Chapman’s Orthopaedic Surgery
3rd Edition

Robert H. Leland
Jeffrey W. Mast
R. H. Leland: Department of Orthopaedic Surgery, Wayne State University School of Medicine, Hutzel Hospital, Detroit, Michigan 48201.
J. W. Mast: 2345 E. Prater Way, Sparks, Nevada 89434.

The superiority of internal fixation over closed treatment for displaced fractures and dislocations of the ankle has been thoroughly demonstrated in the literature (14,22,32,33,37,38,39 and 40,43,47,53,56,60). In this chapter, we devote little attention to closed methods of treatment and discuss in detail modern internal fixation techniques. See Chapter 10 for more detail on closed treatment.
The ankle joint consists of the articulation between the tibia and the talus, the talus and the fibula, and the tibia and the fibula, along with the capsule and stabilizing ligamentous structures, and distal projections from the medial side of the tibia and from the distal fibula, which form the malleoli. Together, these structures form a geometric constraint to transverse movement of the talus (13,41,48,49 and 51,57). The ankle joint is commonly referred to as a mortise-and-tenon joint because of its appearance on the frontal radiograph (Fig. 25.1). This carpentry term describes a technique in which wood is joined by the insertion of a square peg into a square hole, thus offering great rigidity and stability. This particular geometry is best suited to resist rotation of the talus within the ankle mortise.
Figure 25.1. carpenter’s mortise-and-tenon joint, showing the squared-off appearance of the ankle joint seen on the mortise view.
The articular surface of the talus is somewhat wider anteriorly than it is posteriorly and, depending on the shape of the talus, requires a small amount of spreading of the malleoli during dorsiflexion of the foot. In many ankles but not all, any loss of this spreading motion can cause a loss of dorsiflexion. This shape of the articular surface offers some restraint toward posterior subluxation of the talus, but the greater restraint is the cup-shaped distal tibia, which projects distally at its posterior margin.
The ankle owes its soft-tissue stability to the capsule and its ligamentous condensations (Fig. 25.2). The medial ligamentous complex, called the deltoid ligament, consists of a superficial and a deep portion. The superficial portion is large and fan shaped and extends from the medial malleolus to a wide attachment on the talus, calcaneus, and navicular (Fig. 25.2A). The deep portion is a transverse ligamentous connection between the deep surface of the medial malleolus and the talus. This ligament inserts into the axis of rotation of the talus and is one constraint against lateral subluxation of the talus. This portion of the ligament is very short.
Figure 25.2. A: Ligamentous anatomy at the ankle, from the medial side. The fan-shaped deltoid ligament extends distally from the medial malleolus to the calcaneus, talus, and navicular. B: Lateral ligamentous anatomy, showing the anterior and posterior talofibular ligaments and the calcaneofibular ligament, extending distally and posteriorly. C: Anterior view of the ankle, showing primarily the anterior tibiofibular ligament. D: Posterior view showing the posterior tibiofibular ligament.
The lateral ligamentous complex consists of the anterior and posterior talofibular ligaments and the calcaneofibular ligament (Fig. 25.2B). These three ligaments are

helpful in preventing the tilting of the talus within the mortise. The tibia and fibula articulate with each other distally and are held together by a system of ligaments, including the interosseous membrane and the anterior and posterior tibiofibular ligaments (Fig. 25.2C, Fig. 25.2D). These ligaments allow the elastic widening of the ankle mortise during dorsiflexion and, to a certain degree, rotation of the fibula.
The sum of bony and ligamentous stability of the ankle joint results in motion best described as a simple hinge whose axis is parallel to the floor and externally rotated between 15° and 20° from the frontal plane (Fig. 25.3). The range of movement averages 20° of dorsiflexion and 40° of plantar flexion.
Figure 25.3. The true axis of the ankle joint is externally rotated 15° from the axis of the foot. A radiograph through the axis of the foot will not give a true tangential view of the ankle joint.
Proper radiographic examination of the ankle requires anteroposterior, lateral, and mortise views. The anteroposterior view is taken with the beam centered on the ankle joint and directed in the sagittal plane (Fig. 25.4A). The lateral view is taken with the beam centered on the ankle joint and directed in the frontal plane (Fig. 25.4B). The mortise view is taken with the leg internally rotated about 15° so the x-ray beam passes perpendicular to the axis of movement (Fig. 25.4C). The anteroposterior view combined with the mortise view allows detection of avulsion fractures of the malleoli, vertical fractures of the medial malleolus, and lateral subluxation of the talus. The lateral view is most helpful in outlining the configuration of the lateral malleolar fracture and in detecting anterior and posterior tibial fractures.
Figure 25.4. A: A true anteroposterior view along the axis of the foot. B: The true mortise view with the foot internally rotated 15° clearly shows the entire joint space extending from the tip of the medial malleolus to the tip of the lateral malleolus. C:The lateral view of the ankle joint, showing the fibula line posterior to the tibia.
Diagnosis of occult instability of the distal tibiofibular syndesmosis requires careful interpretation of the radiographs, particularly for torsional injuries (Fig. 25.5).

Stress views, particularly under anesthesia, may be helpful. Marginal impaction fractures, particularly in the anterolateral plafond of the tibia, can often be seen on plain radiographs but may require tomograms or CT scans. Full delineation of the various fracture fragments, particularly those involving the articular surface in pylon fractures, often requires CT with sagittal and frontal plane reconstructions. Comparison views of the opposite side occasionally prove useful for preoperative planning. Plain radiographs taken in traction are particularly useful in pylon fractures, as the traction achieves a rough reduction, restores length, and makes the fracture configuration easier to understand (24).
Figure 25.5. A: Anteroposterior projection of an ankle joint: a, lateral border of the lateral malleolus; b, lateral border of the anterior aspect of the tibia; c, medial border of the fibula; d, lateral border of the posterior aspect of the tibia. B: Rupture of the anterior syndesmosis with external rotation of the fibula does not affect the apparent width of the syndesmosis (c–d) or the intermalleolar distance (a–e). However, the amount of overlap of the anterior portion of the tibia on the fibula, distance a–b and distance b–c, change. Distance a–b increases, and b–c decreases. In most ankles, distance b–c is over 50% of a–c on anteroposterior projections. Comparison radiographs of the normal ankle are very helpful. (Modified from Chapman MW. Fractures and Fracture-Dislocations of the Ankle (Chapter 34). In Mann RA, Coughlin MJ, eds. Surgery of the Foot and Ankle,6th edition. Philadelphia: Mosby, 1992:1448.)
A classification system is useful as it helps to determine the proper treatment or predict the outcome (18,21). Two classification systems stand out in any discussion of ankle fractures because they address these issues.
The first, devised by Lauge-Hansen, encompasses well over 95% of all ankle fractures (19,58). It divides ankle fractures into categories by mechanism of injury and secondarily into groups of increasing severity. Lauge-Hansen determined the mechanisms of injury in various fracture types by cadaveric experiment in which he created these fractures in a laboratory setting. He classified ankle fractures into four categories determined by the position of the foot at the time force is applied (pronated or supinated) and by the direction that force is applied (external rotation or straight) (Fig. 25.6). An external rotation force applied as the patient’s body twists over the planted foot causes a supination–external rotation or pronation–external rotation injury. Straight forces, such as when the supinated foot is forced into further adduction, result in the injuries described as supination–adduction. The opposite is the pronation–abduction injury. Each of these four categories is subdivided into stages indicating increasing severity of injury. The higher the stage, the greater is the severity of the injury and, thus, the poorer the prognosis.
Figure 25.6. The Lauge-Hansen classification of ankle fractures. A: The supination–eversion fracture. Stage I: The avulsion of the anterior talofibular ligament from the tibia or simple rupture of the ligament. Stage II: The classic oblique fracture of the distal fibula, beginning anteriorly at the joint line and extending obliquely and posteriorly toward the shaft of the bone. Stage III: Avulsion or rupture of the posterior tibiofibular ligament. Stage IV: Avulsion fracture of the medial malleolus. B: The supination–adduction fracture. Stage I: Avulsion of the tip of the lateral malleolus or rupture of the associated ligaments. Stage II: Vertical fracture of the medial malleolus, usually beginning at the plafond. C: The pronation–eversion fracture. Stage I: Avulsion of the medial malleolus or ruptured deltoid ligament. Stage II: Rupture or avulsion of the anterior tibiofibular ligament. Stage III: A high, short, oblique fracture of the fibula. Stage IV: A posterior lip fracture of the tibia. D: The pronation–abduction fracture. Stage I: Avulsion of the medial malleolus or ruptured deltoid ligament. Stage II: Rupture or avulsion of the syndesmotic ligaments. Stage III: A short, oblique fracture of the distal fibula at about the level of the ankle joint.
A second and equally popular classification scheme is that devised by Weber of the AO group (35). This classification scheme includes three major fracture types, depending primarily on the level of the fibular fracture.
In the Weber type A fracture, the fibula is avulsed distal to the syndesmotic ligaments, and the medial malleolus is fractured vertically (Fig. 25.7A). This fracture type, which roughly corresponds to Lauge-Hansen’s supination–adduction type, is usually unstable, requiring internal fixation. There is often a small compression of the articular surface of the tibia, which should be elevated for complete reduction of the medial malleolus.
Figure 25.7. The Weber classification of ankle fractures. A: Fracture of the fibula below the level of the tibial plafond and vertical fracture of the medial malleolus. B: Avulsion fracture of the medial malleolus and fracture of the fibula, beginning at the level of the tibial plafond. The posterior rim may also be fractured, as shown. C: An avulsion fracture of the medial malleolus or ruptured deltoid ligament with a short oblique fracture of the fibula, well above the level of the tibial plafond. Also, a posterior rim fracture of the tibia may be seen.


The Weber type B (Fig. 25.7B) includes an oblique fracture of the fibula, beginning at the level of the tibial plafond and extending proximally and posteriorly through the fibular shaft. The posterior lip of the tibia is usually fractured; the fragment may be large or small. Also included is an avulsion of the medial malleolus or rupture of the deltoid ligament. This category corresponds to the supination–external rotation type of Lauge-Hansen. When undisplaced, according to criteria to be detailed below, these can be treated by immobilization alone.
The Weber type C (Fig. 25.7C) is characterized by a fibular fracture that is entirely above the level of the tibial plafond. A large or small posterior lip fracture often accompanies this injury, as does a medial malleolar avulsion or deltoid ligament rupture. This category corresponds to Lauge-Hansen’s pronation–external rotation type. The syndesmosis is always ruptured; the need for repair of this part of the injury is detailed later.
Both the Lauge-Hansen and the Weber classifications are well known and widely used. The Lauge-Hansen classification is of greater value in comparing the results of treatment because it accurately describes the severity of the injury. The Weber classification is more useful in deciding on the appropriate form of treatment.

A pylon fracture is one involving not only the articular surface but also the metaphysis. On occasion, it extends into the distal diaphysis as well. Most pylon fractures in urban trauma centers result from higher-energy vertical compressive forces during a fall from a height or a motor vehicle accident. Lower-energy injuries, often incorporating a torsional component, may result from activities such as snow or water skiing. The extent to which pure compressive loads are responsible for the injury is related to the final outcome. High-energy injuries not only produce greater comminution and compression of the fracture fragments but also produce greater soft-tissue damage, worsening the eventual outcome (54). (Note: The term pylon is from the French word “pilon” meaning to ram or hammer, referring to the mechanism of injury of this complex fracture.)
Foot position during impact in compressive-type injuries heavily influences the fracture pattern of the articular surface (7). Foot dorsiflexion during impact produces anterior articular impaction and comminution, whereas a plantarflexed foot is associated with posterior articular damage. Loading a supinated or pronated foot produces a characteristic pattern of articular damage, referred to in the European literature as medial or lateral gap patterns, respectively.
The most commonly used pylon classification is by Ruedi and Allgöwer (42) (Fig. 25.8). Type A fractures describe an intraarticular cleavage-type fracture without joint displacement. Type B fractures demonstrate intraarticular displacement with limited comminution. Type C fractures have intraarticular displacement with marked comminution. The classification has been further subdivided using the AO classification scheme (Fig. 25.9).
Figure 25.8. Reudi and Allgöwer classification of pylon fractures.
Figure 25.9. AO classification of pylon fractures.
The obvious goal of treatment is to restore function to the level before the insult. Restoring the original anatomy is the single best means to restore normal function. For this reason, closed treatment of ankle fractures is not recommended except when the initial displacement is within acceptable limits. Closed reduction of displaced ankle fractures is fraught with difficulty; it usually does not exactly restore the anatomy, it is often a tedious exercise, and it may require repeated reduction attempts to maintain the alignment within acceptable limits (9,16,27,45,59). Open treatment, on the other hand, offers the best possibility of restoring the anatomy to its original condition without forced manipulations or prolonged immobilization.
Close adherence to the principles advocated by the AO group offers the best chance of restoring the anatomy and maintaining that restoration throughout healing (30). One of the basic principles is the compression of fracture surfaces, one against the other, which causes friction and eliminates motion between the fractured parts (20). This compression usually is obtained with lag screws or sometimes with compression plates. One thing worse than inadequate closed reduction of ankle fractures is a poorly performed internal fixation. These techniques are exacting, and the surgeon must be attentive to detail to obtain a good result.
Internal fixation is indicated for all fractures of the articular surface of the ankle with displacement greater than 2 mm lateral or posterior at the lateral or medial malleolus (18). In the absence of a medial malleolar fracture, widening of the medial clear space greater than 2 mm must be considered an unacceptable displacement. Some surgeons would not accept widening of more than 1 mm in young active individuals.
Low-velocity injuries typically result in simple minimally comminuted fracture patterns with mild to moderate soft-tissue injury. Lower-energy ankle fractures commonly occur in an elderly population with osteopenic bone, so fixation may be compromised. Although judicious soft-tissue handling and appropriate surgical timing are still necessary to avoid wound breakdown and infection, surgery usually can proceed immediately after presentation to the emergency room and preparation of the patient for surgery (6).
High-energy ankle fractures resulting from motor vehicle collisions and falls from significant heights pose problems in the management of the bony and soft-tissue injuries. Early closed reduction of these fractures is important to minimize further soft-tissue compromise and to decrease the risk of fracture blister formation. Soft-tissue swelling, as well as abrasions and blisters, may make early open reduction and fixation hazardous. Sometimes temporary external fixation may be advisable, but usually incorporation in well-padded long-leg splints or a cast with elevation of the limb suffices until the soft tissues recover sufficiently to permit fixation.
For open fractures, administer appropriate intravenous antibiotics to the patient as soon as possible. Open ankle and pylon fractures require immediate and thorough irrigation and debridement of nonviable tissue (10) (see Chapter 12). Whereas grade 1 injuries may be primarily closed following a thorough debridement, grade 2 and grade 3 injuries usually require repeated irrigation and

debridement to minimize the risk of infection. Open injuries do not necessarily dictate the type of fixation that should be used to stabilize a fracture because both internal and external fixation principles can be applied, assuming thorough debridement and early soft-tissue coverage are performed. In severe open grade 3 pylon fractures, generally the soft tissues will not tolerate extensive internal fixation of the comminuted metaphyseal portion of the fracture. Most authorities treat these with limited fixation of the articular surface and hybrid or other external fixation (3,29). In some cases, conversion to biological internal fixation, once the soft tissues have recovered, is appropriate (3,48).
Perform a history and physical examination, including a thorough neurovascular examination and evaluation for compartment syndrome. If the patient has a history of vascular insufficiency or clinical findings suggestive of distal arterial compromise, perform noninvasive arterial Doppler studies preoperatively and consider vascular consultation to insure that the wound will have the capability of healing.
Gently palpate along the osseous and ligamentous structures, including the proximal fibula, lateral and medial malleoli, syndesmosis, and lateral and medial ligaments, to fully delineate all aspects of the injury. Carefully palpate the hindfoot, midfoot, and forefoot to rule out associated injuries.
Minimally displaced (less than 1 to 2 mm) stable fracture patterns without disruption of the ankle mortise do not require operative treatment (59). The most common fractures treated closed are Weber A and B fractures without medial injury. All other displaced fractures about the ankle are optimally treated with anatomic reduction, stable internal fixation, and early range-of-motion exercise (15,26,60). Failure to restore the anatomic relationships and articular congruity of the ankle joint increases the risk of pain and loss of motion. Noncongruent ankles can quickly progress to severe degenerative arthritis.
Contraindications to operative treatment include medical conditions precluding safe operative intervention and vascular insufficiency or other skin conditions preventing safe wound healing. Patients with diabetes mellitus, particularly if they have peripheral neuropathy, have a much higher-than-average occurrence of infection and other serious complications.
Severe displacement in an ankle injury, particularly dislocation, can lead to skin necrosis as a result of tension over bony prominences as well as increased swelling and neurovascular compromise. For that reason, markedly displaced ankles should have a provisional reduction performed before radiography unless it will be performed immediately.
After radiographic evaluation, place the provisionally reduced ankle injury in a well-padded cast that has been univalved or in gutter splints, which will hold the provisional reduction. A long-leg cast or splint is required for most ankle fractures. Those that are rotationally stable can be immobilized in a short-leg device. Elevate the limb 10 cm above the heart. Perform surgery as soon as practical. Delay of surgery more than 24 hours may lead to excessive swelling and fracture blisters, which may preclude surgery for a week or more, and that delay could compromise the ability to achieve an anatomic reduction.
If a full range of one-third tubular plates or their equivalent as well as screws are available in the operating room, then templating of routine ankle fractures is rarely necessary. Complex or very long lateral malleolus fractures may require templating to ensure that appropriate implants are available for fixation. Pylon fractures require detailed radiographic assessment of the articular surface of the tibial plafond and the fracture. For complex fractures, draw out the fracture lines on a line drawing traced from plain radiographs of the opposite normal side and use templates to sketch in the implants you plan to use. If staged open treatment following fixation of the fibula and external fixation is planned, radiographs following fibular reduction and provisional tibial–calcaneal fixation are useful in planning the definitive internal fixation.
Extraarticular fractures of the distal tibia and fibula with stable patterns and all nondisplaced fractures of the ankle are suitable for nonoperative treatment. Usually a well-molded short-leg cast suffices, and immediate weight bearing is possible. Univalve all circumferential casts applied acutely and have patients elevate the injured limb 10 cm above their heart until swelling subsides. Fracture braces can be used for some stable lateral malleolus fractures (59).
Displaced fractures of the medial malleolus, with the exception of avulsion fractures of the nonarticular tip of the malleolus, require open reduction and internal fixation (ORIF) because they have a significant incidence of nonunion as a result of soft-tissue interposition.

Fractures of the articular portion of the lateral malleolus with displacement of 2 mm or more require operative treatment.
In patients with systemic or local contraindications to surgery, displaced fractures can be reduced, closed, and managed in well-molded long-leg casts. Precise knowledge of the mechanism of injury based on the Lauge-Hansen classification is necessary to provide appropriate three-point molding of the cast (Fig. 25.10).
Figure 25.10. Molding a cast.
  • Perform closed reduction as soon as possible.
  • Use a general or regional anesthetic.
  • Most fractures require a combination of adduction, internal rotation, and varus forces and positioning to achieve a satisfactory reduction.
  • Apply a short-leg cast with three-point molding and check the reduction on AP, lateral, and mortise radiographs. Fluoroscopy alone is not adequate. Comparisons to the opposite side may be necessary to assure reduction of the syndesmosis if it is torn.
  • If the reduction is adequate, extend the short-leg cast to a long-leg with the knee bent 10° to 15°.
  • Postreduction, prevent swelling and routinely univalve the cast.
  • Follow weekly with radiographs until you are comfortable that the fracture is stable. One or more cast changes may be necessary to maintain the reduction. The patient can usually be transitioned to a short-leg walking cast by 6 to 8 weeks.
Strict adherence to the principles outlined here is essential. Meticulous handling of the soft tissues cannot be overemphasized. The surgeon’s obligation is to minimize additional trauma to the ankle. Gentle reductions and careful technique are the best means of obtaining satisfactory results.
  • Perform ORIF in a conventional operating room under general or regional anesthesia.
  • Give appropriate antibiotics intraoperatively before the tourniquet is inflated, and continue them for 24 hours (three total doses).
  • Tourniquets are useful when bleeding interferes with visualization of the reduction. Because of the rebound edema that occurs after tourniquet use, we now prefer to use good surgical hemostasis and operate without a tourniquet, if possible. Avoid prolonged tourniquet time and under no circumstances exceed a total of 2 hours.
  • Generally, the supine position with a bump under the ipsilateral hip to facilitate lateral exposures suffices. The prone position is useful for some difficult trimalleolar fractures requiring posterior-lateral exposure of the ankle.
  • Gently prepare and drape the extremity from the toes to the upper thigh. Use adhesive, povidone-impregnated plastic drapes where incisions will be made. Expose no bare skin or toes to the operative field.
Surgical exposures of the ankle and the skin incisions are described in Chapter 3. Some additional advice is appropriate here, however. In general, skin incisions should be longitudinal, straight, and located directly over the fracture. The posterior ankle can be exposed through the medial or lateral incisions by making them longer and shifting them somewhat posteriorly. A gentle curve in their distal portion may be helpful, but avoid creating flaps.
  • The utilitarian incision for a pylon fracture is a straight anterior approach just lateral and parallel to the anterior tibial tendon. If the fracture pattern allows, rather than curve it medially distally, a straight incision carried well out onto the neck of the talus facilitates complete exposure of the anterior tibia and syndesmosis.
  • Use a separate incision for the lateral malleolus and a separate short incision directly over the tip of the medial malleolus, if necessary, to insert malleolar screws (Fig. 25.11).
    Figure 25.11. Surgical incisions around the ankle.
  • Avoid injury to subcutaneous sensory nerves.
  • Carry dissection directly down to the periosteum. Expand exposure at the level of the periosteum.
  • Minimize stripping of the periosteum. Expose only a 1- to 2-mm edge along the fracture lines.
  • Thoroughly clean the fracture surfaces of hematoma.
  • Explore the ankle as possible through the available surgical exposure and thoroughly irrigate to identify chondral injury and osteochondral fractures, and remove any loose fragments.
  • P.820

  • In bimalleolar or trimalleolar fracture, consider exposing all of the fractures before inserting any internal fixation because this permits better inspection and irrigation of the ankle as well as facilitating ORIF.
  • Obtain anatomic reductions and render them stable with one or more double sharp-pointed bone reduction forceps of appropriate size.
  • Use completely stable fixation.
  • Always obtain postoperative radiographs intraoperatively prior to wound closure.
  • Close wounds in three layers: the periosteum if possible, subcutaneous tissue, and skin. Use atraumatic skin closure technique. Use 1/8-in. suction drains in pylon fractures and severe trimalleolar fractures or when there is enough bleeding to justify their use.
  • Apply a postoperative dressing and well-padded splints or a Robert-Jones dressing with splints (Fig. 25.12).
    Figure 25.12. The postoperative dressing. A: The dressing is well padded with cotton before plaster application; a foot plate is made of plaster splints, and a plaster stirrup on both medial and lateral sides covers the foot plate. The foot plate is then reversed over the stirrup for further strengthening. B: Close-up view showing the posterior aspect of the plaster. Plaster does not contact the patient’s heel. C: A light coating of cotton is placed over the plaster to prevent the compression dressing from sticking to the plaster and becoming ineffective. Then it is wrapped with an elastic bandage. The foot is in neutral position.
Most medial malleolar fractures occur in conjunction with a lateral injury and should be approached after the lateral malleolus has been exposed. It is usually better to fix the lateral side first.
  • Make an appropriate incision. Develop exposure utilizing dull retractors (Ragnals, Langenbecks), taking care to avoid damage to the saphenous nerve and vein. Strip the thick periosteal layer overlying the medial malleolus only enough to allow for visualization and reduction. It is imperative to visualize the anterior aspect of the fracture to insure an anatomic reduction.
  • Inspect the medial gutter of the ankle joint to assess the talus for osteochondral injuries and to ensure that no loose fragments or infolded soft tissue is blocking the reduction. This is best accomplished by distracting the distal fragment with a dental pick.
  • After anatomically reducing the fragment with a towel clip, sharp-tipped bone forceps, or dental pick, provisionally hold the reduction with a large Weber (two-point reduction) clamp (Fig. 25.13). Occasionally two small Weber forceps are required. Check for stepoffs between the fragments using a dental pick.
    Figure 25.13. Provisional reduction of medial malleolar fracture utilizing a large two-point reduction clamp.
  • Screw fixation is usually optimal for most medial malleolus fractures. Place two parallel screws in lag fashion directed perpendicular to the fracture place. Screw diameter (4.0 mm, 3.5 mm, 2.7 mm) can be varied to accommodate the size of the distal fragment. The sharp-tipped triple drill guide depicted in Fig. 25.14 is useful to provide preliminary fixation with drill points and to assure that the screws are parallel (Fig. 25.15).
    Figure 25.14. This drill guide enables the operator to drill parallel holes to facilitate parallel screw placement. One hole can be drilled, and the drill bit left in place while the second drill bit is used to complete the procedure.
    Figure 25.15. A,B: Preoperative view of an SEIV fracture type or Weber type B fracture. C,D: Postoperative radiographs showing the use of lag screws alone on the oblique fracture of the distal fibula.
For oblique shear-type medial malleolous fractures, which commonly occur with supination–adduction injuries,

screw fixation alone may be suboptimal because the distal fragment tends to displace proximally during screw tightening. In this instance, place an antiglide plate first (an appropriately contoured quarter tubular plate or one-third tubular plate), followed by the distally to proximally directed lag screws. An alternative method is to be certain that screws are at right angles to the fracture surface.
The methods for reduction and fixation of lateral malleolus fractures are dependent on the fracture pattern and mechanism. For most fractures about the ankle, reduce and fix the lateral malleolus first, restoring length and rotational alignment.
  • Approach the majority of lateral malleolar fractures using incision 4 in Figure 25.11B. If posterior fixation or concomitant posterior malleolar reduction is anticipated based on preoperative planning, use incision 6, which is posterior.
  • Consider the anatomic variations of the sural and superficial nerves to avoid inadvertent injury.
Weber A lateral malleolus, transverse–avulsion fractures are optimally treated with tension-band fixation because the fragment is usually too small for screws and a plate. This can be accomplished with Kirschner (K-) wires


and malleable wire. Occasionally, a one-third tubular plate and screws work well. An intramedullary screw can be used as well but provides less rotational stability (Fig. 25.16).
Figure 25.16. A: Preoperative anteroposterior radiograph of a supination-adduction type fracture or Weber type A. B,C: Postoperative radiographs illustrate the usex of an axial lag screw for the avulsion fracture of the distal fibula.
Weber B oblique fractures in the coronal plane ending at the level of the plafond can be stabilized with either a posterior antiglide plate (Fig. 25.17) or a lateral interfragmentary lag screw and a buttress plate (Fig. 25.18). Even though antiglide plating shows some biomechanical advantage (46), it should be reserved for short, oblique noncomminuted fracture patterns. For antiglide plating, a one-third tubular plate is optimal.
Figure 25.17. A: Anteroposterior and lateral radiographs of a SER type lateral malleolar fracture. Notice the medial clear space widening consistent with medial ligamentous injury and dynamic instability. B: Postoperative radiographs demonstrating fixation with a posterior, antiglide technique. C: Radiographs 1 year postoperatively demonstrating osseous union and anatomic restoration of the ankle mortise.
Figure 25.18. A: Anteroposterior and lateral radiographs of a SER type bimalleolar fracture. B: Postoperative radiographs demonstrating various fixation techniques including stacked one-third tubular plates, push-pull screw (empty screw hole proximal to plate), and 2.7-mm screws utilized to secure small medial malleolar fragment.
Posterior Antiglide Plate
  • Minimally strip the posterior soft tissue extraperiosteally. Insert a 3.5-mm screw through the posterior antiglide plate from posterior to anterior just proximal to the fracture line. As the screw is tightened, the plate will reduce the fracture.
  • Fine-tune the reduction with small Weber clamps until an anatomic reduction is achieved.
  • With the fracture held anatomically reduced, place a 3.5-mm or 2.7-mm distal-posterior to proximal-anterior lag screw though the plate across the fracture. The 2.7-mm screw head is less prominent for the peroneal tendons and can be angled perpendicular to the fracture line.
  • Place a 3.5-mm bicortical screw through the plate proximally to serve as a derotation screw (4) (Fig. 25.17).
Lateral Buttress Plate
For lateral plating of these fractures, a one-third tubular plate, stacked one-third tubular plates, or 2.7-mm reconstruction plates provide satisfactory fixation.
  • Mallet a one-third tubular plate flat distally and contour and rotate it to match the contours of the distal fibula. In cases where distal fixation is problematic, a hook can be fashioned out of the distal screw hole and impacted into the bone as an additional point of fixation (26). Do this by cutting the distal end of the plate off through the screw hole and then bending the resulting sharp ends toward the bone.
  • Rather than placing a short unicortical 4.0-mm cancellous screw in the distal holes, 2.7- or 3.5-mm cortical screws can be angled proximally or distally to obtain additional cortical purchase and still avoid penetrating the articular surface in the lateral gutter.
  • Two proximal bicortical screws and an anterior-to-posterior interfragmentary screw complete the fixation (Fig. 25.18). Additional screw fixation proximal to the fracture is rarely necessary and results in unbalanced fixation.
For shortened comminuted fractures or fractures operated on in a delayed manner, indirect reduction techniques are helpful in gaining the appropriate length and rotation.
  • After fixing the plate distally, place a bicortical screw proximal to the plate and in line with it (24). This is known as a “push-pull” screw. Use a bone spreader

    between the push-pull screw and the plate to distract the distal fragment.
  • After anatomic length has been achieved, correct rotational discrepancies before placing proximal screws.
Weber C Fracture
Weber C distal fibula fractures require correction of length and rotational deformities of the distal fragment of the fibula as well as anatomic reduction and fixation of the syndesmosis (1). In a few of these injuries the anterior and interosseous ligaments of the syndesmosis are torn, but the posterior ligaments remain intact. Anatomic reduction and plate fixation of the fibula alone then restores the syndesmosis and renders it stable. Independent fixation of the syndesmosis then is unnecessary. Indirect reduction techniques are ideal for restoring appropriate length. Single one-third tubular plates are usually not strong enough to allow for distraction through the plate. Stacked one-third tubular or 3.5-mm dynamic compression plates (DCP) function well for this task. These plates require precise contouring, as they are too stiff to assume the contour of the lateral fibula when the screws are tightened.
  • Following a lateral approach to the distal fibula, dissect along the anterior fibula to expose the anterior syndesmosis. Careful preoperative and intraoperative planning is required for precise placement of a screw from lateral to medial across the syndesmosis parallel to and 2 to 3 cm above the joint line.
  • After fixing the plate to the distal fragment along the posterolateral aspect of the fibula, place a push-pull




    screw proximal to the plate. Distract through the plate until anatomic length, rotation, coronal plane alignment, and anatomic reduction of the syndesmosis have been accomplished. If there is cortical continuity between the distal and proximal fragments, the fracture can be loaded through the plate using the push-pull screw and a small Verbrugge clamp (24).
  • Secure the plate proximally with two 3.5-mm bicortical screws.
  • Then fix the syndesmosis.
  • Position the hindfoot in slight inversion and the ankle in neutral dorsiflexion and hold the syndesmosis reduced with a two-point reduction forceps. The screw should parallel the joint and be directed from posterolateral to anteromedial at approximately a 15° angle (Fig. 25.19).
    Figure 25.19. A: Radiographs demonstrating a pronation type ankle fracture with syndesmotic disruption. Notice the avulsion fracture at the medial joint line. B: Radiographs following ORIF of the fibula and open reduction of the syndesmosis with transsyndesmotic fixation. C: Radiographs following union of the fracture. Radiolucency around the syndesmotic screw without failure is evident.
  • Use a fully threaded 3.5-mm cortical screw across all four cortices of the fibula and tibia to secure fixation. In larger individuals, two 3.5-mm screws may be necessary. The fully threaded screw functions as a “position” screw by holding the reduced position, avoiding excessive compression of the syndesmosis.
Posterior malleolus fractures often are small enough not to require fixation (28). Fractures can involve only the nonarticular portion of the posterior malleolus, and fragments that are attached to the fibula by the posterior distal tibiofibular ligaments are well reduced and stable after fixation of the fibula. If the fracture involves 25% or more of the articular surface, the talus tends to subluxate posteriorly,

so fixation is indicated (8,31). Because the fracture can be oblique, there is a tendency to underestimate the size of the fragment. Computed tomography (CT) is useful in delineating the size and location of the fragment.
  • Posteromedial fragments can usually be fixed through incision 3 on Figure 25.11A, which is used to fix the medial malleolus as well. Lengthen it as needed to gain adequate exposure. Posterolateral fragments can be approached in a similar way laterally through incision 6 on Figure 25.11B. Use the interval between the peroneal tendons and the flexor hallicus tendon. This incision must be large enough to permit tension-free exposure. The prone position is very helpful for this exposure and fixation.
  • Use a dental tool, large Weber double-pointed forceps, or spiked ball-tip pusher to reduce the fragment. Lock the proximal edge of the fractured fragment into place first and then close the articular surface. Hold it securely with the reduction forceps.
  • After provisional K-wire fixation, obtain definitive fixation with percutaneous anterior-to-posterior 3.5-mm or 2.7-mm lag screws placed through anterior stab wounds. Do not overtighten the screws because this may cause the posterior fragment to displace proximally and anteriorly (Fig. 25.20).
    Figure 25.20. A 28-year-old woman was involved in a high speed motor vehicle accident sustaining multiple injuries including this comminuted intraarticular pylon fracture of the left ankle. A: AP radiograph. B: Lateral radiograph, note the large posterior fragment. C: AP radiograph following open reduction and internal fixation through an anterior approach for the tibia with application of a spoon plate. Today we would prefer the use of a smaller combination of plates. D: A lateral view showing management of the larger posterior malleolar fragment with anterior to posterior lag screw fixation accomplished through the anterior approach using a sharp-tipped tenaculum forceps to reduce the articular fragment by percutaneous means avoiding direct exposure of the posterior fragment.
Disruptions of the syndesmosis require open reductions to insure anatomic restoration of the syndesmosis.



  • Expose the syndesmosis anteriorly as previously described.
  • Before reducing the distal tibial–fibular joint, confirm that the distal anterior tibial–fibular ligaments have not “buttonholed” into the joint, blocking the reduction. Clean out the syndesmosis but do not disturb the articular cartilage or curette the bone in order to prevent a synostosis from forming.
  • Reduce the syndesmosis using a large pointed reduction forceps. Be certain that the fibula slides posteriorly into the sulcus in the tibia and is anatomic.
  • Proceed with screw placement as described for Weber C fractures (8). A two-hole one-third tubular plate on the fibula may be used as well, particularly if two screws are placed (Fig. 25.21).
    Figure 25.21. A: Radiographs following pronation injury resulting in a medial ligamentous injury with syndesmotic disruption.B: Stress radiograph demonstrating syndesmotic disruption with comparative stress view of the uninjured ankle. C: Intraoperative radiograph with compression across the reduced syndesmosis. D: Radiographs following open reduction of the syndesmosis and internal transsyndesmotic fixation. E: Follow-up radiographs demonstrating maintenance of the syndesmotic reduction and development of (asymptomatic) intramembranous calcification.
  • Repair of the anterior distal tibia–fibula ligaments can be performed with a nonabsorbable suture, although this is less important than anatomic reduction with stable screw placement.
  • Repair of a concomitant rupture of the deltoid ligament is unnecessary. If the medial side is explored for other reasons, repair the ligament.
  • Use the lateral incision for lateral malleolar fixation to reduce and stabilize the tubercle of Chaput. Dissect anteriorly with a periosteal elevator along the anterior tibial–fibular ligament to provide access to the tubercle of Chaput.
  • Use a dental pick, spiked pusher, or Weber clamp for reduction.
  • Provisionally stabilize the fracture with K-wires and then place a lag screw from lateral to medial, securing the fragment.
Ligamentous injuries about the ankle that fail to disrupt the integrity of the ankle mortise and that fail to block



anatomic reduction rarely require repair. Deltoid ligament tears in combination with lateral malleolar fractures do not require open treatment unless they prevent an anatomic reduction of the ankle mortise (12).
The goal of surgery is to achieve a precisely reduced joint surface maintained by stable internal fixation. If this can be achieved, functional postoperative treatment with early use of the muscles of the leg and physiologic activity of the joint can be instituted (34,35). Early use of the muscles prevents atrophy, and motion helps to repair injured cartilage (44). The fixation maintains the fracture in the correct position through the period of bone healing. Operatively achieved anatomic reduction and stable internal fixation can produce results impossible to achieve with other therapeutic approaches (2).
Operate on the fracture as soon as possible after injury. This window for intervention extends to about 10 to 12 hours after injury. If more time passes, interstitial edema increases, the skin loses its pliability, and fracture blisters appear. During this later period, surgery is contraindicated.
A closed reduction, external splinting incorporating a compression dressing, and elevation of the extremity may salvage the situation if it is too late to operate. Proper management during this period enables operative intervention when the skin starts to wrinkle, at about 8 to 10 days.
An alternative approach is to place a patient too unstable for emergent surgery into calcaneal pin traction on a Boehler frame and allow the traction to regain length and alignment of the limb. Elevation, reduction, and time allow the posttraumatic inflammatory period to pass. An idea of the relative ease of open reduction and internal fixation may be obtained by viewing radiographs of the reduction obtained by pure distraction during the traction period (23,24) (Fig. 25.22).
Figure 25.22. A: Anteroposterior (AP) radiograph of a type C pylon fracture. Notice the shortening that contributes to displacement of the diaphyseal and articular fracture fragments. B: An AP radiograph of the same fracture with 10 kg (22 lb) of skeletal traction applied through the calcaneus. Notice how simple distraction has reduced most of the diaphyseal and epiphyseal fracture displacements. This is a good prognostic sign, indicating that indirect methods of reduction during surgery can allow an atraumatic reduction of the fracture, which then may be fixed by standard methods of internal fixation. C: Another AP projection of a type C pylon fracture. Although this fracture is more comminuted than the previous example, a more important indicator of problems in reduction during surgery is shown by its failure to reduce or improve with skeletal traction. D: Ten kilograms (22 lb) of traction applied to the calcaneal pin have not markedly improved the radiographic situation. Failure to improve during skeletal traction can be attributed to the interposition of soft tissue. In this fracture, the flexor hallucis and neuromuscular bundle have been displaced into the joint and block reduction of the posterior fragment.
Carry out surgery after the acute effects of the injury

have subsided. This does not represent the ideal situation, however. Surgical intervention is rendered more difficult by the passage of time because the soft tissues are less pliable and the bony fragments become softer and somewhat adherent.
The severity of the injury plays the most important role in determining the final outcome. In high-energy injuries, impaction of the subchondral bone, fragmentation of the epimetaphyseal cortex, and irreparable abrasion of the cartilage of tibia and talus may dictate a poor result regardless of the surgeon’s experience. Under these circumstances, the condition of the soft-tissue sleeve becomes critical.
If surgical intervention is attempted, the operative approach and surgical tactic for the reduction and fixation must be carefully planned. In these fractures, a preoperative drawing may be very enlightening. If the key fragments to be reduced and fixed cannot be identified and drawn, it may be that at surgery they cannot be reduced and fixed (48). A misguided attempt at anatomic reduction and internal fixation under circumstances in which stable fixation cannot be achieved can deteriorate into a lengthy struggle, resulting in frustration for the surgeon, intraoperative acceptance of malreduction, unstable fixation and ensuing skin slough, wound dehiscence, bone and tendon necrosis, and infection. Worse, the patient may be deprived of delayed reconstructive procedures that could produce an acceptable result.
Although indirect reduction techniques are useful in enacting a reduction, pylon fractures, like all articular fractures, should be reduced directly. Regardless of which operative approach to pylon fractures is employed, distraction techniques are required to restore alignment and reduce compressed articular fragments.
Limited internal fixation as an isolated fixation technique should be reserved for undisplaced or anatomically reducible articular fracture patterns without metadiaphyseal extension that are potentially unstable and require additional stabilization. Isolated percutaneous screw fixation of periarticular fragments rarely provides sufficient stability to allow for early range of motion and likely necessitates

cast immobilization to provide stability. This technique is best combined with external fixation, which is described below.
External fixation techniques include large pin fixators, small wire fixators, and hybrid fixators (3,29). Reduction via external fixation relies on traction and resulting ligamentotaxis to help reduce the fracture fragments. Without direct visualization of the articular surface via open or arthroscopic means, treatment by external fixation relies on radiographic joint reduction, which is subject to errors. Although some small wire hybrid techniques do not cross the ankle joint, most large pin fixators rely on fixation that spans the ankle and often the subtalar joints, precluding early joint motion. If external fixation is used as a temporary treatment regimen while soft tissue swelling is allowed to subside, ensure that pin placement does not compromise future open treatment. Specific surgical techniques vary, depending on the type of external fixation employed. Correction of angular, rotational, and length discrepancies is accomplished by distracting through the fixator after connecting the fixator to proximal and distal pins and/or wires. Regardless of the fixator, it is essential that pins and wires be placed without causing thermal necrosis to the bone and soft tissue, which leads to infection and ring sequestrum formation (see Chapter 11 for more details).
Treatment by this method involves limited fixation to stabilize the articular fractures followed by “connecting” the restored joint to the tibial shaft with external fixation. Indirect reduction techniques aid in repositioning of fragments via ligamentotaxis (48).
  • Before attempting reduction of the articular fracture fragments, connect a universal distactor to tibial and talar or calcaneal Schanz screws and correct for length and rotational and angular malalignments. Alternatively, some fixation systems allow for distraction through the fixator.
  • Utilize limited well-planned incisions and stab wounds near the plafond to reduce fracture fragments under fluoroscopic radiographic control. Small elevators, dental picks, pushers, and K-wires are helpful in positioning fragments in a reduced position.
  • After obtaining anatomic reduction and provisional stabilization with K-wires or guide wires for cannulated screws, secure the articular and periarticular fragments with interfragmentary screws.
  • Following reduction and stabilization of the articular fragments, use the external fixator to secure the ankle and distal tibia to the tibial diaphysis.
A variety of small-wire, hybrid, and large pin fixators are available. Small-wire or hybrid fixator fixation that provides stable fixation without spanning the tibial–talar or talocalcaneal joints is preferable when technically feasible because it allows for early ankle (and subtalar) motion, satisfying one of the goals of operative pylon treatment (Fig. 25.23).
Figure 25.23. Radiograph of a pylon fracture in a hybrid or Orthofix fixator with percutaneous screws. A,B: AP and lateral radiographs demonstrating an AO C type pylon fracture with marked metadiaphyseal comminution. C,D: Radiographs with a tibial-calcaneal spanning external fixator, reducing the fracture via ligamente taxis with limited internal fixation of the major articular fragments.
Open reduction and internal fixation performed well gives the best results (25,36,42). Poor soft-tissue handling, inappropriate surgical timing, excessive soft-tissue stripping, and use of excessively large implants, however, can lead to disastrous results.
Timing of pylon ORIF is based on basic soft-tissue injury principles. The safest time periods for open treatment are within 6 hours of the injury or at least 6 days from the injury (34). Staging of open treatment takes advantage of both these “windows of opportunity,” provisionally stabilizing the fracture to aid in soft-tissue healing and allowing for careful radiographic evaluation and preoperative planning.
As soon as possible after a patient with a pylon fracture presents to the trauma center, preferably within 6 hours from time of injury, perform ORIF of the fibula and provisional tibial–calcaneal external fixation.
  • Carefully plan the fibular incision to allow for a 7-cm skin bridge between this and the future anterior tibial incision. Approach the distal fibula fracture essentially the same as for routine lateral malleolar fractures. Direct the incision slightly posteriorly to insure a safe skin bridge. Fibula fractures associated with pylon fractures typically occur proximal to the ankle mortise, but varying patterns may occur.
  • Shortened fibulas from lateral compression modes of failure reduce well with indirect means. Following fixation to the distal fragment, place a 3.5-mm bicortical push-pull screw proximal to the plate. After distracting the fracture out to anatomic length with a bone spreader and correcting rotational malalignments, secure the plate to the proximal fragment. If cortical continuity exists, the fracture can be loaded using the push-pull screw.
  • Place a 5.0-mm Schanz screw in the medial aspect of the tibia and calcaneus perpendicular to the ankle joint using standard techniques. Make sure the tibial pin is far enough proximal to avoid communication with the future tibial incision.
  • Connect the pins to a single medial carbon fiber bar and distract the distal tibia out to length using the


    compression device (Fig. 25.24). Do not place any pins into the talus because this may compromise any incision required for definitive open treatment in the future.
    Figure 25.24. A: Appropriate provisional external fixator placement following first stage of open treatment of a pylon fracture. B: Photographs following ORIF of the fibula fracture and application of a tibial–calcaneal fixator.
Definitive open treatment should be delayed until soft-tissue swelling diminishes. This usually occurs within 7 to 10 days but may take up to 3 weeks.
  • Make an anterior tibial incision (Fig. 25.11C), leaving a 7-cm skin bridge between it and the fibular incision. This will vary somewhat based on the fracture pattern. The standard incision starts just lateral to the crest of the tibia and courses just anterior to the tibialis anterior tendon at the distal limb (34). A posterior (European) approach may occasionally be preferable to accommodate open fracture wounds, but this approach provides limited exposure of the articular surface.
  • P.840

  • Dissect directly down to bone just lateral to the anterior tibial tendon and develop the exposure medially and laterally at the level of periosteum. Incise the anterior compartment fascia just lateral to the tibial crest and reflect the flap medially in an extraperiosteal manner, exposing the medial face of the tibia. Avoid violating the paratenon of the anterior tibial tendon at the distal aspect of the incision. Should the skin slough anteriorly, the paratenon will accept a split-thickness skin graft. In the absence of the paratenon, the tendon will desiccate, leading to infection and other problems.
  • Make an anterior ankle arthrotomy and carry the exposure out onto the neck of the talus to visualize the reduction. Perform minimal periosteal stripping of the fracture fragments.
  • Additional distraction through the medial fixator may aid in the reduction (23).
  • Use a variety of dental picks, reduction forceps, and pushers to tease the fragments into anatomic alignment. Forceful reduction maneuvers are rarely beneficial and increase the risk of further fracture fragmentation. Thoughtful, methodic, fragment-by-fragment reduction and provisional fixation are essential.
  • After reducing the fragments, perform provisional fixation with K-wires. If significant crush of metaphyseal bone exists, place autologous bone graft into the osseous defect to prevent collapse of the reduction and promote osseous union.
  • After confirming an anatomic articular reduction visually and radiographically, replace the provisional K-wires with limited lag screw fixation.
  • Various small and minifragment plates may additionally be contoured to adequately stabilize the periarticular fracture fragments and stabilize the metaphyseal component to the distal diaphysis of the tibia (Fig. 25.25). It is



    rare that a plate larger than 3.5-mm limited-contact DC plates is required.
    Figure 25.25. A: Anteroposterior radiographs of a C-type tibial pylon fracture. B: Radiographs following ORIF of the lateral malleolar component and application of a provisional tibial–calcaneal external fixator. C: Clinical photo before second stage of surgery. D: Anteroposterior radiographs following ORIF of tibial plafond and autogenous bone grafting of the metaphyseal defect. E: Weight-bearing radiographs following osseous union. F: Weight-bearing radiographs following hardware removal, demonstrating articular congruity and maintenance of tibial–talar joint space.
If skin closure is difficult because of tension, try to close all deep tissues over the bone and implants, leaving the fibular incision open, allowing for primary closure of the tibial wound with delayed closure or split-thickness skin grafting of the fibular incision. Delayed closures under sterile conditions are far safer than attempting to primarily close an overly tight wound.
During the early postoperative period, keep the limb in a well-padded compression dressing and splints to prevent the foot from dropping into equinus. Elevate the limb until swelling subsides. Gentle range-of-motion exercises can begin as tolerated if the surgeon feels the fixation is stable. On the first postoperative office visit, apply a removable below-knee cast. Keep patients touch-down weight bearing but remove the cast or brace daily to perform active, active-assisted, and gentle passive ankle and subtalar range-of-motion exercises. Patients with persistent swelling despite stable internal fixation and an anatomically reduced fracture often benefit from a knee-high medium compression stocking. Based on the fracture pattern, continue limited weight bearing for at least 6 weeks. Most fractures require limited weight bearing and protection for 12 weeks.
Complications may be loosely grouped into intraoperative (or technical) errors and early and late postoperative complications.
Technical mistakes typically involve failure to achieve anatomic reductions and failure to adequately stabilize the fracture. Articular incongruity and inability to restore the anatomic relationships of the ankle mortise increase the probability of postoperative pain and early posttraumatic arthrosis (52). Failure to achieve stable fixation allowing for early range of motion leads to “fracture disease” and chondrolysis. Malreductions that have yet to result in significant levels of joint destruction are amenable to restorative osteotomies (55). Advanced ankle joint destruction often requires arthrodesis as a salvage procedure. Early total ankle arthroplasty results from newer generation ankle prostheses are an encouraging alternative to joint fusion.
Wound healing delays, nonunions, and infection following operative treatment of ankle and pylon fractures present a difficult challenge to the orthopaedic surgeon. Frequently, these postoperative complications stem from decisions made before and during operative treatment. Proper surgical timing, avoidance of undue soft-tissue and osseous devascularization, utilizing appropriate-sized implants, and adhering to principles of treatment of open fractures prevent the majority of these potentially disastrous complications. Even though operative treatment utilizing external fixation is usually considered safer than open techniques, complications can result from either treatment protocol. Superficial wound infections and breakdowns may be amenable to local wound care and oral antibiotics. Deep infection and full-thickness wound sloughs must be treated with aggressive debridements of devitalized tissue, full-thickness soft-tissue coverage, and intravenous antibiotics. Salvage following these grave complications may require extraordinary techniques such as free tissue transfer or bone transport procedures in order to achieve osseous union and restore limb length and function. Failure to eradicate deep infection or achieve union may necessitate a below-knee amputation.
The complexity of surgery of ankle and pylon fractures is frequently underestimated, leading to pitfalls in treatment. Although various surgical modalities (internal fixation, external fixation) may be employed in the operative treatment of ankle fractures, ideal surgical treatment should produce anatomic restoration of the articular congruity of the tibial plafond and restoration of the ankle mortise with sufficient stability to allow for early joint motion. Each surgeon will choose different treatment modalities in order to accomplish these goals. We routinely treat ankle and pylon fractures by open reduction and internal fixation. By protecting the soft tissues, operating during safe periods, preserving the osseous vascular supply, and utilizing appropriately sized implants, we have been able to avoid the majority of complications associated with ORIF. Other, less-invasive techniques may potentially minimize the risk of morbidity, but they often preclude anatomic restoration of the articular surface and prevent early restoration of ankle and subtalar motion.
Each reference is categorized according to the following scheme: *, classic article; #, review article; !, basic research article; and +, clinical results/outcome study.

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