Fractures of the ankle: pathogenesis and treatment.

From the foregoing, one may reduce the following principles for the management of ankle injuries: The mechanism of injury and the diagnosis, including ligamentous injury, can be made from initial radiographs. A displaced fracture of only one malleolus must be accompanied by ligamentous injury of either the deltoid or syndesmotic ligaments, or both. When there is only one break in the ring of the ankle mortise, there is no potential for significant displacement; thus, ORIF is rarely necessary. With two breaks in the ring, the potential for displacement exists, even after successful manipulation, which usually makes operative treatment a more attractive option. Closed reduction is done by reversing the direction of the injuring forces, though it is not necessary to do so in precise inverse order to their occurrences. When ORIF is used, all significant malleolar fractures should be rigidly fixed to allow early motion, which, along with delayed weight bearing, is especially beneficial when comminution of the articular surface exists. Syndesmotic fixation is usually unnecessary if the malleolar fractures can be reduced anatomically and securely fixed. The reduction, whatever technique is used, should result in full congruency of the ankle mortise and a level joint line. Trimalleolar fractures, especially when they involve more than 25% of the tibial plafond, are much more likely than bimalleolar fractures to be associated with posttraumatic arthritis.