Journal of Foot and Ankle Surgery (Asia Pacific)

Register      Login

VOLUME 5 , ISSUE 1 ( June, 2018 ) > List of Articles


Addressing Controversies in the Management of Ankle Fractures

Amin Kheiran, Jitendra Mangwani

Keywords : Ankle fracture, Posterior malleolus, Stress views of ankle, Syndesmotic injury, Tightrope

Citation Information : Kheiran A, Mangwani J. Addressing Controversies in the Management of Ankle Fractures. J Foot Ankle Surg Asia-Pacific 2018; 5 (1):27-34.

DOI: 10.5005/jp-journals-10040-1085

License: CC BY-NC 4.0

Published Online: 01-03-2017

Copyright Statement:  Copyright © 2018; The Author(s).


Ankle fractures account for approximately 10% of all fractures and are among the most common orthopedic injuries treated surgically. The incidence of these injuries has increased significantly in the last decade, particularly in the elderly population. Regardless of the method of intervention, the primary goal is restoration of normal anatomy to achieve normal biomechanics, painless function, and prevent long-term posttraumatic degeneration. Surgical treatment carries a potential risk of complications, such as nonunion, implant failure, and soft tissuerelated complications. Despite the invention of novel devices, surgical techniques and biomechanical studies for restoration and maintenance of the congruent ankle joint following ankle fractures, several aspects of management of these injuries still remain controversial. The aim of this article is to address these controversies based on the available evidence base.

PDF Share
  1. Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury 2006 Aug;37(8):691-697.
  2. Court-Brown C, McBirnie J, Wilson G. Adult ankle fractures: an increasing problem? Acta Orthop Scand 1998 Feb;69(1): 43-47.
  3. Kannus P, Palvanen M, Niemi S, Parkkari J, Järvinen M. Increasing number and incidence of low-trauma ankle fractures in elderly people: Finnish statistics during 1970-2000 and projections for the future. Bone 2002 Sep;31(3):430-433.
  4. Weber, BG. Die verletzungen des oberen sprunggelenkes. 2nd ed. Berne: Verlag Hans Huber; 1972.
  5. Lauge-Hansen N. Fractures of the ankle. III. Genetic roentgenologic diagnosis of fractures of the ankle. Am J Roentgenol Radium Ther Nucl Med 1954 Mar;71(3):456-471.
  6. Broos PL, Bisschop AP. Operative treatment of ankle fractures in adults: correlation between types of fracture and final results. Injury 1991 Sep;22(5):403-406.
  7. Egol KA, Tejwani NC, Walsh MG, Capla EL, Koval KJ. Predictors of short-term functional outcome following ankle fracture surgery. J Bone Joint Surg Am 2006 May;88(5): 974-979.
  8. Shah NH, Sundaram RO, Velusamy A, Braithwaite IJ. Five year functional outcome analysis of ankle fracture fixation. Injury 2007 Nov;38(11):1308-1312.
  9. Schepers T, Lieshout EM, De Vries MR, Van der Elst M. Increased rates of wound complications with locking plates in distal fibular fractures. Injury 2013 Oct;42(10): 1125-1129.
  10. SooHoo NF, Krenek L, Eagan MJ, Gurbani B, Ko CY, Zingmond DS. Complication rates following open reduction and internal fixation of ankle fractures. J Bone Joint Surg Am 2009 May;91(5):1042-1049.
  11. Höiness P, Engebretsen L, Strömsöe K. The influence of perioperative soft tissue complications on the clinical outcome in surgically treated ankle fractures. Foot Ankle Int 2001 Aug;22(8):642-648.
  12. Carragee EJ, Csongradi JJ. Increased rates of complications in patients with severe ankle fractures following interinstitutional transfers. J Trauma 1993 Nov;35(5):767-771.
  13. Mehta SS, Rees K, Cutler L, Mangwani J. Understanding risks and complications in the management of ankle fractures. Indian J Orthop 2014 Sep;48(5):445-452.
  14. Rammelt S, Endres T, Grass R, Zwipp H. The role of external fixation in acute ankle trauma. Foot Ankle Clin 2004 Sep;9(3):455-474.
  15. Breederveld RS, van Straaten J, Patka P, van Mourik JC. Immediate or delayed operative treatment of fractures of the ankle. Injury 1998 Nov;19(6):436-438.
  16. Konrath G, Karges D, Watson JT, Moed BR, Cramer K. Early versus delayed treatment of severe ankle fractures: a comparison of results. J Orthop Trauma 1995 Oct;9(5):377-380.
  17. Miller AG, Margules A, Raikin SM. Risk factors for wound complications after ankle fracture surgery. J Bone Joint Surg Am 2012 Nov;94(22):2047-2052.
  18. Uebbing CM, Walsh M, Miller JB, Abraham M, Arnold C. Fracture blisters. West J Emerg Med 2011 Feb;12(1):131-133.
  19. Varela CD, Vaughan TK, Carr JB, Slemmons BK. Fracture blisters: clinical and pathological aspects. J Orthop Trauma 1993 Oct;7(5):417-427.
  20. Morel-Lavallée M. Degloving of skin and underlying tissues. Arch Gen Med 1863;1:20-38, 172-200, 300-332.
  21. Giordano CP, Koval KJ. Treatment of fracture blisters: a prospective study of 53 cases. J Orthop Trauma 1995 Apr;9(2): 171-176.
  22. Strauss EJ, Petrucelli G, Bong M, Koval KJ, Egol KA. Blisters associated with lower-extremity fracture: results of a prospective treatment protocol. J Orthop Trauma 2006 Oct;20(9):618-622.
  23. Michelson JD, Hamel AJ, Buczek FL, Sharkey NA. Kinematic behavior of the ankle following malleolar fracture repair in a high-fidelity cadaver model. J Bone Joint Surg Am 2002 Nov;84-A(11):2029-2038.
  24. Ramsey PL, Hamilton W. Changes in tibiotalar area of contact caused by lateral talar shift. J Bone Joint Surg Am 1976 Apr;58(3):356-357.
  25. Yablon I G, Heller F G, Shouse L. The key role of the lateral malleolus in displaced fractures of the ankle. J Bone Joint Surg Am 1977 Mar;59(2):169-173.
  26. Michelson JD, Magid D, Ney DR, Fishman EK. Examination of the pathologic anatomy of ankle fractures. J Trauma 1992 Jan;32(1):65-70.
  27. Harper MC. The short oblique fracture of the distal fibula without medial injury: an assessment of displacement. Foot Ankle Int 1995 Apr;16(4):181-186.
  28. DeAngelis NA, Eskander MS, French BG. Does medial tenderness predict deep deltoid ligament incompetence in supination-external rotation type ankle fractures? J Orthop Trauma 2007 Apr;21(4):244-247.
  29. Pettrone FA, Gail M, Pee D, Fitzpatrick T, Van Herpe LB. Quantitative criteria for prediction of the results after displaced fracture of the ankle. J Bone Joint Surg Am 1983 Jun;65(5): 667-677.
  30. van den Bekerom MP, Mutsaerts EL, van Dijk CN. Evaluation of the integrity of the deltoid ligament in supination external rotation ankle fractures: a systematic review of the literature. Arch Orthop Trauma Surg 2009 Feb;129(2):227-235.
  31. Koval KJ, Egol KA, Cheung Y, Goodwin DW, Spratt KF. Does a positive ankle stress test indicate the need for operative treatment after lateral malleolus fracture? A preliminary report. J Orthop Trauma 2007 Aug;21(7):449-455.
  32. Cheung Y, Perrich KD, Gui J, Koval KJ, Goodwin DW. MRI of isolated distal fibular fractures with widened medial clear space on stressed radiographs: which ligaments are interrupted? AJR Am J Roentgenol 2009 Jan;192(1):W7-W12.
  33. Weber M, Burmeister H, Flueckiger G, Krause FG. The use of weightbearing radiographs to assess the stability of supination-external rotation fractures of the ankle. Arch Orthop Trauma Surg 2010 May;130(5):693-698.
  34. Egol KA, Amirtharajah M, Tejwani NC, Capla EL, Koval KJ. Ankle stress test for predicting the need for surgical fixation of isolated fibular fractures. J Bone Joint Surg Am 2004 Nov;86-A(11):2393-2398.
  35. Hoshino CM, Nomoto EK, Norheim EP, Harris TG. Correlation of weightbearing radiographs and stability of stress positive ankle fractures. Foot Ankle Int 2012 Feb;33(2):92-98.
  36. Haraguchi N, Haruyama H, Toga H, Kato F. Pathoanatomy of posterior malleolar fractures of the ankle. J Bone Joint Surg Am 2006 May;88(5):1085-1092.
  37. Büchler L, Tannast M, Bonel HM, Weber M. Reliability of radiologic assessment of the fracture anatomy at the posterior tibial plafond in malleolar fractures. J Orthop Trauma 2009 Mar;23(3):208-212.
  38. De Vries JS, Wijgman AJ, Sierevelt IN, Schaap GR. Long term results of ankle fractures with a posterior malleolar fragment. J Foot Ankle Surg 2005 May-Jun;44(3):211-217.
  39. Gardner MJ, Brodsky A, Briggs SM, Nielson JH, Lorich DG. Fixation of posterior malleolar fractures provides greater syndesmotic stability. Clin Orthop Relat Res 2006 Jun;447:165-171.
  40. Egol KA, Pahk B, Walsh M, Tejwani NC, Davidovitch RI, Koval KJ. Outcome after stable ankle fracture: effect of syndesmotic stabilization. J Orthop Trauma 2010 Jan;24(1):7-11.
  41. Tejwani NC, Pahk B, Egol KA. Effect of posterior malleolus fracture on outcome after unstable ankle fracture. J Trauma 2010 Sep;69(3):666-669.
  42. Dattani R, Patnaik S, Kantak A, Srikanth B, Selvan TP. Injuries to the tibiofibular syndesmosis. J Bone Joint Surg Br 2008 Apr;90(4):405-410.
  43. Schepers T. To retain or remove the syndesmotic screw: a review of literature. Arch Orthop Trauma Surg 2011 Jul;131(7): 879-883.
  44. Xenos JS, Hopkinson WJ, Mulligan ME, Olson EJ, Popovic NA. The tibiofibular syndesmosis: evaluation of the ligamentous structures, methods of fixation, and radiographic assessment. J Bone Joint Surg Am 1995 Jun;77(6):847-856.
  45. Marmor M, Hansen E, Han HK, Buckley J, Matityahu A. Limitations of standard fluoroscopy in detecting rotational malreduction of the syndesmosis in an ankle fracture model. Foot Ankle Int 2011 Jun;32(6):616-622.
  46. Beumer A, van Hemert WL, Niesing R, Entius CA, Ginai AZ, Mulder PG, Swierstra BA. Radiographic measurement of the distal tibiofibular syndesmosis has limited use. Clin Orthop 2004 Jun;423:227-234.
  47. Beumer A, Valstar ER, Garling EH, Niesing R, Heijboer RP, Ranstam J, Swierstra BA. Kinematics before and after reconstruction of the anterior syndesmosis of the ankle: a prospective radiostereometric and clinical study in five patients. Acta Orthop 2005 Oct;76(5):713-720.
  48. Schuberth JM, Collman DR, Rush SM, Ford LA. Deltoid ligament integrity in lateral malleolar fractures: a comparative analysis of arthroscopic and radiographic assessments. J Foot Ankle Surg 2004 Jan-Feb;43(1):20-29.
  49. Takao M, Ochi M, Naito K, Iwata A, Kawasaki K, Tobita M, Miyamoto W, Oae K. Arthroscopic diagnosis of tibiofibular syndesmosis disruption. Arthroscopy 2001 Oct;17(8):836-843.
  50. Takao M, Ochi M, Oae K, Naito K, Uchio Y. Diagnosis of a tear of the tibiofibular syndesmosis: the role of arthroscopy of the ankle. J Bone Joint Surg Br 2003 Apr;85(3):324-329.
  51. van den Bekerom MP, Hogervorst M, Bolhuis HW, van Dijk CN. Operative aspects of the syndesmotic screw: review of current concepts. Injury 2008 Apr;39(4):491-498.
  52. Candal-Couto JJ, Burrow D, Bromage S, Briggs PJ. Instability of the tibiofibular syndesmosis: have we been pulling in the wrong direction? Injury 2004 Aug;35(8):814-818.
  53. Jenkinson RJ, Sanders DW, Macleod MD, Domonkos A, Lydestadt J. Intraoperative diagnosis of syndesmosis injuries in external rotation ankle fractures. J Orthop Trauma 2005 Oct;19(9):604-609.
  54. Sinisaari IP, Lüthje PM, Mikkonen RH. Ruptured tibio-fibular syndesmosis: comparison study of metallic to bioabsorbable fixation. Foot Ankle Int 2002 Aug;23(8):744-748.
  55. Thordarson IP, Samuelson M, Shepherd LE, Merkle PF, Lee J. Bioabsorbable versus stainless steel screw fixation of the syndesmosis in pronation-lateral rotation ankle fractures: a prospective randomized trial. Foot Ankle Int 2001 Apr;22(4):335-338.
  56. Kaukonen JP, Lamberg T, Korkala O, Pajarinen J. Fixation of syndesmotic ruptures in 38 patients with a malleolar fracture: a randomized study comparing a metallic and a bioabsorbable screw. J Orthop Trauma 2005 Jul;19(6):392-395.
  57. Thornes B, Walsh A, Hislop M, Murray P, O'Brien M. Sutureendobutton fixation of ankle tibio-fibular diastasis: a cadaver study. Foot Ankle Int 2003 Feb;24(2):142-146.
  58. Schepers T. Acute distal tibiofibular syndesmosis injury: a systematic review of suture-button versus syndesmotic screw repair. Int Orthop 2012 Jun;36(6):1199-1206.
  59. Laflamme M, Belzile EL, Bédard L, van den Bekerom MP, Glazebrook M, Pelet S. A prospective randomized multicenter trial comparing clinical outcomes of patients treated surgically with a static or dynamic implant for acute ankle syndesmosis rupture. J Orthop Trauma 2015 May;29(5):216-223.
  60. Beumer A, Valstar ER, Garling EH, Niesing R, Ranstam J, Löfvenberg R, Swierstra BA. Kinematics of the distal tibiofibular syndesmosis: radiosterometry in 11 normal ankles. Acta Orthop Scand 2003 Jun;74(3):337-343.
  61. Needleman RL, Skrade DA, Stiehl JB. Effect of the syndesmotic screw on ankle motion. Foot Ankle 1989 Aug;10(1): 17-24.
  62. Heim D, Heim U, Regazzoni P. Malleolar fractures with ankle joint instability: experience with the positioning screw. Unfallchirurgie 1993 Oct;19(5):307-312.
  63. Stuart K, Panchbhavi VK. The fate of syndesmotic screws. Foot Ankle Int 2011 May;32(5):S519-S525.
  64. Lin CW, Donkers NA, Refshauge KM, Beckenkamp PR, Khera K, Moseley AM. Rehabilitation for ankle fractures in adults. Cochrane Database Syst Rev 2012 Nov;11:CD005595.
  65. Lehtonen H, Järvinen TL, Honkonen S, Nyman M, Vihtonen K, Järvinen M. Use of a cast compared with a functional ankle brace after operative treatment of an ankle fracture. A prospective, randomized study. J Bone Joint Surg Am 2003 Feb;85-A(2):205-211.
  66. Schock HJ, Pinzur M, Manion L, Stover M. The use of gravity or manual-stress radiographs in the assessment of supination-external rotation fractures of the ankle. J Bone Joint Surg Br 2007 Aug;89(8):1055-1059.
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.