Supine position with bump under ipsilateral hip.Pre-operative antibiotics, +/- regional block.FHL is medial and protects posterior tibial artery/nerve. Find interval between FHL and peroneal tendons. Incision between Achilles and peroneal tendons. Posterior approach only needed for large posterior malleolar fragments-prone position.Posterior malleolar fragments >25% of the plafond may be fixed via percutaneous clamp reduction through the medical mallellar fracture or direct reduction through a posterolateral or posteromedial approach.Delayed surgery done when blisters have resolved, skin wrinkles normally (average 14 days) has equivalent outcomes (Karges/Watson, JOT 1995 9:377). Ideally surgery is done before any true swelling or fracture blisters have developed. Timing of surgery is dictated by the status of the soft tissues.ORIF Ankle Fracture Pre-op Planning / Special Considerations Soft tissue compromise - severe swelling.Lateral malleolus fracture with syndesmosis injury.Lateral malleolus fracture with tibio-talar instability.To do this, emergency physicians need to employ stress radiographs to assess the stability of the ankle joint.Synonyms: ORIF Ankle Fracture, open reduction internal fixation ankle, medial malleolus ORIF, lateral malleolus ORIF 3 For this reason, assessing deltoid ligament integrity is of critical importance in determining the stability of an ankle fracture. 5Ĭlinical signs such as medial ankle pain, swelling, and ecchymosis are not reliable in identifying a deltoid ligament injury. 4 In what appears as an otherwise isolated Weber B fibular injury, a tear of the deltoid ligament can be considered “equivalent to a medial malleolar fracture,” qualifying the fracture mechanically as unstable, thus requiring operative management. A talar shift of 1 mm results in a 42 percent decrease in tibiotalar contact area, which can lead to significant increases in contact stress. The deltoid ligament, which runs from the medial malleolus to the calcaneus, talus, and navicular bones, plays a vital role in maintaining correct talus positioning. With Weber B fractures, the stability of the ankle joint depends on injury to the tibiofibular ligaments and the deltoid ligament. Any bi- or trimalleolar fracture should be considered unstable because of the disruption of the bony architecture on both the medial and lateral side of the joint. Unstable ankle fractures are one of the primary indications for orthopedic referral. In general, most stable ankle fractures can undergo nonoperative management by a primary care physician. The primary consideration regarding need for operative management of a closed ankle fracture is stability. The focus of this article is to help emergency physicians choose the proper method for determining that stability. 3 These type B fractures are sometimes stable, and patients can ambulate on them as tolerated in other cases, they are unstable and require open reduction and internal fixation (ORIF). Weber B fractures occur at the level of the tibiofibular ligaments, just above the talar dome, and happen primarily through a mechanism of ankle supination and external rotation (SER). Weber C fractures are almost always unstable and require surgical intervention. Weber C fractures are above the ankle joint and are associated with a syndesmotic injury. Injuries to the distal fibula, below the talar dome, are classified as type A and are stable fractures. Tips for Diagnosing Occult Fractures in the Emergency DepartmentĮxplore This Issue ACEP Now: Vol 39 – No 04 – April 2020.Tips for Catching Commonly Missed Ankle Injuries.Tips for Managing Suspected Occult Fractures.
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