Indications

• The various existing classifications are inadequate to guide the treatment of these common injuries.

• Fractures with talar displacement.

• Almost all bimalleolar fractures.

Preoperative planning

Clinical assessment

• The mechanism of injury most commonly points to indirect rotational, translational and axial forces applied to the ankle joint.

• Soft tissue swelling, ecchymosis, tenderness.

• Look for associated osseous and/or soft tissue injuries.

• Assess the neurovascular integrity of the extremity.

• Obtain a careful patient history.

• Evaluate age, osteoporosis and systemic conditions.

• Smoking and diabetes are well known to adversely affect the operative management of ankle fractures.

Radiological assessment

• High-quality anteroposterior and lateral radiographs (Fig. 14.1.1a, b).

• Mortise view: AP in 20 degrees of internal rotation.

• CT scan: for evaluation of posterior malleolus. A CT scan is useful in abduction injuries when an injury to the talar dome is suspected.

• Assess degree of fragment displacement, quality of bone.

Timing of surgery

• In cases of an ankle subluxation, reduction is necessary in the emergency department (Fig. 14.1.1c, d).

• Dictated by the sot tissue condition.

• Before the development of sot tissue swelling or blisters.

• Delayed ORIF when sot tissue injury resolves. In these cases think about soft tissue resuscitation by means of a spanning external ixator to the ankle prior to the internal ixation.