in the incisura is vital Stress ER views or cotton hook test are used to check the syndesmosis A clamp is used to hold the reduction during fixation The inferior screw should be at the junction of the superior margin of the tibia-fibula joint i.e. the inferior screw should be in the physeal growth plate region at the flair of the lateral tibia From the lateral approach the hands need to be dropped to 20300 as the fibular is posterior to the tibia Controversies arise from 1 or 2 screws & 3 or 4 cortices Unusual Repairs Tilleaux Chaput Anterolateral tibia from ligament avulsion use screw and washer Wagstaffe Anterior fibula – use screw and washer or suture anchor Reduced and stabilised with a 3.5 mm lag screw Neutralised with 1:3 tubular plate, 7 holed amd 3.5 mm screws Images satisfactory and saved Posterior malleolar fragment too small to be fixed Articular surface of the distal tibia well aligned Syndesmosis stable on stressing Closure in layers Ethilon to skin Local infiltration cleaned and dressed compression bandage TQ down ´+ 46 mins Back slab ´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´ Limb elevation MonitorCSM Antibiotics x 3 doses Analgesics Wound check 48 hrs Closure 5/0 nylon mattress or vicryl rapide to skin Join corners up 1st Non adherent dressing Splint the hand in intrinsic plus position to mid forearm o Wrist extended 100 o MCPs flexed 800 o IPJs fully extended For extensor tendons apply volar splint For flexors tendons apply dorsal splint to avoid over flexion or extension of repairs Operative Note WEBER B FRACTURE LEFT ANKLE ORIF ´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´´ GA, supine position TQ control Time ??? Lateral approach Fracture exposed Mobilise non weight bearing 6 weeks Review 2 weeks Evidence: >20% posterior malleolus causes worse prognosis. Mont et al. J Orthop Trauma 1992 >2mm shortening or lateral shift cause increase contact pressures. Thordarson et al. JBLS (Am) 1997 Complications: NB diabetics require double the time for non weight bearing to avoid fracture fixation failure Early n/v or tendon damage infection failure Late removal of metal work non or mal-union stiffness OA CRPS Page 2 of 2
