Preoperative Patient Care A Outpatient Evaluation and Management 1 Obtain focused history and performs focused exam recognize implications of soft tissue injury check neurovascular status 2 Interpret basic imaging studies interpret triplanar radiographs of the ankle 3 Makes informed decision to proceed with operative treatment describes accepted indications and contraindications for surgical intervention 4 Modifies and adjusts post-operative treatment plan as needed postop: 2-3 week postoperative visit remove sutures wound check remove splint and place in short-leg cast boot, non-weight bearing can allow ROM if soft tissue is appropriate postop: 6 weeks advance weight-bearing status in CAM boot advance rehabilitation if syndesmotic screw(s) placed, need to be non-weightbearing postop: 12 Weeks postoperative visit advance weight-bearing if diabetic, insensate, or syndesmotic screws present syndesmotic screws to stay in for at least 12 weeks B Advanced Evaluation and Management 1 Recognizes indications for and provides non-operative treatment of an unstable fracture diabetes medical comorbidities noncompliance 2 Capable of treating complications both intraoperatively and post-operatively wound breakdown following malleolar fixation 3 Appropriately orders and interprets advanced imaging studies stress views CT scan 4 Provides a comprehensive assessment of most fractures on imaging studies C Preoperative History and Physical 1 Obtain history and perform basic physical exam document neurovascular status 2 Order basic imaging studies order weight bearing triplanar radiographs of the ankle 3 Splint fracture appropriately place in posterior splint with stirrups 4 Perform operative consent describe complications of surgery including 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 Operative Techniques E Preoperative Plan 1 Radiographic templating of 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 2 Execute surgical walkthrough resident can describe the key 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 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) 2 Room setup and equipment radiolucent table c-arm from contralateral side, perpendicular to table, monitor at foot of bed 3 Patient positioning 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 G Lateral Malleolus Approach 1 Mark fibula anatomy and fracture site mark out lateral malleolus and anterior and posterior borders of fibula mark estimated location of fracture site check with C-arm if unsure 2 Make incision perform a straight longitudinal incision 4-6cm in length centered on fracture make incision along posterior fibula if access to the posterior malleolus is needed create full thickness flaps over distal fibula ensure hemostatsis with cautery 3 Dissect through subcutaneous tissue proximally, use tenotomy scissors to spread subcutaneous tissue in vertical direction with minimal soft tissue stripping identify superficial peroneal nerve with more proximal fractures 4 Perform 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 H Lateral Malleolus Reduction 1 Prepare the fracture open fracture site with Freer elevator remove hematoma and interposed soft tissue with curettes, small rongeur and right angle snap 2 Reduction 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 fibula out to length for right sided fractures, supinate for left sided fractures (SER patterns) use another clamp to hold reduction once achieved I Lateral Malleolus Lag Screw and Plate Fixation 1 Drill holes 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 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 2 Insert screw 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 3 Place Fixation with 1/3 tubular plate determine length of plate 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 insert screws drill bicortically with 2.5mm drill bit, then use depth gauge insert appropriate length 3.5mm screw, alternating proximal to fracture then distal 4.0mm cancellous screw used in this instance alternatively, can drill and place a unicortical locking screw antiglide plate technique determine length of 1/3 tubular plate needed ( typically 6-8holes) prepare fracture identify apex of fracture spike posteriorly plate fixation 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 confirm Plate & Screw Position check with C-arm on mortise and lateral views J Medial Malleolus Approach 1 Superficial Dissection Make 10cm longitudinal, curved incision on medial ankle begin 5cm proximal to medial malleolus over subcutaneous tibia continue incision across anterior third of medial mallelous this can be curved apex anteriorly for improved visualization of the ankle joint finish 5cm distal and 5cm anterior to tip of medial malleolus mobilize skin flaps identify and protect long saphenous vein just anterior to medial malleolus identify and protect long saphenous nerve, if possible, next to vein clear remaining tissues down to periosteum 2 Deep dissection expose fracture site incise the anterior joint capsule to visualize joint and dome of talus split fibers of deltoid ligament to allow hardware to seat directly on bone posterior tibial tendon should be visualized to ensure that it remains intact K Medial Malleolus Reduction and Fixation 1 Prepare fracture site evert the foot to increase exposure of the fracture site remove any loose bodies or osteochondral defects visualize posterior tibial tendon for potential tears 2 Reduce fracture use 2.0-2.5 mm drill bit to drill a unicortical hole 2 cm proximal to fracture site place a pointed reduction clamp and compress across fracture place additional clamp over distal fragment to control position of distal fragment 3 Confirm reduction with mortise view 4 Obtain screw fixation for 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 cortical screws (70-100mm) if bicortical place partially threaded cancellous screw (typically ~45mm) if unicortical drill and place second screw screw placement should not be posterior in malleolus posterior placement increases posterior tibial tendon irritation for 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 L Syndesmosis Exam & ORIF 1 Syndesmosis Exams 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 2 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 3 Cortical Screw 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 4 Confirm reduction and implant placement obtain final AP, mortise, and lateral radiographs 5 Treat intraoperative and postoperative complications wound breakdown following malleolar fixation N Wound Closure 1 Irrigation and hemostasis irrigate wounds thoroughly and deflate tourniquet if used cauterize any bleeding vessels watching out for saphenous vein medially and SPN laterally 2 Deep closure Use 0-vicryl to close deep fascia over plate ensure no entrapment of the SPN 3 Superficial closure 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 4 Dressing and immediate immobilization soft incision dressing followed by AO splint with extra padding under heel for immobilization crutches or walker for ambulation Postoperative Patient Care O Perioperative Inpatient Management 1 Discharge patient appropriately take xrays of the ankle in postop to verify reduction oral pain meds schedule follow up wound care instructions outpatient PT R Complex Patient Management 1 Develops unique, complex post-operative management plans
A Outpatient Evaluation and Management 1 Obtain focused history and performs focused exam recognize implications of soft tissue injury check neurovascular status 2 Interpret basic imaging studies interpret triplanar radiographs of the ankle 3 Makes informed decision to proceed with operative treatment describes accepted indications and contraindications for surgical intervention 4 Modifies and adjusts post-operative treatment plan as needed postop: 2-3 week postoperative visit remove sutures wound check remove splint and place in short-leg cast boot, non-weight bearing can allow ROM if soft tissue is appropriate postop: 6 weeks advance weight-bearing status in CAM boot advance rehabilitation if syndesmotic screw(s) placed, need to be non-weightbearing postop: 12 Weeks postoperative visit advance weight-bearing if diabetic, insensate, or syndesmotic screws present syndesmotic screws to stay in for at least 12 weeks B Advanced Evaluation and Management 1 Recognizes indications for and provides non-operative treatment of an unstable fracture diabetes medical comorbidities noncompliance 2 Capable of treating complications both intraoperatively and post-operatively wound breakdown following malleolar fixation 3 Appropriately orders and interprets advanced imaging studies stress views CT scan 4 Provides a comprehensive assessment of most fractures on imaging studies C Preoperative History and Physical 1 Obtain history and perform basic physical exam document neurovascular status 2 Order basic imaging studies order weight bearing triplanar radiographs of the ankle 3 Splint fracture appropriately place in posterior splint with stirrups 4 Perform operative consent describe complications of surgery including 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
E Preoperative Plan 1 Radiographic templating of 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 2 Execute surgical walkthrough resident can describe the key 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 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) 2 Room setup and equipment radiolucent table c-arm from contralateral side, perpendicular to table, monitor at foot of bed 3 Patient positioning 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 G Lateral Malleolus Approach 1 Mark fibula anatomy and fracture site mark out lateral malleolus and anterior and posterior borders of fibula mark estimated location of fracture site check with C-arm if unsure 2 Make incision perform a straight longitudinal incision 4-6cm in length centered on fracture make incision along posterior fibula if access to the posterior malleolus is needed create full thickness flaps over distal fibula ensure hemostatsis with cautery 3 Dissect through subcutaneous tissue proximally, use tenotomy scissors to spread subcutaneous tissue in vertical direction with minimal soft tissue stripping identify superficial peroneal nerve with more proximal fractures 4 Perform 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 H Lateral Malleolus Reduction 1 Prepare the fracture open fracture site with Freer elevator remove hematoma and interposed soft tissue with curettes, small rongeur and right angle snap 2 Reduction 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 fibula out to length for right sided fractures, supinate for left sided fractures (SER patterns) use another clamp to hold reduction once achieved I Lateral Malleolus Lag Screw and Plate Fixation 1 Drill holes 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 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 2 Insert screw 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 3 Place Fixation with 1/3 tubular plate determine length of plate 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 insert screws drill bicortically with 2.5mm drill bit, then use depth gauge insert appropriate length 3.5mm screw, alternating proximal to fracture then distal 4.0mm cancellous screw used in this instance alternatively, can drill and place a unicortical locking screw antiglide plate technique determine length of 1/3 tubular plate needed ( typically 6-8holes) prepare fracture identify apex of fracture spike posteriorly plate fixation 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 confirm Plate & Screw Position check with C-arm on mortise and lateral views J Medial Malleolus Approach 1 Superficial Dissection Make 10cm longitudinal, curved incision on medial ankle begin 5cm proximal to medial malleolus over subcutaneous tibia continue incision across anterior third of medial mallelous this can be curved apex anteriorly for improved visualization of the ankle joint finish 5cm distal and 5cm anterior to tip of medial malleolus mobilize skin flaps identify and protect long saphenous vein just anterior to medial malleolus identify and protect long saphenous nerve, if possible, next to vein clear remaining tissues down to periosteum 2 Deep dissection expose fracture site incise the anterior joint capsule to visualize joint and dome of talus split fibers of deltoid ligament to allow hardware to seat directly on bone posterior tibial tendon should be visualized to ensure that it remains intact K Medial Malleolus Reduction and Fixation 1 Prepare fracture site evert the foot to increase exposure of the fracture site remove any loose bodies or osteochondral defects visualize posterior tibial tendon for potential tears 2 Reduce fracture use 2.0-2.5 mm drill bit to drill a unicortical hole 2 cm proximal to fracture site place a pointed reduction clamp and compress across fracture place additional clamp over distal fragment to control position of distal fragment 3 Confirm reduction with mortise view 4 Obtain screw fixation for 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 cortical screws (70-100mm) if bicortical place partially threaded cancellous screw (typically ~45mm) if unicortical drill and place second screw screw placement should not be posterior in malleolus posterior placement increases posterior tibial tendon irritation for 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 L Syndesmosis Exam & ORIF 1 Syndesmosis Exams 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 2 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 3 Cortical Screw 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 4 Confirm reduction and implant placement obtain final AP, mortise, and lateral radiographs 5 Treat intraoperative and postoperative complications wound breakdown following malleolar fixation N Wound Closure 1 Irrigation and hemostasis irrigate wounds thoroughly and deflate tourniquet if used cauterize any bleeding vessels watching out for saphenous vein medially and SPN laterally 2 Deep closure Use 0-vicryl to close deep fascia over plate ensure no entrapment of the SPN 3 Superficial closure 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 4 Dressing and immediate immobilization soft incision dressing followed by AO splint with extra padding under heel for immobilization crutches or walker for ambulation
O Perioperative Inpatient Management 1 Discharge patient appropriately take xrays of the ankle in postop to verify reduction oral pain meds schedule follow up wound care instructions outpatient PT R Complex Patient Management 1 Develops unique, complex post-operative management plans