Pearls & Pitfalls Orthobullets Technique Guides cover information that is "not testable" on ABOS Part I Preparation identify ankle fracture pattern (Lauge-Hansen SA, SER, PA, PER). radiolucent table and C-arm from contralateral side. Positioning patient supine with feet at end of bed and bump under hip for neutral limb rotation. Approach direct approach to lateral and medial malleoli Lateral Reduction and Fixation reduction tenaculums to reduce fibular fracture 2.0/2.7mm or 2.5/3.5mm lag screw perpendicular across fracture neutralization plate direct lateral or antiglide plate posterolateral Medial Reduction and Fixation pointed reduction tenaculums used for anatomic reduction reduction evaluated on mortise view unicortical versus bicortical small fragment screw fixation Syndesmosis Exam and Fixation perform Cotton test / external rotation stress test to determine if syndesmosis injured 1 or 2 screws, 3.5mm or 4.5mm, tricortical or quadricortical Postoperative 2-3 weeks non-weight bearing in AO splint 4-6 wks in CAM boot with progression of weight bearing and range of motion exercises ROM and weightbearing delayed ~2x if diabetic Planning & Preparation Template Fracture identify ankle fracture pattern (Lauge-Hansen SA, SER, PA, PER) based on mechanism and pre/post-reduction xrays systematically make list of damaged structures that need to be repaired Plan Approach plan out relevant approaches to lateral and medial malleoli Table and Imaging radiolucent table c-arm from contralateral side, perpendicular to table, monitor at foot of bed Equipment & Positioning Potential Hardware Systems small fragment set (2.0/2.5/2.7/3.5mm drill bits, 2.7/3.5mm cortical screws, 4.0mm cancellous screws, 1/3 tubular plates) 4.0mm cannulated screws (guidewires, 2.5mm cannulated drill, 4.0mm cannulated partially threaded screws, washers) Patient Position supine with feet at the end of the bed, bump under hip to get limb into neutral rotation (patella pointed towards ceiling) thigh tourniquet optional can elevate distal limb with bump or foam to minimize overlap from other ankle during lateral radiograph Lateral Malleolus ORIF Approach approach to the fibula mark out lateral malleolus and anterior and posterior borders of fibula mark estimated location of fracture site (check with C-arm if unsure) straight longitudinal incision 4-6cm in length centered on fracture make incision along posterior fibula if access to the posterior malleolus is needed Soft Tissue Dissection sharp dissection through skin create full thickness flaps over distal fibula; hemostatsis with cautery proximally, use tenotomy scissors to spread subcutaneous tissue in vertical direction with minimal soft tissue stripping identify superficial peroneal nerve with more proximal fractures 2-3mm subperiosteal dissection at fracture edges with scalpel extraperiosteal dissection more proximal and distal to fracture site with knife and/or wood handled elevator Fracture Preparation and Reduction open fracture site with Freer elevator remove hematoma and interposed soft tissue with curettes, small rongeur, right angle snap Lag Screw and Neutralization Technique use reduction tenaculums to reduce fracture using hand rotation and contralateral thumb to help guide fragments together lobster clamp has good hold on bone but damages more periosteum pointed clamps have a more fine-tuned feel for reduction need to be perpendicular to vector of fracture line apply pressure, then pronate hand to bring fibular out to length for right sided fractures, supinate for left sided fractures (SER patterns) use another clamp to hold reduction once achieved mark out perpendicular line to fracture and place 2.7/3.5mm drill bit with sleeve on superior ridge of fibula in same perpendicular line lag screw technique drill first cortex only with 2.7mm drill (for 2.7mm screw) or 3.5mm drill (for 3.5mm screw) insert 2.0mm sleeve into hole (2.7mm screw) or 2.5mm sleeve (3.5mm screw) drill far cortex with 2.0 bit (2.7mm screw) or 2.5mm bit (3.5mm screw) can countersink first cortex to increase surface area distribution for screw use depth gauge to measure length keep depth gauge in drill hole to maintain orientation for screw placement insert lag screw and hand tighten carefully to not break bone, watch for compression across fracture site plate placement determine length of 1/3 tubular plate needed and check placement on C-arm plan out 2 vs. 3 bicortical 3.5mm screws above and below fracture site plan hole placement for possible syndesmotic screw placement screw fixation will contour plate in non-osteopenic bone contour distal aspect of plate if poor bone or very distal screw placement contouring is done by by bending against screw driver tip or using handheld plate benders distal fibula typically flares out laterally and then in more distally screw placement drill bicortically with 2.5mm drill bit, then use depth gauge insert appropriate length 3.5mm screw, alternating proximal to fracture then distal most distal screw(s) are near joint, therefore drill unicortically and aim most distal screw in distal to proximal direction 4.0mm cancellous screw used in this instance alternatively, can drill and place a unicortical locking screw Antiglide Technique determine length of 1/3 tubular plate needed ( typically 6-8holes) after fracture prepared, identify apex of fracture spike posteriorly place plate posteriorly over spike, ensuring appropriate proximal-distal placement clamp plate to bone proximally and drill/place non-locking screw in proximal hole in plate drill and place another non-locking screw in the hole just proximal to the fracture line to obtain a reduction place another screw proximally distally, you can place a lag screw if desired, or place 1-2 screws to stabilize distal fragment these screws can be bicortical as you are aiming anterior/lateral to the joint leave distal hole empty if possible to minimize risks of peroneal tendon irritation Confirm Plate & Screw Position check with C-arm on mortise and lateral views Medial Malleolus ORIF Approach anteromedial approach to medial malleolus and ankle incision ~4cm centered over fracture curved slightly anterior to visualize anterior edge of fracture line Soft Tissue Dissection scalpel through skin tenotomy scissors for dissection in vertical direction, watch out for saphenous vein elevate periosteum over fracture and clean out Fracture Preparation and Reduction evert foot for increased fracture exposure remove any loose bodies or osteochondral defects visualize posterior tibial tendon for potential tears use 2.0-2.5 mm unicortical drill hole 2 cm proximal to fracture site allow pointed reduction clamp placement and compression across fracture place additional clamp over distal fragment to control position of distal fragment confirm reduction with mortise view Fixation cortical (solid) screws use 2.5mm drill bit to drill from tip of malleolus proximally can drill unicortically or bicortically bicortical screws more biomechanically sound place partially threaded cancellous screw (typically ~45mm) if unicortical cortical screws (70-100mm) if bicortical drill and place second screw screw placement should not be posterior in malleolus posterior placement increases posterior tibial tendon irritation cannulated screws insert 2 parallel k-wires from 4.0mm cannulated screw set across fracture site k-wires to be overlapping on AP view and directed ~60 degrees up through fracture avoiding articular surface on lateral view, K-wires need to be parallel and evenly spaced apart use cannulated drill over first k-wire can use unicortical or bicortical technique place screw across fracture and drill/place second screw Syndesmosis Exam & ORIF Cotton Test reduction tenaculum is placed ~2cm above joint and lateral pull applied opening of the syndesmosis is indicative of a positive stress test External Rotation Stress Test firmly hold proximal tibia contralateral hand dorsiflexes and externally rotates foot if increased opening of tibia-fibular overlap on mortise view syndesmosis is injured anterior-posterior instability exam is most sensitive for syndesmosis injury Syndesmosis Reduction formally open the anterior aspect of the syndesmosis (anterior to fibula) remove interposing tissue if preventing reduction place Weber pointed clamp or large periarticular clamp across syndesmosis one tine on medial tibia and other in screw head or empty screw hole on fibula hold foot in neutral dorsiflexion and inspect syndesmosis from lateral incision make sure no bump under heel (will translate talus and cause malreduction) tighten clamp to maintain reduction inspect syndesmosis from lateral incision to ensure anatomic reduction Fixation use 2.5mm (or 3.5mm) long drill bit to drill across fibula into tibia drill bit orientation parallel to joint 2-4cm above joint drill bit is angled ~20-30° posterior to anterior due to fibular position in syndesmosis can drill either 3 or 4 cortices can use either 3.5/4.5mm screws remove large clamp obtain final AP, mortise, and lateral radiographs Closure Irrigation & Hemostasis irrigate wounds thoroughly and deflate tourniquet if used cauterize any bleeding vessels watching out for saphenous vein medially and SPN laterally Close Fascia deep fascial closure over plate with 0-vicryl ensure no entrapment of the SPN 2-0 vicryl for subcutaneous tissue 3-0 nylon for skin with horizontal mattress stitches in diabetics or patients with high risk for skin breakdown use modified Allgower-Donati stitch to reduce tension on skin Dressing & Splint soft incision dressing followed by AO splint with extra padding under heel for immobilization crutches or walker for ambulation Postoperative Care 2-3 Weeks wound check and remove sutures remove splint and place in short-leg cast boot, non-weight bearing can allow ROM if soft tissue is appropriate 6 Weeks advance weight-bearing status in CAM boot advance rehabilitation if syndesmotic screw(s) placed, need to be non-weightbearing 12 Weeks advance weight-bearing if diabetic, insensate, or syndesmotic screws present syndesmotic screws to stay in for at least 12 weeks can remove or leave in place no difference in outcomes with removal syndesmotic screws will loosen or break if maintained Complications Document Complications wound breakdown (4-5%) superficial and deep infections (1-2%, up to 20% in diabetics, peripheral neuropathy) hardware loosening and/or failure (highest incidence in neuropathic patients) post-traumatic arthritis