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

2. Case presentation
45-year-old man fell from a bicycle and twisted his ankle
On examination there was pain on the medial and anterior aspect of the ankle

3. Initial evaluation Type of fracture? Is this enough information?
What clinical evaluation is needed?
Is this information sufficient?

4. Examine the whole lower leg What is the proposed treatment?

5. 1 3 2 4 4 5 What are the options for evaluating fibular reduction?
Discuss:
Open vs closed reduction of syndesmosis
3-D vs 2-D evaluation
Radigraphic signs, eg, dime sign, Menard-Shenton line (Weber circle and Weber nose) 4 4 5

6. Postoperative CT scans– criteria
Translation (AP)
Rotation
Fibular length
References:
Rammelt S, Zwipp H, Grass R. Injuries to the distal tibiofibular syndesmosis: an evidence-based approach to acute and chronic lesions. Foot Ankle Clin Dec;13(4):611–633, vii–viii.
Rammelt et al. Foot Ankle Clin. 2008;13:611–633, vii–viii

7. Discussion points One or two screws or even 2-hole plate?
Three or four cortices?
When to remove?
Alternatively, intraoperative 3-D scan if available

8. Take-home messages
Examine whole lower leg in “isolated” medial malleolar fractures, deltoid ligament ruptures, and posterior malleolar fractures
Open reduction of the syndesmosis in Maisonneuve fractures
Perform a follow-up CT scan or intraoperative 3-D image and early correction in case of malreduction