Preoperative Patient Care A Intermediate Evaluation and Management 1 Obtain focused history and perform focused exam evaluate degree of soft tissue injury open wounds swelling (fracture blisters) deformity check soft tissue for wrinkles await return of skin wrinkles prior to ORIF to decrease wound complications for 10-14 days check compartments identify risk factors that correlate with complications and poor outcomes comorbidities diabetes social factors smoking 2 Appropriately interprets basic imaging studies AP/Lat/Mortise views of ankle, AP/Lat views of tibia/fibula characterize fracture pattern, amount of comminution, metaphyseal bone loss, shortening, and angulation commonly 3 fragments according to ankle ligaments: medial malleolar (deltoid), anterolateral (AITFL, Chaput), and posterolateral (PITFL, Volkmann) fragments 75% of fractures have associated fibula fractures location and angulation of fracture fragments influences surgical approach severely comminuted fractures with poor bone quality may require definitive management with external fixator vs. tibiotalar arthrodesis CT scan often performed after placement of spanning ankle external fixator to delineate fracture fragments once length restored 3 Makes informed decision to proceed with operative treatment describes accepted indications and contraindications for surgical intervention 4 Provides post-operative management and rehabilitation immediate Post-op non-weight bearing in splint vs. external fixator, crutches for ambulation 2 weeks post-op wound check sutures removed repeat xrays of ankle and tibia/fibula 8-12 weeks postop xrays to evaluate union and fracture consolidation range of motion exercises to ankle advance weight bearing status and rehabilitation B Advanced Evaluation and Management 1 Provides comprehensive assessment of complex fracture patterns on imaging studies 2 Recognizes indications for and provides non-operative treatment of an unstable fracture diabetes medical comorbidities noncompliance C Preoperative History and Physical 1 Obtain history and perform basic physical exam document neurovascular status check compartments 2 Order basic imaging studies order biplanar radiographs of the tibia and weight bearing triplanar radiographs of the ankle 3 Splint fracture appropriately place in posterior splint with stirrups 4 Perform preoperative consent wound breakdown (10%) superficial/deep infection (5-15%) symptomatic hardware malunion nonunion post-traumatic arthritis (30-70% depending on articular injury) ankle stiffness neurovascular injury Operative Techniques E Preoperative Plan 1 Template fracture template fracture pattern and instrumentation 2 Execute surgical walkthrough describe steps of the procedure verbally to the attending prior to the start of the case describe potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation Synthes Variable Angle Locking Ankle Fracture System Synthes Small Fragment Set 1.2mm kwires osteotomes 2 Patient positioning patient supine with feet at the end of the bed, small bump under ipsilateral thigh, tourniquet on thigh if external fixator in place need to scrub down frame and pins thoroughly as this is a source of contamination 3 OR setup and C-arm radiolucent OR table c-arm from contralateral side perpendicular to bed G Superficial Dissection 1 Incorporate External Fixation into Approach Strategy If necessary leave external fixator fully or partially intact during approach and fracture reduction/fixation to maintain traction and fracture length 2 Draw out anterolateral incision and any additional incisions. use internervous plane between peroneus tertius and brevis, mark out lateral malleolus and course of peroneus tertius When using multiple approaches used must maintain ~7cm distance between full thickness skin flaps to decrease wound complications 3 Exsanguinate extremity and inflate tourniquet 4 Make incision start 2-3cm anterior to anterior border of fibula in line with 4th ray down to ankle joint identify and protect SPN in subcutaneous tissue immediately under skin incise fascia and extensor retinaculum in line with skin incision retract and elevate anterior compartment tendons medially If needed extend distally to talonavicular joint Anteromedial approach mark out medial malleolus and distal tibia crest, incision medial to tibialis anterior tendon sheath make incision centered on distal tibia then curving medial across ankle joint elevate full thickness skin flaps, leave tibial anterior tendon sheath intact elevate anterior compartment tendons and retracted laterally H Deep Dissection 1 Use sharp dissection down to bone 2 Perform subperiosteal elevation use a wood handled elevator and knife to elevate the muscles and tendons off of the anterior border of the tibia and fibula need to visualize extent of fracture fragments medially and laterally I Bony Preparation and Intraarticular Reduction 1 Prepare fracture site identify distal tibia fracture site and book open anterolateral vs. anteromedial fragment clean out with rongeur, curettes or dental pic 2 Use osteotomes to tamp down impacted central piece a central bone void should remain inspect talus for OCD lesions at the same time perform microfracture technique with kwire as needed 3 Join fragments together attach medial malleolus to impacted central fragment and lateral malleolus with kwires can use additional medial incision to expose medial fragment and reduce using k-wires join smaller fragments to larger fragments in a systematic fashion with kwires to restore articular surface join articular surface to tibia shaft use pointed reduction clamps to reduce larger fragments J Fixation 1 Fix anterior and posterior fragments place 2.7mm lag screw (2.0 mm drill) anterior to posterior to join fragments together place anterolateral vs. medial plate with at least 3 screws above (3.5 cortical) and 3 below (2.7 locking) key is metadiaphyseal screws distally in subchondral bone to support distal tibia articular surface need to be parallel to joint 2 Check anatomic placement of plate check plate contour and make sure no riding up off the distal tibia 3 Fix plate to bone place medial malleolus 1/3 tubular plate with 3.5 cortical screws to buttress down medial fragment insert allograft chips and autologous bone graft for distal tibia bone defect K Fibula Fixation (Optional) 1 Prepare fracture site clean out fracture site using freer to open fracture site use curettes, small rongeur, dental pick, and irrigation to remove hematoma and interposed soft tissue 2 Perform reduction use lobster clamp and pointed clamps to reduce fracture using hand rotation and contralateral thumb to help guide fragments together 3 Place lag screw place 2.7mm lag screw (2.0 mm drill) perpendicular to fracture line if possible 4 Place final fixation determine length of 1/3 tubular plate needed (~6-8holes) and check placement on fluoro place plate directly lateral for neutralization and insert 3 screws (3.5 mm) above and below fracture site L Confirm Intraarticular reduction and Hardware Position 1 Take final fluoro AP/Lat/Mortise of ankle and AP/Lat of tibia/fibula check screw lengths to ensure no penetration into ankle joint or surrounding tendons 2 Check limb length, rotation, and alignment N Wound Closure 1 Irrigation & Hemostasis deflate tourniquet irrigate and cauterize peripheral bleeding vessels place medium hemovac drain exiting proximal and lateral 2 Closure fascia and retinaculum closure with 0-vicryl, watch out for SPN laterally subcutaneous with 2-0 vicryl and skin closure with 3-0 nylon 3 Dressing soft incision dressings and postmold splint with stirrups for immobilization vs. pin site dressings if external fixator maintained Postoperative Patient Care O Perioperative Inpatient Management 1 Write comprehensive admission orders Serial compartment checks x24 hours IV fluids DVT prophylaxis pain control advance diet as tolerated foley out when ambulating check appropriate labs wound care drain out post-operative day 1 appropriately orders and interprets basic imaging studies xrays of the ankle in postop 2 Appropriate medical management and medical consultation 3 Inpatient physical therapy non weightbearing crutches for ambulation 4 Discharge home appropriately pain meds outpatient PT schedule follow up appointment in 2 weeks R Complex Patient Care 1 Develops unique, complex post-operative management plans
A Intermediate Evaluation and Management 1 Obtain focused history and perform focused exam evaluate degree of soft tissue injury open wounds swelling (fracture blisters) deformity check soft tissue for wrinkles await return of skin wrinkles prior to ORIF to decrease wound complications for 10-14 days check compartments identify risk factors that correlate with complications and poor outcomes comorbidities diabetes social factors smoking 2 Appropriately interprets basic imaging studies AP/Lat/Mortise views of ankle, AP/Lat views of tibia/fibula characterize fracture pattern, amount of comminution, metaphyseal bone loss, shortening, and angulation commonly 3 fragments according to ankle ligaments: medial malleolar (deltoid), anterolateral (AITFL, Chaput), and posterolateral (PITFL, Volkmann) fragments 75% of fractures have associated fibula fractures location and angulation of fracture fragments influences surgical approach severely comminuted fractures with poor bone quality may require definitive management with external fixator vs. tibiotalar arthrodesis CT scan often performed after placement of spanning ankle external fixator to delineate fracture fragments once length restored 3 Makes informed decision to proceed with operative treatment describes accepted indications and contraindications for surgical intervention 4 Provides post-operative management and rehabilitation immediate Post-op non-weight bearing in splint vs. external fixator, crutches for ambulation 2 weeks post-op wound check sutures removed repeat xrays of ankle and tibia/fibula 8-12 weeks postop xrays to evaluate union and fracture consolidation range of motion exercises to ankle advance weight bearing status and rehabilitation B Advanced Evaluation and Management 1 Provides comprehensive assessment of complex fracture patterns on imaging studies 2 Recognizes indications for and provides non-operative treatment of an unstable fracture diabetes medical comorbidities noncompliance C Preoperative History and Physical 1 Obtain history and perform basic physical exam document neurovascular status check compartments 2 Order basic imaging studies order biplanar radiographs of the tibia and weight bearing triplanar radiographs of the ankle 3 Splint fracture appropriately place in posterior splint with stirrups 4 Perform preoperative consent wound breakdown (10%) superficial/deep infection (5-15%) symptomatic hardware malunion nonunion post-traumatic arthritis (30-70% depending on articular injury) ankle stiffness neurovascular injury
E Preoperative Plan 1 Template fracture template fracture pattern and instrumentation 2 Execute surgical walkthrough describe steps of the procedure verbally to the attending prior to the start of the case describe potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation Synthes Variable Angle Locking Ankle Fracture System Synthes Small Fragment Set 1.2mm kwires osteotomes 2 Patient positioning patient supine with feet at the end of the bed, small bump under ipsilateral thigh, tourniquet on thigh if external fixator in place need to scrub down frame and pins thoroughly as this is a source of contamination 3 OR setup and C-arm radiolucent OR table c-arm from contralateral side perpendicular to bed G Superficial Dissection 1 Incorporate External Fixation into Approach Strategy If necessary leave external fixator fully or partially intact during approach and fracture reduction/fixation to maintain traction and fracture length 2 Draw out anterolateral incision and any additional incisions. use internervous plane between peroneus tertius and brevis, mark out lateral malleolus and course of peroneus tertius When using multiple approaches used must maintain ~7cm distance between full thickness skin flaps to decrease wound complications 3 Exsanguinate extremity and inflate tourniquet 4 Make incision start 2-3cm anterior to anterior border of fibula in line with 4th ray down to ankle joint identify and protect SPN in subcutaneous tissue immediately under skin incise fascia and extensor retinaculum in line with skin incision retract and elevate anterior compartment tendons medially If needed extend distally to talonavicular joint Anteromedial approach mark out medial malleolus and distal tibia crest, incision medial to tibialis anterior tendon sheath make incision centered on distal tibia then curving medial across ankle joint elevate full thickness skin flaps, leave tibial anterior tendon sheath intact elevate anterior compartment tendons and retracted laterally H Deep Dissection 1 Use sharp dissection down to bone 2 Perform subperiosteal elevation use a wood handled elevator and knife to elevate the muscles and tendons off of the anterior border of the tibia and fibula need to visualize extent of fracture fragments medially and laterally I Bony Preparation and Intraarticular Reduction 1 Prepare fracture site identify distal tibia fracture site and book open anterolateral vs. anteromedial fragment clean out with rongeur, curettes or dental pic 2 Use osteotomes to tamp down impacted central piece a central bone void should remain inspect talus for OCD lesions at the same time perform microfracture technique with kwire as needed 3 Join fragments together attach medial malleolus to impacted central fragment and lateral malleolus with kwires can use additional medial incision to expose medial fragment and reduce using k-wires join smaller fragments to larger fragments in a systematic fashion with kwires to restore articular surface join articular surface to tibia shaft use pointed reduction clamps to reduce larger fragments J Fixation 1 Fix anterior and posterior fragments place 2.7mm lag screw (2.0 mm drill) anterior to posterior to join fragments together place anterolateral vs. medial plate with at least 3 screws above (3.5 cortical) and 3 below (2.7 locking) key is metadiaphyseal screws distally in subchondral bone to support distal tibia articular surface need to be parallel to joint 2 Check anatomic placement of plate check plate contour and make sure no riding up off the distal tibia 3 Fix plate to bone place medial malleolus 1/3 tubular plate with 3.5 cortical screws to buttress down medial fragment insert allograft chips and autologous bone graft for distal tibia bone defect K Fibula Fixation (Optional) 1 Prepare fracture site clean out fracture site using freer to open fracture site use curettes, small rongeur, dental pick, and irrigation to remove hematoma and interposed soft tissue 2 Perform reduction use lobster clamp and pointed clamps to reduce fracture using hand rotation and contralateral thumb to help guide fragments together 3 Place lag screw place 2.7mm lag screw (2.0 mm drill) perpendicular to fracture line if possible 4 Place final fixation determine length of 1/3 tubular plate needed (~6-8holes) and check placement on fluoro place plate directly lateral for neutralization and insert 3 screws (3.5 mm) above and below fracture site L Confirm Intraarticular reduction and Hardware Position 1 Take final fluoro AP/Lat/Mortise of ankle and AP/Lat of tibia/fibula check screw lengths to ensure no penetration into ankle joint or surrounding tendons 2 Check limb length, rotation, and alignment N Wound Closure 1 Irrigation & Hemostasis deflate tourniquet irrigate and cauterize peripheral bleeding vessels place medium hemovac drain exiting proximal and lateral 2 Closure fascia and retinaculum closure with 0-vicryl, watch out for SPN laterally subcutaneous with 2-0 vicryl and skin closure with 3-0 nylon 3 Dressing soft incision dressings and postmold splint with stirrups for immobilization vs. pin site dressings if external fixator maintained
O Perioperative Inpatient Management 1 Write comprehensive admission orders Serial compartment checks x24 hours IV fluids DVT prophylaxis pain control advance diet as tolerated foley out when ambulating check appropriate labs wound care drain out post-operative day 1 appropriately orders and interprets basic imaging studies xrays of the ankle in postop 2 Appropriate medical management and medical consultation 3 Inpatient physical therapy non weightbearing crutches for ambulation 4 Discharge home appropriately pain meds outpatient PT schedule follow up appointment in 2 weeks R Complex Patient Care 1 Develops unique, complex post-operative management plans