Case for small group discussion Ankle fracture Case for small group discussion AOTrauma—Foot & Ankle Module 1a: Ankle trauma—ankle fractures Stefan Rammelt, DE

Case description 45-year-old woman Slipped and fell Closed fracture Minimal soft-tissue swelling Type of fracture? Reduction/ fixation?

Internal fixation Syndesmotic stability—Hook test (Heim) Discuss: direction of pull on fibula to check for instability; both laterally and posterially.

Syndesmosis stabilization Open reduction Curved reduction clamp Tibiofibular set screw (diastasis screw)

Take-home message Not all Weber B type fractures have a stable syndesmosis — be suspicious! Syndesmosis controversies: Screw or other device? Size and type of screw? When to remove? Three or four cortices? To lag or not to lag? How high above the syndesmosis?