In the past, lateral column integrity was thought to be the key to a well-fixed and stable ankle fracture. It is these deep fibres of the deltoid ligament that play a key role in the stability of ankle fractures, especially if the PTTL remains intact following an injury. Thus, it is tight when the foot bears weight. It is important to note that this ligament is tight when the foot is plantigrade, and loose with the foot plantar-flexed. It originates from the posterior part of the medial malleolus and inserts into the posteromedial talus, plantar to its articular surface. The posterior component is the stronger of the two. Furthermore, the deep deltoid consists of two parts: the anterior and posterior talotibial ligaments (ATTL and PTTL). It consists of superficial and deep components. The medial column consists of the medial malleolus and the medial collateral ligament, known as the deltoid ligament, which is stronger than its lateral counterpart. The lateral ligaments are the anterior talofibular (ATFL), calcaneofibular (CFL) and posterior talofibular (PTFL) and these connect the lateral malleolus to the talus. The syndesmosis between the fibula and tibia is formed by the anterior and posterior inferior tibiofibular ligaments (AITFL and PITFL) and the interosseus ligament, which is the lower part of the interosseus membrane. The lateral column consists of the fibula, the syndesmosis and the lateral ligaments. The ankle is also divided into two columns: lateral and medial. If this ‘ring’ is broken at one site only, it remains stable, but if it is broken at two or more sites, it becomes unstable. The ankle joint can be considered as a ‘ring’ in which bones and ligaments contribute to the overall stability. This review will analyse the principles of stability assessment for ankle fractures and provide a rationale for diagnosis and management.Īpplied anatomy, biomechanics, and classifications However, more complex injuries, such as those involving the posterior structures, require in-depth knowledge of the fracture pattern and careful evaluation and planning of any surgery. 1, 3 Internal fixation can lead to surgical complications in up to 20% of cases 4, 5 and is therefore best avoided for those fractures where non-operative management can offer optimal outcomes. To illustrate, the second of these statements is based on an article published in 1940 reviewing only eight ankle fractures involving the posterior malleolus. 1, 2 The orthopaedic and trauma community needs to move away from the almost anecdotal ‘principles’ suggesting, for example, that 2 mm displacement of a distal fibula fracture requires surgical reduction and fixation, or that posterior malleolus fractures affecting less than 25% of the tibial plafond can be treated non-operatively. As such, it has become apparent that the ‘key issue’ in achieving good outcomes when treating these common injuries is to follow the principle of restoring the stability and alignment of the fractured ankle, using either non-operative or operative treatment, as appropriate. As scientific (laboratory, cadaveric and clinical) research has led to better understanding of the biomechanics and patho-anatomy of the ankle, this has allowed more accurate evaluation of all elements and characteristics of injuries to bone and soft tissues associated with malleolar fractures.
Management of ankle fractures has evolved over the last 10 years.
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